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introduction systematic socioeconomic inequalities in health persist and continue to widen within many economically prosperous countries across the globe 12 the socioeconomic gradient in health remains one of the main challenges for public health as socioeconomically disadvantaged individuals have a lower life expectancy and a higher risk of developing lifelimiting illnesses such as diabetes and cardiovascular disease compared to their advantaged counterparts 34 the theories and frameworks developed to understand the causes of and solutions to the socioeconomic gradient in health are undoubtedly complex for example the world health organizations commission on the social determinants of health developed a conceptual framework to illustrate the relationship between the social determinants of health and equity in health and wellbeing which was multilevel and contained feedback loops 5 the csdh framework highlights the multifaceted nature of inequality from the impact of the socioeconomic and political context to psychosocial factors and biology thus there is an increasing recognition that health inequality is a complex or wicked problem and systems simulation models are a useful tool to understand the underlying causes and mechanisms 6 complex systems are systems which consist of interacting parts or subsystems some key characteristics of complex systems are dynamic resulting in adaptation to change nonlinear relationships feedback loops tipping points and the emergence of macrophenomena from interactions at the micro level 7 it is difficult to capture these relationships using a traditional epidemiological risk factor approach which uses linear reductionist models to test the relationships between decontextualised dependent and independent variables 8 agentbased modelling a wellestablished methodological approach used widely in the field of social science has been highlighted as a methodological approach that can be used to address this problem 6 abm involves simulating the actions and interactions of individual agents with other agents and their environment based on a set of specified rules and observing emergent phenomena 9 agents may adapt their own behaviour in response to previous behaviour their social network or environmental stimuli 9 not only can abm be used to understand complex phenomena but they can also be used to test the impact of policy interventions and inform policy decisions and have been successfully applied in other areas of public health particularly for the control of infectious diseases 10 abm has been used successfully to understand the causes of inequality more broadly outside the field of public health famously the schelling model of segregation which identified residential segregation is generated in the presence of relatively simple nearest neighbour preferences and could be used to understand the racial segregation patterns in the usa 11 additionally the sugarscape model developed by epstein and axtell has offered insights into the generation of wealth inequality using a relatively simple model which simulates the land in which sugar is grown and can be harvested by individuals to become their wealth 1213 individuals in the simulation are programmed to harvest the sugar closest to them strikingly even when the wealth available to all individuals at the beginning of the simulation is equal trends in wealth inequality are produced even after a short simulation period additionally only a very small proportion of individuals have high levels of wealth while a much larger proportion have low levels of wealth these models alongside many others developed in the field of social science have illustrated the benefits of using abm to understand complex observable phenomena a review by speybroeck and colleagues covering research published before january 2013 explored how simulation models had been used in the field of socioeconomic inequalities in health specifically 14 they found only four abm studies which focused on understanding differences in health behaviour or infectious disease transmission between socioeconomic groups speybroeck and colleagues concluded that abm is the most appropriate computational modelling method to examine health inequalities as they can incorporate all the characteristics of a complex system such as the heterogeneity interactions feedback and emergence 14 however while the four identified models contained many of the expected features of abm the speybroeck review concluded that to better understand the complex mechanisms underlying health inequalities more abm that features feedback loops temporal changes and agentagent and agentenvironment interactions are required since the speybroeck review there has been a methodological shift towards using complex system methods in public health and public policy much supported by large investments in data accessibility and computing power in the uk this is also reflected in the medical research councils updated guidance for the development and evaluation of complex interventions 15 and the her majesty treasurys magenta book annex handling complexity in policy evaluation both published in 2021 16 this methodological turn has resulted in a significant increase in computational modelling papers in the public health literature in recent years therefore it is now timely to update and deepen the previous review here we focus on the contribution of abm to understand the socioeconomic inequalities in health specifically by reviewing the application area and the measure of socioeconomic position and the details of the abm approach the aim of this review was to synthesise the growing evidence based on the use of abm in the field of health inequalities research materials and methods we followed the guidelines of the preferred reporting items for systematic reviews and metaanalyses 17 the protocol for this review was developed and registered on the international prospective register of systematic reviews pubmed scopus and web of science were searched from 1 january 2013 to 15 november 2022 the scopus search was limited by subject area to medicine social sciences computer science multidisciplinary mathematics nursing economics econometrics and finance neuroscience health professions psychology decision sciences and engineering for web of science searches were made of the editions of science citation index expanded and social sciences citation index for both web of science and pubmed only the titles and abstracts were searched an extensive list of search terms was used to capture the themes of simulation modelling socioeconomic inequality and health the search strategy was validated against that used in the speybroeck review 14 confirming that all abm studies included in that review also appeared using our search strategy eligibility criteria table 1 lists the inclusion criteria for this review this criterion includes the population exposures comparisons outcomes and study designs required for a study to be eligible for inclusion studies were included if they were full papers published in english and the paper described an abm study with the purpose to understand the emergence andor persistence of health inequalities in relation to either noncommunicable disease or the differential response of different socioeconomic groups to healthrelated interventions papers were only included if they simulated human individuals or groups and investigated withincountry socioeconomic inequalities in health restricted to the differences in the health status health behaviour or access to healthcare papers in which healthy food access was modelled as a proxy for the consumption of healthy food were also included studies that developed abm in combination with system dynamics or populationbased models were included there were no geographical restrictions papers that modelled communicable diseases or water or food accesssecurity as the health outcomes were outside the scope of this review and were therefore excluded the studies published before 2013 were also excluded as these studies were covered in the speybroeck review 14 screening searching returned a total of 2533 records all the records were downloaded to endnote x9 and imported to the eppireviewer the total records were reduced to 1436 following the removal of duplicates an initial screening was carried out by one reviewer following title screening 477 records were identified for abstract screening a second reviewer independently doublescreened a randomly selected subset of abstracts after title and abstract screening 51 records were selected for fulltext screening and 18 of these met the eligibility criteria for data synthesis the second reviewer also independently screened all the selected fulltext studies to validate that the included papers met all the eligibility criteria any disagreements were recorded and discussed to ensure consistency two further reviewers assisted with the screening for papers queried on methodological grounds in instances where it was uncertain whether a simulation model met the inclusion criteria manual reference searching identified two additional papers which met the inclusion criteria giving a final sample of 20 included studies screening searching returned a total of 2533 records all the records were downloaded to endnote x9 and imported to the eppireviewer the total records were reduced to 1436 following the removal of duplicates an initial screening was carried out by one reviewer following title screening 477 records were identified for abstract screening a second reviewer independently doublescreened a randomly selected subset of abstracts after title and abstract screening 51 records were selected for fulltext screening and 18 of these met the eligibility criteria for data synthesis the second reviewer also independently screened all the selected fulltext studies to validate that the included papers met all the eligibility criteria any disagreements were recorded and discussed to ensure consistency two further reviewers assisted with the screening for papers queried on methodological grounds in instances where it was uncertain whether a simulation model met the inclusion criteria manual reference searching identified two additional papers which met the inclusion criteria giving a final sample of 20 included studies data extraction data from the papers were extracted by one reviewer a second reviewer assessed the accuracy of the data extraction for all the included studies in the case of a disagreement both reviewers referred to the paper in question and a consensus was reached a data extraction matrix was developed which included the basic characteristics of the studies variables modelled model characteristics if and how the model was validated the models function and the relevant findings the models characteristics were not always explicit but could be derived from the methods section the relevant findings were defined as those related to health or intervention outcomes stratified by a measure of the socioeconomic position quality assessment given the lack of an appropriate quality assessment or a risk of bias assessment tool to assess abm a quality assessment was not conducted but we recorded the compliance with the reporting guidelines of the odd 18 analysis descriptive summary statistics were used to describe the search results and studys characteristics we describe the specific modelling details of the included studies using a narrative synthesis in which we group models based on the health outcome results descriptive analysis the study characteristics for the 20 included papers are displayed in table 2 the most common geographical settings for the models were the usa and the uk the other models were set in the netherlands mexico india south korea canada and japan only two models were abstract and did not have a geographical setting most of the included models were set at the city level other settings included the national state and district level most of the included papers described the abm of the socioeconomic differences in health behaviour three papers focused on explaining the socioeconomic differences in the physical health outcomes and three papers modelled a mental health outcome the measures of the socioeconomic position covered the income educational attainment social grade and wealth all of the included models were multilevel dynamic stochastic and had heterogeneous agents most models represented both the individuals and the environment with environmental features often in the models agents could age die and change their behaviour over the course of the simulation only three papers used the odd reporting guidelines when writing descriptions of their abm 18 examine the impact of a free bus policy on public transit use and depression among older adults individual incomedivided into quintiles prevalence percentage of agents with depression mlmultilevel ddynamic ststochastic flfeedback loop spspatial htiheterogeneous individuals aiagentagent interactions eiagentenvironment interactions vvalidation fframework itest an intervention health behaviours most models with a focus on the health behaviour modelled dietary behaviours four of the models were concerned with physical activity and the access to green space and three modelled substance use specifically the consumption or purchase of alcohol and tobacco as a proxy for consumption dietary behaviour papers that used abm to model the socioeconomic differences in dietary behaviours tested the impact of interventions on the consumption of sugarsweetened beverages 19 the purchase of ultraprocessed food 20 the consumption of fruits and vegetables 2122 and the access to healthy food outlets 23 the interventions were educational campaigns advertising campaigns changes to tax increasing access to vegetables and reducing the cost of vegetables however two papers focused on the impact of residential segregation on the access to healthy food outlets as an explanation for the socioeconomic differences in dietary behaviours 2425 all models used the level of income of the individual or household educational achievement or both as the measure of the socioeconomic position the only paper that did not include a spatial component to the model was set at a national level and explored the impact of tax nutrition warnings and advertising on the purchase of ultraprocessed food in mexico 20 the other six models used artificial grid space 24 a 1dimensional linear township 25 a raster map to represent the spatial distribution of income 21 or actual geographic space including gis modelling of reallife cities 192223 six of the models included agentenvironment interactions which often captured how individual agents engage with food outlets 21 22 23 24 25 only two of the included papers modelled agentagent interactions through dietary social norms operationalised via a social network which influenced the taste preferences and health beliefs 22 and the purchasing of ultraprocessed foods 20 five of the models featured feedback loops these included the update of social norms based on behaviour over the course of the simulation 2022 and the food outlet responses to the agents behaviour by closing and opening outlets 23 changing the type of food available for sale 24 or an increasing appetite and overeating following the consumption of foods high in fat sugar and salt 21 only two of the papers had attempted validation by comparing the simulated outcomes to the observed outcomes in real world data 1922 physical activity and use of urban green space all the models that investigated the socioeconomic differences in physical activity simulated intervention scenarios these scenarios included additional physical education in schools the promotion of active travel educational campaigns increasing the availability and affordability of sports activities improving neighbourhood safety and increasing the expense associated with driving 26 27 28 all the models focusing on physical activity used the level of income of the individual or household as the measure of the socioeconomic status and explored a range of physical activityrelated outcomes including the minutes of physical activity per day 26 sports participation 27 and walking 28 models concerning physical activity involved a spatial component operationalised as either a representation of the actual geographical space 2627 or an artificial grid 28 all the models simulated both agentagent interactions and agentenvironment interactions two models contained feedback loops including the updating of social norms regarding exercise and travel preferences 2728 and environmental feedback including the safety and traffic levels of travel routes on the attitudes towards transport methods 28 two models were validated by comparing the simulated outcomes to the outcomes observed in the preexisting data 2628 one paper modelled intraand intercity inequalities in visiting urban green spaces specifically testing the mechanism that the decision to visit these spaces is influenced by an individuals assessment of who had previously visited the space 29 given conflicting evidence the model explored two possibilities that agents visit spaces that people like themselves to visit and that individuals with a lower ses prefer to spend time in areas which those of a high ses visit this model used the occupational grade to classify the agents into either a high or low ses the model spatially represented the cities of edinburgh glasgow aberdeen and dundee and simulated both agentenvironment interactions in the form of visiting urban green spaces and agentagent interactions via agents assessing the similarity of other agents visiting the green space the feedback loop in this model was the update of who visited green spaces which was a function of the update to whether in or out group members were present in those spaces given a lack of observed data the model was validated using a pattern matching approach the model could reproduce the observed patterns of urban green space visitation in a spatial microsimulation of glasgow substance use two of the models that focused on the socioeconomic differences in substance use tested the impact of interventions including alcohol taxation 30 and the restriction of menthol cigarette sales and tobacco retailer density 31 one paper simulated several counterfactual scenarios which varied the degree of socioeconomic disparity and genderrelated susceptibility to social influence in the context of smoking 32 all the models used the income level of the individual or household as the measure of the socioeconomic position and investigated substance use in the form of smoking prevalence 32 tobacco purchasing 31 and the average number of alcoholic drinks per day 30 two models simulated agentagent interactions including the influence of gender and socioeconomic social norms on an individuals own smoking 32 and social network influences on drinking behaviour 30 two models were spatial one represented the city of new york 30 and the other an abstract town called tobacco town 31 two models simulated agentenvironment interactions such as travelling to and from locations and engaging with tobacco and alcohol retail outlets 3031 one paper not only focused on the consumption of alcohol but also examined the interaction between neighbourhood characteristics social networks sociodemographic characteristics drinking and violence 30 two models featured feedback loops in the form of updates to norms based on drinking and smoking behaviour 3032 one model validated the simulated outcomes by comparing these to the outcomes observed in realworld data on the prevalence of smoking in japan 32 physical health of the three models that focused on physical health outcomes one examined the incidence of severe neonatal morbidity and deaths per 1000 live births averted 33 one looked at the health status and care need 34 and the other investigated the impact of an exposure to air pollution on the health status 35 two of the papers modelled the effect of potential interventions on the physical health outcomes 3334 in one the intervention was the alteration of the eligibility criteria for governmentfunded social care in the other increasing the responsibilities and coverage of community health workers all the models used a different measure of the socioeconomic position including wealth quintile 33 approximated social grade 34 and educational attainment 35 all three models included the individual and household levels and two included additional levels such as kinship networks and the regional level one study represented space using a grid based on the geography of the modelled country 34 and two represented the actual geographic space 3335 an interaction with the environment was in the form of migration seeking treatment at facilities and the exposure to pollution only two models included a feedback loop including feedback between the parental income level and childhood educational attainment and feedback between the level of disease and the probability of developing a further disease 3435 only one model involved agents interacting with each other in the form of a kinship network which consisted of familial relationships 34 none of these models validated their results using real world data one of the models was used to create a complex theoretical framework to represent the social care system the geographical and population data inputted into this framework could then be adjusted to model and understand the drivers of the unmet social care need in different countries 34 mental health two of the three papers focusing on a mental health outcome examined the impact of transport on depression among older adults the first examined the impact of multiple transport interventions 36 and the second examined that of a free bus policy on public transit use and depression 37 an individuals income was used as a measure of the socioeconomic status in both papers one model carried out three experiments increasing the walkability and safety of neighbourhoods to promote walking decreasing bus fares and bus waiting times and adding bus lines and stations 36 while the second model focusing on transport carried out four experiments altering mean attitudes towards the bus bus waiting times the cost of parking and fuel prices each experiment was also carried out with and without the inclusion of the free bus policy 37 both models captured the individual and neighbourhood level a feedback loop resulted in improved attitudes towards a certain mode of travel following the positive experience of that mode the spatial element was applied to income segregation patterns in one model the agents interacted with each other in the form of social networks influencing the travel behaviour 37 in both models agents interacted with the environment by using transport both models were validated against empirical data on the prevalence of depression in the united states by gender age and income level the third paper examined the impact of reducing income inequality on depression among expectant mothers 38 four interventions to increase income were tested two child benefit programs universal basic income and increasing minimum wage this model focused on individuals and while it captured the neighbourhood characteristics for each individual the environment was not spatially represented in the model agents could decide to make or break social connections with other agents and whether to break ties with other agents with depression this model was not validated what can abm tell us about socioeconomic inequalities in health studies investigating the explanations for the socioeconomic differences in health found that those of a higher socioeconomic position were more likely to be exposed to healthier environments and therefore engage in healthier behaviours and have better health outcomes for example one model found that a greater income segregation in communities led to a decreased access to healthy food for lower income households 25 another study which modelled agents movements from work to home found that regardless of the level of air pollution those with a lower level of education consistently had the highest risk of developing an illness 35 models which tested the impact of interventions on the socioeconomic inequalities in health found that some interventions increased inequalities for example those of a high socioeconomic position improved their health behaviour more in response to educational campaigns concerning nutrition 2223 it was argued that nutritional education campaigns may be ineffective for those of a lower socioeconomic position due to a sensitivity to food prices and a lack of access to healthy alternatives 22 similarly it was found that the promotion of active travel had greater benefits for those of a high socioeconomic position as they are more likely to travel by car and travel by car more often to extracurricular activities prior to the intervention 26 however there were some modelled interventions that decreased the socioeconomic inequalities in health for example one model tested the impact of a sugarsweetened beverage tax and found that at 25 tax the reduction in the consumption of sugarsweetened beverages was greater in those from lowincome populations 19 this finding was largely the result of increases in price which made sugarsweetened beverages less affordable to lowincome households another study which modelled the expanded responsibilities and increased coverage for accredited social health activists who perform postnatal checkups found that these interventions resulted in greater decreases in the neonatal morbidity and mortality among those of a low socioeconomic position 33 yang and colleagues also showed that in older adults when attitudes towards bus use improved and the waiting time decreased decreases in depression were estimated to be greater among lowincome groups 37 this larger increase was because those of a low income are less likely to own cars and are therefore more susceptible to an intervention to increase the uptake of public transport which increases the number of nonwork trips they take which was beneficial to their mental health discussion this review included 20 papers that described the abm of the socioeconomic inequalities in health that have been published since january 2013 the end point of the speybroeck review which found only four abm studies on the topic 14 using abm in the context of socioeconomic health inequalities was most common in the usa and uk the included studies illustrated that abm is a useful tool to understand complex problems and has been used flexibly to represent dynamic multilevel processes often in physical space and to capture the interactions between individuals and interactions with their environment these models can tell us about the causes of health inequalities potential interventions to reduce health inequalities and which interventions may inadvertently increase health inequalities typically abm has been used to explore socioeconomic differences in health behaviours including diet physical activity access to green space and substance use but few have approached the socioeconomic differences in physical and mental health outcomes additionally only one paper modelled access to healthcare as a potential explanation for socioeconomic inequalities in health 33 to an extent this is unsurprising given a historic focus on health behaviours in public health 39 coupled with the fact that abm as a method captures how behaviours at the microlevel give rise to emergent phenomena at the macrolevel 40 most abm were used to test a range of interventions from educational campaigns to taxation and were underutilised for other purposes such as testing the explanatory value of the theory or mechanisms to explain the generation or persistence of socioeconomic inequalities in health this is consistent with the speybroeck review which found that all abm studies were used to test an intervention or scenario 14 and highlights that a valuable feature of abm is the ability to experiment and test a range of interventions in silico 40 less than half of the included studies attempted to validate their models and to varying degrees some using observational data or pattern matching methods however none of the included studies used structural validation techniques which would ensure that it is the intended structure of the model that drives its behaviour 41 this finding is consistent with the speybroeck review which found that only one abm had been validated using observational data 14 additionally only three of the included papers explicitly used and referred to the odd protocol the guidelines with the purpose of ensuring that abm is described fully to facilitate its replication 18 it is clear from the findings of this review that most existing abm studies investigating the socioeconomic inequalities in health have focused on health behaviour this individualistic focus on health inequalities in abm efforts on this topic so far is not reflective of abms in the field of social science more generally abm has been used to understand broader social phenomena such as racial segregation and the generation of wealth inequality at the societal level 11 12 13 while these patterns are generated by individuallevel behaviours these models do not seek to explain these behaviours reducing health inequality to understanding the differences in health behaviour is problematic given that research has shown that for the same level of any given behaviour the health outcomes remain worse for the most socioeconomically deprived 42 limitations currently there is no available tool to assess the quality of abm studies and therefore we could not ensure that the models included in this review were of a high quality there are a variety of quality assessment tools available to assess other study types for example the appraisal tool for crosssectional studies which can be used to assess a studys design reporting quality and risk of bias 43 given the increase in abm studies in public health it is critical to consider how we will assess the quality of these studies going forward while the speybroeck review considered a breadth of simulation models 14 we chose to focus on abm only given the particular promise of abm applied to health inequality research and the rapid increase in the use of simulation modelling techniques since 2013 10 the application of alternative simulation modelling techniques to the socioeconomic inequalities in health in recent years awaits a further examination future research efforts thus far to use abm to understand socioeconomic inequalities in health have focused on the contribution of health behaviour however this focus on health behaviour is at odds with calls from researchers to move beyond bad behaviours 44 and the position of influential public health organisations for example the who concluded that it is the underlying social and economic factors that determine health and health inequalities as opposed to health behaviours 45 we are increasingly aware that health inequalities are not only the result of differences in health behaviour yet little has been done using abm to attempt to understand the complex relationships between the social and economic environment people live in and the influence on their health via pathways other than health behaviour there are explanations for socioeconomic inequalities in health that shift the focus from individuallevel behaviours to the social determinants which themselves determine health and to an extent behaviour 45 existing abms have started to look at the social drivers of health behaviours 2022 however they avoid alternative pathways through which social and economic factors directly or indirectly impact health it has been argued that abm could be used to investigate the mechanisms specified in social and economic explanations for health inequality 46 an existing hypothetical example of how this may be done is the operationalisation of psychosocial theory 46 instead of a focus on health behaviours operationalising psychosocial theory would involve simulating support seeking and giving among friendship networks which mediates health outcomes via stress pathways future research should consider how we can use abm to simulate alternative mechanisms which could explain the socioeconomic inequalities in health that are not exclusively focused on health behaviour conclusions in recent years abm has increasingly been used to explain socioeconomic inequalities in health abm allows us to develop a deeper understanding of the complex consequences of individual heterogeneity spatial settings feedback and adaptation resulting from agent interactions with each other and their environment however to date much of the focus has been on understanding the role of health behaviours the features of abm provide the opportunity to investigate alternative more complex explanations for socioeconomic health inequalities therefore an important next step in public health is to attempt to operationalise explanations for the causes and consequences of health inequalities beyond representations of health behaviour the following supporting information can be downloaded at table s1 systematic search strategy data availability statement not applicable

there is an increasing focus on the role of complexity in public health and public policy fields which has brought about a methodological shift towards computational approaches this includes agentbased modelling abm a method used to simulate individuals their behaviour and interactions with each other and their social and physical environment this paper aims to systematically review the use of abm to simulate the generation or persistence of health inequalities pubmed scopus and web of science 1 january 201315 november 2022 were searched supplemented with manual reference list searching twenty studies were included fourteen of them described models of health behaviours most commonly relating to diet n 7 six models explored health outcomes eg morbidity mortality and depression all of the included models involved heterogeneous agents and were dynamic with agents making decisions growing older andor becoming exposed to different health risks eighteen models represented physical space and in eleven models agents interacted with other agents through social networks abm is increasingly contributing to our understanding of the socioeconomic inequalities in health however to date the majority of these models focus on the differences in health behaviours future research should attempt to investigate the social and economic drivers of health inequalities using abm

introduction while early research has conceptualized emotions as largely intrapersonal experiences that take place within individuals emotions are also social and emerge from dynamic interactions between individuals and their social environment because the social environment is culturally constructed the interaction between individuals and their social environment can lead to variations in emotional experiences across cultures at one level this cultural emotional fit and individual wellbeing there is growing evidence to support the notion that experiencing similar patterns of emotions to others within the same culture is important for individual wellbeing in a series of studies de leersnyder and colleagues directly measured rather than inferred emotional fit with culture by using a profile correlation approach correlating each individuals pattern of emotions in response to different situations with the average emotional pattern of the group they then assessed the association between emotional fit and wellbeing in three different cultures their results revealed that having higher emotional fit in relationshipfocused situations was associated with greater relational wellbeing across all cultures emotional fit also predicted psychological wellbeing across cultures although the specific contexts in which emotional fit mattered varied depending on culture these findings suggest that although there may be some cultural variability in how emotional fit relates to individual wellbeing emotional fit is generally important for wellbeing at some basic level across cultures evidence from research examining cultural norms and wellbeing further support this point being in alignment with the normative practice of ones own culture is important for individuals adjustment and wellbeing while the cultural mandates for wellbeing may vary across cultures it is universal for people to achieve wellbeing through actualizing their respective cultural mandates for example actualizing values of autonomy and personal control would lead to wellbeing in western culture whereas actualization of the values of interdependence and relational harmony leads to wellbeing in east asian culture in a crosscultural study comparing americans and japanese it was indeed shown that personal control was the strongest predictor of wellbeing in the united states but the absence of relational strain was most predictive of wellbeing in japan similarly attaining relational goals and thus actualizing cultural mandates of interdependent culture was closely associated with wellbeing among asian americans and japanese but not among european americans in contrast attaining independent goals was related to wellbeing in european americans but not among asian americans or japanese in sum these studies suggest that fitting with norms of cultures is important for achieving individual wellbeing regardless of ones cultural orientation even if those norms vary from culture to culture emotional fit and collective identity parallel to the individualistic focus on the conceptualization and study of emotions as an intraindividual phenomenon studies of wellbeing and adjustment have also traditionally emphasized the individualistic personal aspects of wellbeing yet individuals wellbeing and adjustment are also closely related to the collectivistic aspects of the self for example having a positive collective identity indexed via collective selfesteem the tendency to have a positive view about ones group identity has been found to be associated with psychological wellbeing this relationship was evident especially in asians even after controlling for the effect of personal selfesteem reflecting the greater emphasis on the group and group experiences in asian culture given that collective identity may be an important index of wellbeing that complements the index of individualistic wellbeing the current study focuses on the relationship between emotional fit and collective identity in addition to the individualistic indices frequently used in studies of wellbeing previous research suggests that the experience of shared emotions with group members is important for constructing a positive group identity for instance páez et al found that perception of emotional synchrony while participating in collective gatherings led to greater collective selfesteem and increased identity fusion with the group similarly in a laboratory study that employed an experimental manipulation of emotional fit with preexisting and arbitrary groups participants with increased emotional fit with the group indicated greater identification with the group even when the group was created arbitrarily and carried no real meaning on the other hand some research also suggests that group identification may lead to shared emotional experience as well for example tanghe et al showed that increasing group identification through a laboratory manipulation led to greater similarity in emotional experience among group members while these studies suggest that emotional fit may be generally important for achieving positive collective identity studies have not yet examined cultural differences in how emotional fit relates to collective identity however crosscultural theorists have long discussed how ones sense of self is closely tied to others in interdependent cultures whereas it is construed more independently in independent cultures thus it follows that collective identity should be affected by the degree of shared experiences with group members to a greater extent in interdependent cultures than in independent cultures making the link between shared emotional experiences and collective selfesteem and group identification especially pronounced in east asian culture broadening the assessment of emotional fit previous work on emotional fit has primarily focused on similarity in the patterns of subjective emotional responses between an individual and a reference group the current study takes a multimethod approach to the assessment of emotions and therefore to the measurement of emotional fit we see emotions as a multicomponential construct that comprise subjective behavioral and physiological responses although some theories of emotion assume response coherence across the various components of an emotional response empirical support for the response system coherence is largely inconsistent recently a dualprocess perspective on emotion response coherence has been proposed to reconcile this inconsistency this framework suggests two relatively independent emotion systems one automatic system that is relatively unconscious and fast and another reflective system that is relatively conscious and deliberate while the two emotion systems are thought to work together to promote adaptive behaviors the response coherence between the two systems tends to be weak or nonexistent in contrast to the coherence evident between varying indicators within each system this lack of coherence suggests that emotional fit in one of these response domains may not necessarily be associated with emotional fit in another the potential variability in emotional fit across emotional response domains may also carry important implications for how emotional fit plays out in different cultures according to levensons biocultural model of emotion selfreports of subjective experience are highly susceptible to cultural influences facial expressions are somewhat susceptible to cultural influences and physiological response tendencies are relatively uninfluenced by culture because selfreports and behavioral expressions of emotions are visible and can directly influence social interactions these may need to be modulated according to cultural norms more so than physiology therefore emotional fit with culture may be more likely among subjective and behavioral response domains than in physiological responses these ideas have yet to be examined empirically however because of the narrow interpretation of emotional fit in the literature given the complexity of emotional experiences and varying cultural influence on emotion systems the current study sought to broaden the concept of emotional fit by using assessments of both automatic and reflective emotion systems we assessed individuals subjective behavioral and physiological responses to emotional stimuli to determine indices of selfreported behavioral and physiological emotional fit selfreport measures of emotion are thought to capture the reflective emotion system and physiological arousal associated with an emotional response are believed to reflect the automatic system facial expressions likely represent a combination of both reflective and automatic processes given evidence for both universal and culturally variable components of facial expressions the present study the present study examines the associations between emotional fit and individual and collective aspects of wellbeing among a sample of east asiansasian americans and european americans because we were interested in capturing representatives of two broad cultural groups whose traditional values regarding self and relationship are quite different we employed stringent criteria that made use of behavioral markers of cultural orientation family origin criteria and selfidentification to operationalize our cultural groups these criteria are outlined in the methods and are meant to increase the likelihood that the cultural groups studied reflect the traditional norms and values associated with their respective cultural heritages which include differential emphasis on social contexts in determining wellbeing in measuring the construct of emotional fit we used a method from de leersnyder et al that considers the patterns of emotional experience in relation to those of the same cultural group here we measured emotional fit objectively by taking the correlation between the individuals emotional pattern and the average pattern of the group thus rather than reflecting a subjective awareness of ones fit with ones cultural group this conceptualization of emotional fit reflects an objective measure of normative emotional responding while it is possible that subjective awareness of emotional fit may also provide valuable information about the relationship between emotional fit and wellbeing the subjective measure of fit may be susceptible to demand characteristics on the other hand the objective measure of emotional fit allowed us to explore the direct link between normative emotional responding and wellbeing while separating the effect of demand characteristics to test our research question we reanalyzed data originally collected as part of a large multimethod project investigating cultural difference in emotional reactivity and regulation results of the rest of the experiment are reported elsewhere although these data were not designed for the purposes of analyzing emotional fit and therefore was largely a convenience data set it did afford several opportunities to advance the emotional fit work and expand it in novel ways this was an experimental study that collected selfreport behavioral and physiological responses to varying emotional stimuli with participants being asked to regulate their emotional behavior for a subset of the trials assessing various components of emotions in this study allowed us to explore emotional fit at multiple levels and in multiple ways thus in the present study we examined emotional fit based on selfreported emotions as well as emotional fit based on behavioral and physiological responses we were also able to look at emotional fit in different emotional response contexts we tested two primary hypotheses in the present study based on previous studies supporting the relationship of individual wellbeing with selfreport emotional fit and with actualization of cultural norm across cultures we hypothesized that selfreport emotional fit would be associated with greater individual wellbeing in both asian americans and european americans in addition we hypothesized that selfreport emotional fit would be associated with more positive collective identity based on previous evidence supporting this link importantly we also predicted that culture would moderate this relationship because in many east asian cultures the self is construed in relation to others and thus being in alignment with others may have a greater impact on the collective identity of asian americans than european americans thus we expect that the positive association between selfreport emotional fit and collective identity will be stronger in asian americans than in european americans in addition to testing these hypotheses we conducted a series of exploratory analyses to test whether or not the hypothesized patterns of results for selfreport emotional fit would replicate with the behavioral and physiological emotional fit indices lastly the design of the original experiment allowed us to investigate emotional fit across different emotional contexts it is becoming increasingly important to recognize the contextualized nature of emotions emotion researchers have called for increased attention to the cultural and social context of emotions at the collective level in order to enhance our understanding of emotions as a whole this view also calls for the need to understand emotions in the context of particular emotional situations this is because cultural differences in emotional experience occur in part as a function of varying situation selections across cultures this means that findings from cultural investigation of emotions may vary depending on what emotional situation has been examined in the study this highlights the importance of studying and understanding emotions in relation to particular emotional situations thus in this study we examined participants emotional fit at three different experimental time points prior to the introduction of any emotional stimuli in response to a neutral film and in response to a disgustinducing film previous studies on emotional fit examined mostly participants broad emotional patterns in a particular environment we thought that this approach would be most comparable to selfreport emotional fit at baseline where participants were in the same setting prior to presentation of any laboratory emotional stimulus thus our primary hypotheses relating to selfreport emotional fit and wellbeing are specific to measurement of emotional fit at time 0 however we also explored whether or not any of the findings observed at time 0 are also seen at times 1 and 2 when specific emotional stimuli are introduced materials and methods eligibility criteria we relied on several pieces of culturally relevant information including behavioral information such as language preferences to go beyond racial or ethnic selfidentification to characterize our groups based on criteria employed in previous studies of culture and emotion see soto et al and soto and levenson for full discussion of the rationale behind the criteria european americans must have been born and raised in the united states and had to selfidentify as white or european american participants also had to report that their parents and grandparents were born in the united states and identified as white or european american in addition european american participants had to report being of christian or catholic religion or growing up with these religions being practiced in their households finally participants had to report that over 50 of their friends while growing up and over 40 of their neighborhood while growing up were of european american background asian american participants had to selfreport their ethnicity as asian or east asian and have been born either in an east asian country or in the united states south asian participants from countries such as india pakistan or bangladesh were not eligible in addition participants parents and grandparents also had to meet the same birthcountry requirements furthermore participants had to be conversant though not fluent in both english and in the asian language of their culture of origin there were no religious criteria for the asian american participants the criteria around childhood friends and neighborhood were also not applied to this group while the original criteria were developed for participants living in a large metropolitan area where exposure to culturally similar others is common this assumption would have been an unrealistic standard for the east asian and asian american participants in the community from which participants in the current study were sampled procedure data used for the present study were collected as part of a large multimethod project investigating cultural differences in the experience and regulation of physiological behavioral and selfreported responses to emotional stimuli upon arriving at the lab room participants signed the informed consent form and sat in a comfortable chair 3 feet away from a 19 lcd monitor participants completed a series of questionnaires including measures of emotion depression life satisfaction collective selfesteem the importance of their racial group membership to their identity and other measures outside of the scope of the present study after this point an experimenter of the same gender applied the physiological sensors to participants participants then watched a total of five film clips previously used in emotion regulation research while their facial and physiological responses were collected after each film participants completed a selfreport measure of emotion all films were between 52 and 62 s in duration with the exception of the first film which lasted 22 s film 1 was the same across all participants and was a neutral film films 24 were disgust films the first disgust film always depicted an eye operation and was not associated with any specific emotion regulation instructions the next two films were of a burn victims skin graft and an arm amputation and participants were asked to either amplify or suppress their emotional expression while viewing the films the order of regulation instructions and the actual film presentation for films 3 and 4 were counterbalanced film 5 was a slightly positive film used to help participants recover from negative emotions induced by previous films see soto et al for more detailed information about the methods and procedures the fact that this convenience dataset consisted only of neutral relaxing and disgust elicitors limited the scope of our emotional fit variable however given that disgust reactivity does not tend to vary greatly across cultures we also thought this would provide a more conservative test of our research question pertaining to cultural moderation in addition examining emotional fit in response to neutral stimuli may provide important information that has been hitherto unexamined given that neutral stimuli are often processed similarly as negative stimuli especially so among clinical populations thus responses to the neutral stimuli could reflect individual differences in responding that could lead to variability in emotional fit that may be meaningfully related to wellbeing outcomes the present study examined emotional fit at the first three time points prior to the introduction of emotional regulation instructions emotional fit at baseline emotional fit in response to neutral film and emotional fit in response to the disgust film we did not include time points after emotion regulation instructions were presented because the impact of these instructions on emotional fit is outside of the scope of the present study because the collection of behavioral and physiological data began with the introduction of neutral film baseline response consisted of the selfreport measure of emotion only responses to neutral film and disgust film consisted of selfreport behavioral and physiological responses measures satisfaction with life scale participants completed a fiveitem measure of life satisfaction the swls assesses global judgments of satisfaction with ones life participants are asked to rate their responses to questions such as in most ways my life is close to my ideal and the conditions of my life are excellent using a 7point likert scale higher scores indicate greater satisfaction with life the swls has shown good internal consistency in previous studies with alpha coefficients ranging from 079 to 089 cronbachs alpha coefficients in the current sample were 079 for asian americans and 084 for european americans indicating acceptable to good reliability center for epidemiologic studies depression scale the cesd is a 20item selfreport inventory of depressive symptoms participants use a 4point likert scale to rate the degree to which they experienced over the past week major symptoms of depression including depressed mood feelings of guilt and worthlessness feelings of helplessness and hopelessness psychomotor retardation loss of appetite and sleep disturbance higher scores indicate greater depressive symptoms the cesd has shown good internal consistency with alpha coefficients ranging from 085 to 090 in previous studies in the current study the cesd also indicated good internal consistency with an alpha coefficient of 085 for both asian americans and european americans collective selfesteem scale private collective selfesteem and importance to identity subscales the 4item private collective selfesteem and 4item importance to identity subscales of the cses were used to measure participants positive collective identity and identification with their group the private collective selfesteem refers to ones evaluation of how good ones ethnic group is importance to identity assesses how important ones ethnic group is to ones self concept the public collective selfesteem and membership esteem subscales were not included because they were less relevant to the focus of the present study participants use a 7point likert scale to rate their collective selfesteem higher scores indicate greater collective selfesteem the original validation study reported alpha coefficients ranging from 073 to 085 indicating acceptable to good internal consistency in the current sample the private collective selfesteem subscale indicated acceptable internal consistency with alpha coefficients of 079 for asian americans and 072 for european americans the alpha coefficients for the identity subscale were 079 and 086 for asian americans and european americans respectively indicating acceptable to good internal consistency multidimensional inventory of black identity centrality subscale to assess the degree to which participants identify with their ethnic group we used the 8item centrality subscale of the mibi the centrality subscale of the mibi assesses a broader concept of group identification than the cses identity subscale in addition to assessing the degree to which ethnic group membership is central to ones core selfconcept the mibi centrality scale also captures participants sense of connectionbelonging to other members of their ethnic group because the items in the original mibi were developed for african americans only we modified the wording of items to accommodate other ethnic groups as well items include overall being of my racial group has very little to do with how i feel about myself and i have a strong sense of belonging to people of my racial group this modification has been used previously with ethnic minority groups other than african americans participants rated their response using a 7point likert scale and higher score indicated greater importance of racial group membership to their identity the internal consistency of the centrality subscale of the mibi was 077 in the original validation study which indicates acceptable consistency the current sample also indicated acceptable consistency with alpha coefficients of 079 and 077 for asian americans and european americans respectively selfreported emotional experience at six different time points throughout the experiment participants were asked to use a 9point likert scale to rate their current experience of 16 different emotions interest happiness surprise amusement contentment relief anxiety sadness annoyance disgust embarrassment boredom fear anger contempt and stress this rating scale has been used to measure the experience of specific emotions in previous emotion research facial emotional expression participants facial expressions during the presentation of films were video recorded and then coded into six discrete emotions using the commercial face reading software facereader v 61 facereader objectively estimates the presence of emotion expressions by utilizing over 500 facial landmark cues typically present in emotion expressions as well as specific action units as defined by paul ekmans facial affect coding system for each video frame facereader supplies a confidence score between 0 and 1 representing the likelihood that each discrete emotion is present facereader was trained on over 10000 expertcoded images and has demonstrated high accuracy for emotion expression classification for the present study we averaged confidence estimates for the presence of each emotion expression over the 1min film presentation period this resulted in six scores per film clip per participant representing the average likelihood that each of the emotions were present over the films presentation physiological response electrocardiography and skin conductance level were recorded using a mindware impedance cardiograph in conjunction with the biopac mp150© device consisting of an eightchannel polygraph and a microcomputer all physiological data were collected secondbysecond using acqknowledge© software ekg which provides a measure of cardiac activity was measured through three biopac pregelled selfadhering disposable electrodes placed at three places on the torso the right clavicle at the midclavicular line just above the last bone of the ribcage at the left midaxillary line and just below the last bone of the ribcage at the right midaxillary line cardiac impedance was collected with four selfadhering electrodesone placed at the suprasternal notch one at the inferior end of the sternum and two on the back mindware impedance cardiography and mindware hrv 251 software were used to clean raw data and extract the systolic time intervals and heart rate variability using spectral analysis clear artifacts in ekg data were deleted and excluded from analyses in addition scl was measured using two disposable electrodes filled with isotonic recording gel that were placed on the middle phalange of the second and fourth fingers of the nondominant hand while indicators of both sympathetic and parasympathetic nervous system arousal can be obtained from analysis of physiological data the present study focused on the pattern of sns arousal sns indices include hr cardiac output stroke volume left ventricular ejection time cardiac impedance preejection period and scl hr is the number of contractions of the heart per minute co is a measure of the overall volume of blood being pumped by the heart per minute sv represents the volume of blood ejected by the left ventricle of the heart in one beat lvet is a measure of myocardial contractility zo is an indicator of blood flow through the thoracic cavity pep is an indicator of sympathetic myocardial drive and indicates the interval between onset of the ekg qwave and onset of the left ventricular ejection scl is an index of sweat gland activity at the surface of the skin emotional fit indices following a calculation method used in previous studies of emotional fit with culture three types of emotional fit with individuals own culture were calculated using selfreport emotion ratings behavioral responses and physiological responses the means and variances of all variables used to calculate emotional fit are presented in table 1 in order to calculate selfreport emotional fit we first calculated the groups average rating for each of the 16 different emotions excluding the respondents own scores which constituted the groups average emotional profile we then correlated each individuals emotional profile consisting of 16 emotions to the groups average emotional profile the derived correlation coefficients were fishers ztransformed in order to achieve a normal distribution of data the final correlation coefficient for each individual served as selfreport emotional fit score the degree to which individuals emotional profile resembles the normative emotional profile of ones group this process was repeated three times for each of the three time points resulting in three separate selfreport emotional fit scores for times 0 1 and 2 behavioral emotional fit was calculated using the facial expression data six emotions used for behavioral emotional fit were happiness sadness anger surprise fear and disgust following the same procedure as selfreport emotional fit the groups average behavioral emotional profile was derived from the groups average score on each of the six different emotions excluding the respondents own scores then the groups emotional profile was correlated to each individuals emotional profile and the fishers ztransformation was applied this process was repeated two times each using the responses to films 1 and 2 resulting in two separate behavioral emotional fit scores for each individual in times 1 and 2 for calculating physiological emotional fit we used seven different indices of sympathetic activation collected during the first two films these were hr co sv lvet zo pep and scl among these zo and pep decreases as sns activity increases thus zo and pep indices were reverse coded by multiplying them by 1 so that the increase in number would indicate greater sns arousal in addition each of these indices were originally on different scales therefore we standardized the scores using the formula which transformed the data into a 01 scale the rest of the process of calculating emotional fit was identical to that of selfreport and behavioral emotional fit we first calculated the groups average scores for each of the seven sympathetic indices while excluding the respondents own score and used it as the groups average emotional profile this was correlated to individuals profile of physiological responses the correlation coefficients were then fishers ztransformed the process was repeated two times for each individual using the responses to films 1 and 2 which resulted in two separate physiological emotional fit scores for each individual in times 1 and 2 results dataanalytic approach to test the link between participants wellbeing and emotional fit and whether culture moderates this link we conducted a series of multiple regression analyses in these analyses emotional fit variables were always entered as step 1 followed by culture in step 2 and the interaction between emotional fit and culture in step 3 to test for the hypothesized moderation of culture on the link between emotional fit and wellbeing when significant interactions between emotional fit and culture emerged the identified interaction effects were decomposed using a simple slopes analysis in addition based on prior evidence suggesting gender differences in response to disgust we examined the effects of gender on the emotional responses to the disgust film and our indices of emotional fit some gender differences emerged across specific facial expressions in response to disgust and behavioral emotional fit also varied significantly by gender 1 1 we explored gender differences in selfreported behavioral and physiological responses to the disgust film selfreported emotions in response to the disgust film did not differ by gender ps 005 similarly there were no significant gender differences in facial expressions of disgust anger and fear in response to the disgust film ps 005 however males showed more happiness expressions than females t 235 p 0023 while females showed more expressions of surprise t 291 p 0005 and sadness t 296 p 0004 relative to males looking at physiological responses males showed greater scl responses than females t 244 p 0017 but there were no other significant gender differences across the remaining physiological indices ps 005 we also examined whether emotional fit differed by gender there were no gender differences in selfreport emotional fit at all three time points as well as physiological emotional fit at the two available time points ps 005 however there were significant gender differences in behavioral emotional fit indices at both times 1 and 2 such that males showed greater behavioral emotional fit than did females t 224 p 0027 t 278 p 0006 for times 1 and 2 respectively given these gender differences in facial expressions in response to disgust film as well as in behavioral emotional fit we included gender as a covariate in the regression models testing the effect of behavioral emotional fit on outcome variables this did not change any of the reported patterns of results and therefore these analyses were not included in the manuscript given that examination of gender was outside of the scope of the present study as a result we reran our regression models controlling for gender and this did not change any of our reported findings therefore we report the models without gender for the sake of parsimony in reporting of the results we focus on the main effect of emotional fit in step 1 and interaction between emotional fit and culture in step 3 correlations between emotional fit and wellbeing variables and descriptive statistics are presented in table 2 for our primary analyses we chose not to correct the alpha level to preserve power and because we were testing a priori hypotheses and only conducted five regressions to test two questions for the exploratory analyses we employed the bonferroni correction given the large number of tests conducted in all we tested how three types of fit relate to two types of outcomes using a total of 30 regressions relating to variations in the specific outcome variables and time points considered thus the adjusted pvalue of 0002 was used to reevaluate any of the significant findings that emerged from analysis using an uncorrected pvalue we chose to present the results of the test both before and after the bonferroni correction given the recommendation that corrections for multiple comparisons also has the drawback of reducing power selfreport emotional fit we first examined the link between selfreport emotional fit at time 0 and individual wellbeing variables and whether culture moderated this relationship there was a significant main effect of ef t0sr on depression with higher emotional fit predicting reduced depression β 545 t 391 p 0001 as predicted the interaction means with asterisks significantly differ between groups p 005 p 0001 between ef t0sr and culture on depression was not significant similarly a significant main effect of ef t0sr was found in predicting life satisfaction such that higher emotional fit predicted greater life satisfaction β 329 t 305 p 0003 as hypothesized culture did not moderate this relationship either next we tested the link between selfreport emotional fit at the remaining time points and individual wellbeing variables the results were largely consistent with time 0 findings there was a significant main effect of selfreport emotional fit at time 1 on depression such that higher emotional fit predicted reduced depression β 426 t 321 p 0002 there was a significant main effect of ef t1sr on life satisfaction with higher emotional fit predicting greater life satisfaction β 250 t 244 p 0016 the same pattern of results emerged with selfreport emotional fit at time 2 there were significant main effects of ef t2sr on both depression and life satisfaction β 356 t 219 p 003 β 275 t 224 p 0027 respectively after applying a bonferroni correction to these exploratory analyses at times 1 and 2 only the relationship between ef t1sr and depression remained significant culture did not moderate any of the associations between selfreport emotional fit at t1 and t2 and individual wellbeing next looking at the effects of emotional fit on collective aspects of wellbeing there was a significant main effect of emotional fit at time 0 on collective selfesteem with higher emotional fit predicting greater collective selfesteem β 164 t 243 p 0017 as hypothesized this main effect was qualified by a significant interaction between ef t0sr and culture β 279 t 208 p 004 a followup simple slopes analysis revealed that the simple slope of the regression of collective selfesteem onto ef t0sr for asian americans was significant t 320 p 0002 with higher ef t0sr predicting greater collective selfesteem in european americans the relationship between collective selfesteem and ef t0sr was nonsignificant t 028 p 0779 these findings were specific to time 0 emotional fit there were no significant main effects of ef t1sr and ef t2sr on collective selfesteem and no cultural moderation was found at these additional time points the effects of emotional fit on measures of how important ones ethnicity is to ones own selfconcept were nonsignificant across all three time points that is ef sr in times 1 2 and 3 did not predict either cses identity or racial centrality and there was no cultural moderation all ps 005 additional indices of emotional fit next we explored whether behavioral and physiological indices of emotional fit predicted individual and collective aspects of wellbeing both behavioral emotional fit at time 1 and time 2 did not predict any of the outcome variables and there was no interaction between ef beh and culture looking at physiological indices of emotional fit there was no main effect of physiological emotional fit at time 1 on any of the outcome variables and no cultural moderation was found similarly there was no main effect of physiological emotional fit at time 2 on any of the outcome variables however there was a marginally significant interaction effect between ef t2phy and culture in predicting racial centrality β 403 t 192 p 0058 a followup simple slopes analysis indicated that the simple slope of the regression of racial centrality onto ef t2phy for asian americans was significant t 209 p 004 with higher ef t2phy predicting greater racial centrality in contrast the simple slope was nonsignificant in european americans t 032 p 0753 this marginally significant interaction became nonsignificant when the bonferroni corrected pvalue was applied discussion the present study examined the association between emotional fit and individual and collective aspects of wellbeing and the role of culture in this relationship emotional fit based on selfreport ratings of emotions significantly predicted individual wellbeing including reduced depression and greater life satisfaction in both asian americans and european americans in contrast selfreport emotional fit in the absence of laboratory stimuli predicted collective aspects of wellbeing particularly collective selfesteem only in asian americans in addition emotional fit based on physiological response to a strong negative stimulus predicted greater identification with ones group only in asian americans though this cultural moderation was only marginally significant in the initial test and disappeared when the bonferroni correction was applied selfreport emotional fit emotional fit based on selfreported emotions in all three timepoints was associated with individual wellbeing across cultures this finding is in line with the view that while there may be different cultural mandates for wellbeing in interdependent and independent cultures being in alignment with ones own cultural norms around emotion is generally important for individual wellbeing across cultures it has been shown that even though different emotions are preferred in japan and the united states the experience of culturally preferred emotions was associated with happiness in both cultures in a similar vein experiencing a culturally normative pattern of emotions has been found to be important for psychological wellbeing in both independent and interdependent cultures although the specific contexts in which emotional fit becomes crucial varies depending on respective cultural values because peoples emotions are shaped by how they perceive and appraise their environment their fit with the average emotional pattern of others in the same culture may represent their level of sharing and participating in the predominant worldview of that culture thus emotional fit to a certain extent may reflect a general level of social adjustment which may have universal implications for ones psychological wellbeing while we have conceptualized the above relationship as one where emotional fit with ones group might lead to increased wellbeing we can also consider the pathway in which individual wellbeing leads to increased emotional fit for instance the cultural norms hypothesis of depression suggests that the symptoms of depression may impair individuals abilities to attend to and enact cultural norms and ideals regarding emotion and emotional expression indeed it has been demonstrated that depressed individuals showed lower emotional fit with their cultural group than did nondepressed individuals these findings demonstrate that perhaps individuals who have lower wellbeing and greater depression may have more difficulty responding in a culturally concordant manner as such more research is needed in order to establish the directionality of the relationship between emotional fit and wellbeing in contrast to the individual wellbeing findings culture moderated the relationship between selfreport emotional fit and collective identity particularly individuals evaluation of their own cultural group in asian americans greater emotional fit predicted more positive evaluation of their own cultural group whereas such a relationship was not present in european americans people generally experience similarity as safe and comforting and similarity leads to greater liking this may be especially so in cultures where social harmony and conformity are greatly valued and practiced previous research has shown that people in collectivistic societies conform more than those in individualistic societies it is possible that this greater importance of similarity in east asian cultures leads to greater liking or more positive evaluation of the group that one also shares an emotional response pattern with alternatively individuals may be more motivated to behave consistently with the group when they feel positively about their own cultural group it is possible that we see this pattern only in asian american individuals because conformity in general is practiced more in collectivistic than individualistic societies on the other hand the inconsistency between ones own emotions and the modal emotional pattern of ones culture may be more selfthreatening in interdependent culture negative evaluation of a group that is seen as dissimilar to oneself may represent an attempt to reconcile this threat to self by degrading dissimilar others and in turn preserving or enhancing the self alternatively however the experience of dissimilarity may lead to negative evaluation of both the individual and group in interdependent cultures extensive research on interdependent selfconstrual in interdependent cultures suggests that there may be a greater overlap between individual and collective selves in asian cultures although the evaluation of individual self was not measured in the current study it is possible that reduced fit with other asian americans led to more negative evaluations of the individual self which in turn spilled over to the evaluation of their collective self in addition to the possible role of interdependence and collectivist values in the present findings the role of asian americans position as a racial minority group in the united states cannot be ignored for instance the status of a racial minority and the repeated experience of being marginalized may have led asian americans to seek belonging and to place a greater value on the group through which they can fulfill such a need as such asian americans who share emotional similarity to the members of their cultural group may be able to more readily satiate their need for belonging through their group membership and in turn evaluate their group more positively additionally because a minority often experiences being perceived as representing ones broader minority group as a whole asian americans may be more aware of and sensitive to how their individual behavior reflects on outside perceptions of their group as a whole in the presence of this heightened sense of prescribed connection between their own behaviors and the outside perception of their group asian americans may experience the group with which they share emotional similarity less effortful to represent and thus leading to greater liking or more positive evaluation interestingly the results relating to selfreport emotional fit and collective selfesteem were specific to emotional fit at baseline before any specific laboratory stimuli were presented this could be because reflective responses to a strong emotional stimulus may override individual or cultural variability in emotional patterns leading to too little variability in emotional fit indices which in turn may limit the possibility of identifying any meaningful patterns between emotional fit and outcome measures in fact the variance in selfreport emotional fit was lowest in time 2 when the fit was measured in response to a strong negative stimulus the pattern of results regarding individual wellbeing is somewhat consistent with this point as well while the effect of selfreport emotional fit on individual wellbeing was observed at all three time points the magnitude of effect decreased from emotional fit at time 0 to time 1 and to time 2 and some of the times 1 and 2 effects were eliminated when employing the bonferroni correction additional indices of emotional fit another aim of this study was to explore whether any of the effects found with selfreport emotional fit is replicated with other indices of emotional fit such as behavioral and physiological emotional fit we did not find the comparable patterns of results with other indices of emotional fit which is consistent with the dualprocess perspective suggesting that there is little response coherence between reflective and automatic emotion systems in addition indices of emotional fit at different levels were largely uncorrelated to each other although emotional fit indices within the same level were generally related to each other behavioral emotional fit in response to both neutral and disgust films did not predict any individual and collective aspects of wellbeing similarly physiological emotional fit in response to the neutral film did not predict any of the outcome variables however a marginally significant interaction pointed to a pattern consistent with our prediction such that higher physiological emotional fit in response to disgust film was associated with greater racial centrality in asian americans whereas there was no such relationship in european americans in other words the perceived level of group identification was mirrored in greater individualgroup synchrony in automatic responses to a strong emotional situation in asian americans it is conceivable that when members of interdependent culture identify with their group their collective identity gets deeply internalized to the point that this is reflected in a greater physiological concordance with their group members this result however became nonsignificant after employing the bonferroni correction given the small sample size we believe this finding may nevertheless be worth testing in future studies especially since we observed the similar pattern found in the primary analyses although only in response to a strong negative stimulus future studies aiming to measure physiological emotional fit may note that in the absence of a stimulus to respond there may be too much variabilityphysiological noise across subjects to be able to calculate a meaningful fit index however the introduction of a punctate stimulus may organize the physiological system enough to be able to calculate the fit indices discussed the variance in physiological emotional fit in time 1 was considerably greater than that of time 2 which further support this possibility thus while these findings are not robust they are suggestive of a possible future direction to pursue when there is adequate power to test the hypothesis limitations and future directions the current study has a few important limitations that are worth noting first while we used data from previous study that allowed us to also explore behavioral and physiological emotional fit in addition to selfreport emotional fit we did not have behavioral and physiological emotional fit indices at time 0 thus we cannot know whether our selfreport emotional fit findings from time 0 will be corroborated with behavioral and physiological emotional fit measured in the same context in addition the choice of emotion elicitors was restricted by the nature of convenience dataset in particular given that disgust may be an emotion with the least cultural variability the use of the disgust film at time 2 allowed for a more conservative test of our research question but also may have underestimated the impact of emotional fit future studies employing varying indices of emotional fit across diverse emotional contexts are needed for a more indepth investigation into the effects of emotional fit second our study is crosssectional and thus cannot answer questions regarding the directionality in the observed links between emotional fit and wellbeing additionally the design of the current study does not allow us to explore the specific mechanisms underlying the relationship between emotional fit and wellbeing as well as the cultural moderation observed in predicting collective aspects of wellbeing important next steps would be to examine the causality in the link between emotional fit and wellbeing through a longitudinal design or a laboratory experiment where emotional fit is manipulated and through what processes such causal effects emerge third it will be important to replicate these results in east asians residing in east asian countries to disentangle the potential role of interdependence with that of being a minority experience in the current finding fourth careful studies examining gender effects on emotional fit would also be a fruitful avenue of future research based on the observed gender differences in behavioral emotional fit it may be worth examining genderspecific emotional fit and how it relates to wellbeing lastly prior studies examining emotional fit using the same profile correlation approach have used a relatively larger sample compared to the current study the relatively small size of the current sample especially in regard to exploratory analyses with physiological emotional fit may have limited our ability to detect significant relationships between primary variables of interest although this preliminary result is interesting future studies using a larger sample should further examine this finding to draw more meaningful conclusions conclusion individuals must constantly navigate through their social worlds while paying simultaneous attention to both their individual needs and behaviors and the needs and behaviors of those around them however the extent to which individual and group behaviors fit with each other can vary meaningfully across cultural groups as can the relationship between this fit and wellbeing the present study revealed that emotional fit based on individuals subjective emotional experience predicted individual wellbeing across cultures but predicted collective selfesteem only in asian americans being the first study to examine the relationship between emotional fit and collective aspects of wellbeing the current finding adds to the growing research attempting to understand emotions as social and interpersonal processes that are naturally imbedded in cultural contexts we believe this underscores the need to consider not only how emotions may conform to normative patterns in ones cultural milieu but that this degree of fit may impact members of different cultures in different ways ethics statement this study was carried out in accordance with the recommendations of the american psychological associations ethical standards with written informed consent from all subjects all subjects gave written informed consent in accordance with the declaration of helsinki the protocol was approved by the penn state universitys institutional review board conflict of interest statement the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest

the present study examined how emotional fit with culture the degree of similarity between an individual emotional response to the emotional response of others from the same culture relates to wellbeing in a sample of asian american and european american college students using a profile correlation method we calculated three types of emotional fit based on selfreported emotions facial expressions and physiological responses we then examined the relationships between emotional fit and individual wellbeing depression life satisfaction as well as collective aspects of wellbeing namely collective selfesteem ones evaluation of ones cultural group and identification with ones group the results revealed that selfreport emotional fit was associated with greater individual wellbeing across cultures in contrast culture moderated the relationship between selfreport emotional fit and collective selfesteem such that emotional fit predicted greater collective selfesteem in asian americans but not in european americans behavioral emotional fit was unrelated to wellbeing there was a marginally significant cultural moderation in the relationship between physiological emotional fit in a strong emotional situation and group identification specifically physiological emotional fit predicted greater group identification in asian americans but not in european americans however this finding disappeared after a bonferroni correction the current finding extends previous research by showing that while emotional fit may be closely related to individual aspects of wellbeing across cultures the influence of emotional fit on collective aspects of wellbeing may be unique to cultures that emphasize interdependence and social harmony and thus being in alignment with other members of the group

building a human reference atlas andreas bueckle indiana university bloomington indiana united states the human reference atlas is a comprehensive highresolution threedimensional atlas of all the cells in the healthy human body the hra provides standard terminologies and data structures for describing specimens biological structures and spatial positions linked to existing ontologies in this talk we will present a highlevel overview of the major components of the hraincluding 67 anatomically correct 3d reference objects for 29 organs and 31 anatomical structure cell types and biomarker tablesand the tools to explore use author and review the hraincluding the registration user interface the exploration user interface the asctb reporter and the hra organ gallery in virtual reality we welcome experts and practitioners to join the monthly wg meetings to explore and contribute to this effort and to provide feedback on the evolving hra from diverse perspectives session 4205 abstract citation id igad1041557 findings from nshap social connectedness health indicators medication effects and predicting mortality chair lissette piedra discussant amelia karraker the national social life health and aging projects broad range of both social measures and objective and selfreported health measures enable detailed analysis of the intersections between these fundamental aspects of older adults lives the papers in this symposium explore various aspects of these topics from different angles the first explores employment as an important form of social participation establishing that fulltime employment among respondents is associated with better cognitive function and less adl and iadl difficulties the second examines how social isolation affects men and women differently social networks are the focus of the third paper and compare family to friendship ties using nshaps unique medication log wilder examines sleep disturbances and the prevalence of respondents taking medications with somnolence as an adverse event demonstrating the need for more research into how this might affect older adults health and wellbeing li uses nshap data to develop machine learning models to predict 10year mortality of older adults in the us which perform with better accuracy than logistic regression abstract citation id igad1041558 employment as a form of social participation among older adults links to cognitive and functional health peilin yang 1 linda waite 2 and ashwin kotwal 3 1 university of michigan ann arbor ann arbor michigan united states 2 university of chicagochicagoillinoisunited states3 university of california san franciscosan franciscocaliforniaunited states within the active aging literature studies on social participation and health concur that people who are better socially integrated and engage in social activities tend to have better physical mental and cognitive health this study revisits the literature by aiming to address three primary knowledge gaps in prior literature 1 we explicitly examine the change within the 5yearinterval in cognition activities of daily living instrumental activities of daily living associated with social participation five years prior 2 we examine diversity in participations association with not only cognitive function but also adl and iadl which we lack knowledge of 3 we conceptualize employment in later life as a kind of social participation a part of older adults lives that is overlooked in the social participation literature we also examine whether the relationship between social participation and cognition adl and iadl is the same for men and women and for those employed and those not employed the study finds that neighborhood participation at a high level indicates worse cognitive adl and iadl outcomes 5 years later and a higher level of neighborhood participation is more indicative of worse cognitive outcomes for men than for women fulltime employment predicts better cognitive adl and iadl outcomes 5 years later we also find evidence that fulltime work creates a stronger buffer against cognitive decline developing adl difficulties and iadl difficulties even among older adults who socialize with family and friends participate in the community and the neighborhood at a high level respectively abstract citation id igad1041559 selfneglect among older adults is characterized by inattention to hygiene and ones immediate living conditions and may reflect unmet needs from social relationships we therefore determined if social isolation was associated with selfneglect and how the association differed by gender we used data from the national social life health and aging project wave 3 a nationallyrepresentative survey of 3677 communitydwelling older adults social isolation was determined using a 12item scale assessing household contacts social network interaction and community engagement selfneglect was assessed inperson and included 1 body neglect and 2 household neglect logistic regression was used to determine the adjusted probability of selfneglect by social isolation and interaction terms with gender results indicated the association between social isolation and selfneglect differed by gender among women social isolation was associated with a higher risk of body neglect and household neglect for men social isolation was not associated with body neglect or household neglect in summary social isolation was associated with body and household neglect among women but was not associated with neglect among men future work should investigate mechanisms for gender differences and interventions to address or prevent selfneglect through enhancing social connectedness the relationship of social isolation to selfneglect among older adults results of a national survey abstract citation id igad1041560 local family and friend ties and their relationship to social support and strain among older adults won choi university of chicago chicago illinois united states family members and friends who live nearby are likely valuable sources of support for older adults at the same time local family and friend ties may also be a source of strain as spatial proximity to close ties can generate more intense interactions using data from round 3 of the national social life health and aging project this study examines how local family and friend ties reported in older adults social network roster are associated with instrumental and emotional support and social strain among communitydwelling older adults aged 50 and older results from ordered logistic regression models show that having a local friend tie is associated with higher levels of instrumental and emotional support from friends and lower levels of instrumental and emotional support from family having a local family tie on the other hand is associated with higher levels of instrumental support from family and lower levels of emotional support from friends having a local family tie is not related to emotional support from family or instrumental support from friends results also indicate that having a local friend tie increases the odds of reporting that friends make too many demands whereas having a local family tie is not a predictor of family strain together results suggest that spatial proximity to friends and to a lesser degree family members are linked to how older adults experience social support and strain abstract citation id igad1041561 use of prescription medications with somnolence as a potential adverse effect among older adults in the united states jocelyn wilder norc chicago illinois united states over half of communitydwelling older adults experience sleep disorders with approximately 40 reporting somnolence orand excessive daytime sleepiness associated with an increased risk for cognitive impairment and premature mortality the use and concurrent use of prescription medication with somnolence as an adverse effect may be an overlooked contributor to this growing problem this study aims

nih sennet consortium aims to dissect the heterogeneity of senescent cells sncs and map their impact on the microenvironment at a single cell resolution and in the spatial tissue context which requires the implementation of an array of omics technologies to comprehensively identify characterize and spatially profile sncs across tissues in humans and mice these technologies are broadly categorized into two groups single cell omics and spatial mapping to achieve single cell resolution and overcome the scarcity of sncs highthroughput singlecell and singlenucleus transcriptomic techniques have become a mainstay tool for surveying tens of thousands of cells to identify transcriptional signatures in rare cell populations enabling discovery of potential new snc biomarkers novel single cell mass spectrometry methods are developed for unbiased discovery of proteomic signatures of sncs a hallmark of sncs is the senescenceassociated secretory phenotype sasp which requires the use of proteomics secretomics metabolomics and lipidomics especially saspassociated extracellular vesicles for comprehensive characterization of saps high resolution molecular and cellular imaging of gene expression eg merfish or protein markers eg codex is critical for the study of sncs in the largescale tissue context ngsbased spatial omics sequencing is poised to bridge the gap to realize both genome scale and cellular resolution in mapping sncs in tissue novel technologies such as seqscope and pixelseq developed within sennet further enabled subcellular resolution sennet investigators also developed spatially resolved epigenome and multiomics sequencing techniques to link transcriptional or proteomic phenotype of sncs to epigenetic mechanism further integration with highresolution imaging makes spatial omics the crucial linchpin in connecting mechanistic underpinnings and molecular signatures with morphological features and spatial distribution all these are critical for the construction of a map of sncs and associated niches in the native tissue environment implicated in human health aging and disease which is one of the main goals of the sennet consortium

the reproductive approach has achieved astounding successes very quickly and promises to continue to advance exponentially where being able thanks to ai toolsto do reprogramming helped managing the deluge of data associated with the project1 in so many areas reproductive ai is better and tends to replace human intelligence because it is faster more reliable and more consistent in its results the absolute reliability of ai in standardized tasks is probably the main difference with a human operator while the latter may manifest greater degrees of freedom in task execution automated systems guarantee unambiguous infinitely repeatable performance without fluctuations this is also a cultural feature that cannot be overlooked when considering the labour market and industrial production indeed one can identify a characteristic sought by both the supply side and the demand side namely the desire for a product that is perfect insofar as it is not limited or influenced by human imperfections the delegation to a dumbas floridi calls itbut exceptionally effective ai allows us to make our lives much easier and less tiring ai as a reservoir of capabilities can therefore tackle any number of problems and tasks for which human intelligence characteristics of understanding awareness sensitivity semantics and meaning are not needed and this happens as proposed by floridi among others as the world adapts to reproductive ai and not vice versa industrial automation follows this paradigm the introduction of robots or devices that carry out the production and distribution processes with reduced human intervention or diminishing participation is done by circumscribing the work environment to the limited capabilities of simple machines we dont try to build a humanoid robot to wash clothes in a bathtub but build a microenvironment that takes advantage of available technology the same happens with automated ironing this changes not only the way people work towards the realization of these activities but also the products for which the services are designed we are talking here about technologies that are not cuttingedge where ai plays a limited role consider however other procedures such as house cleaning robot vacuum cleaners take advantage of ai to move with increase effectiveness in complex environments however it is clear that it will soon be the design of homes that will adapt to automated service systems especially with the needs of the elderly in mind if robotic assistants become more prevalent for lonely people the selfdriving car may be one example among the hightech ones where engineering ai is the absolute protagonist the selfdriving car does not start out as a classic selfdriving car that is adaptable to different road locations and can if need be travel on unpaved terrain or in adverse environmental conditions such as a blackout of lighting and electronic signage the selfdriving car comes with specific requirements due to ai technology that allows the vehicle to move without a human driver it must move in an environment that allows it to have all the feedback necessary for the efficient execution of its task which is to move from point a to point b with maximum safety and comfort of the passengers and all who may be in its path this can be accomplished by engineering the roads making them suitable for the selfdriving car it is not the car that has to adapt to the environment but it is the environment that is wrappedaround a tool that we find particularly useful in terms of saving effort time and traffic accidents paradoxically at an early stage selfdriving cars will have a narrow range of available destinations and thus condition the mobility of those who want to rely on them for instance robotaxis can only circulate on a few streets in san francisco or in very small cities in general wrapping the environment in an infosphere has become an increasingly common practice to exploit the potential of ai where the infosphere is the whole system of services and documents encoded in any semiotic and physical media whose contents include any sort of data information and knowledge with no limitations either in size typology or logical structure hence it ranges from alphanumeric texts and multimedia products to statistical data from films and hypertexts to whole textbanks and collections of pictures from mathematical formulae to sounds and videoclips connected to the infosphere is the onlife dimension ie the activity that everyone performs while being connected to digital devices which are also embedded in the wrappingaround logic we referred to above environments are changing so that artificial agentsrobots bots algorithmscan move with greater ease than humans can now do in highly digitally wrapped environments all relevant data are collected and analysed without the need for other interventions thus decisions and actions can be made automatically by applications and actuators in this context consider the process of datafication which is illustrative of many of the ideas discussed above datafication according to mayer schoenberger and cukier 1 3 is the transformation of social action into online quantified data a procedure that allows for realtime tracking and predictive analysis of consumers behaviors simply stated datafication is all about accessing with the help of ai tools previously inaccessible processes or activities and turning them into data that can be subsequently monitored tracked analyzed and optimized or even sold to be sure the exploitation of big data can unlock significant value in areas such as decision making customer experience market demand predictions product and market development and operational efficiency and many of the technologies we use in our daily life have enabled different ways of datafying our basic activities and behaviors social networks notoriously collect and monitor data information to market products and services with the intent to produce recommendations to potential buyers yet datafication is a much more pervasive phenomenon than the naïve eye may prima facie meet as it is actively pursued by many industries for example • by insurance companies where the data gathered is used to update risk profile development and business models • by banks to establish the trustworthiness of a certain individual requiring for examplea loan • by human resources and hiring managers at various level which use datafication to identify risktaking profiles or even to spot potential personality issues • by governments and institutions where datafication and digitalization are often pursued with the intent of minimizing bureaucracy and optimizing transparency in both decision making and resource allocation • by investors worldwide to boost business opportunities credentials and productivity for example very successful companies typically merge the resourcefulness of big data with the power of ai to offer their users products that are smart and reliable in short one can argue that datafication especially if pursued in an infospherecan make our lives smoother and in doing sofundamentally change our societies how people interact between each other and with their institutions and probably even transform peoples understanding of the concept of community as a whole nevertheless in the face of these positive effects any datadriven endeavor that takes place in an infosphere must also be considered against the backdrop of complex and multidimensional issues or challenges that it may contribute to form concerning for instancedecisionmaking processes social solidarity privacy security the management of public goods of civil liberties or even sovereignty for example in the health care sector concerns about the datafication of the infosphere relate to the difficulty of respecting ethical boundaries relating to sensitive data datafication it has been argued has the potential to erode goal orientation and the room for professional judgement favoring varieties of neoliberal subjectification in the form of tools that may accelerate the withdrawal of the welfare state from citizens lives which can eventually turn health care into selfcare in the education sector the major risk involved is that students may feel constantly under liquid surveillance due to the continuous collection and processing of their data on all levels of their learning trajectory in the educational system this it has been observedcan potentially lead to a reduction of their creativity andor in higher levels of stress thus while wrapping up environments to harness the potential of ai represents a good way to improve humans condition the future of our lives is marked by datafication which may actively modify our environments in the attempt to achieve more effectiveness and efficiency the modification of work processes pursued within the infosphere of an increasingly datafied society has several consequences while many researchers have investigated the consequences of datafication in separate fields not much work has been done so farto bring all these insights together in one research paper this is what we propose to do in our contribution specifically we show that datafication in a rich infosphere may determine that the full protection of privacy may become structurally impossible thus leading to undesirable forms of political and social control workers degrees of freedom and security may be reduced creativity imagination and even divergence from ai logic might be channeled and possibly discouraged there will likely be a push towards efficiency and instrumental reason which will become preeminent in production lines as well as in society all this encourages reflections on the ways in which digital technologies may foster or hinder decisionmaking processes in future societies and on how increasingly automatized algorithms based on machine learning may gradually take over certain roles that were previously uniquely attributed to humans algorithms as kennedy et al brilliantly put it the advent of big data brings with it new and opaque regimes of population management control discrimination and exclusion something very much akin to what foucault called biopolitics a pervasive mode of power that attempts to understand control influence and even regulate the vital characteristics of any given population in agreement with lupton we believe that we are now entering an era in which biopolitics may be enforced through datafication that is through the joint combination of extensive datasets of digital information gathered synchronously across multiple domains all this raises crucial issues surrounding the privacy of individuals as well as their basic civil liberties that are now it seems to usmore than ever under threat consider the following example as a paradigmatic illustration of this claim it involves the collection of biometric data through face recognition algorithms based on machine learning this is just an example of a more general trend we note that the rolling out of this technology is taking place as we write this paper in many countries especially in those in which there is a rich infosphere that supports widespread technological advancements biometrics can be defined as the science of automatic identification or identity verification of individuals using unique physiological or behavioral characteristics roughly speaking biometric systems can be divided into two main categories hard biometrics and soft biometrics hard biometrics include traditional biometric identifiers that are normally used for identity verification technologies soft biometrics are instead parameters that can complement hard biometrics and be used to increase the precision or the accuracy of the recognition system soft biometrics typically provides information about a person without on its ownnecessarily providing sufficient evidence to precisely determine the identity of that person the process of biometric identification is quite complicated and can be summarized in four basic steps which include enrollment recognition comparison and decision a this does not necessarily mean that the development of ai to improve working conditions should be resisted rather we should reflect on how to better organise the process to achieve social and moral good the first concern of ethics in the face of the advance of ai is with workers and their condition the goal is therefore to identify the risks that individuals and society at large may face and to find regulatory remedies to those risks in the next four sections we will look at areas where the spread of ai in workplaces and processes may require conceptual clarification and both ethical and legislative regulation privacy issues several researchers working on datafication argue that surveillance is too optically freighted and centrally organized a phenomenon to adequately characterize the networked continuous tracking of digital information processing and algorithmic analysis that occurs in the world in which we nowadays live on these grounds such researchers propose to replace the term surveillance with the term dataveillance by which they mean that the act of surveillance in todays world does not take place directly from the above but rather becomes distributed across multiple parties and several domains these researchers also notice a different telos between surveillance and dataveillance where the end goal of surveillance might be defined as the ability to constantly see something or someone the telos of dataveillance is rather concerned with the capability of continuously tracking information across multiple domains to capture emergent patterns capable of predicting peoples behaviors yet algorithms and tracking ai tools are not only used to detect and predict ones behavior but also to shape and actively modify it for example the data that users generate might be gathered and processed to give a digital feedback capable of indirectly modulating and orienting someones action in a way that subtly departs from direct panoptic forms of discipline but could be argued to be even more effective an illustration of this claim is the growing usage of wellness programs in corporate settings such programs typically encourage employeesthrough incentives or rather penaltiesto engage in selftracking activities with the intent of gathering data that employers can then analyze by using proprietary 1 3 as an ideal trait to use for automated biometric recognition face recognition systems typically utilize the spatial relationship among the locations of facial features in conjunction with rapidly developing artificial intelligence technologies to provide information that can be used for security and law enforcement purposes see ali et al and boutros et al for surveys of recent face recognition technologies for example western countries being at the forefront of the development of comprehensive surveillance systems increasingly use such technologies for security purposes the expanding use of this technology therefore raises pressing ethical and social concerns regarding its adoption in society central to the ethical legal and policy issues is the tension that exists between the legitimate collection of biometric information for law enforcement national international security and government service provision on the one hand and the rights to privacy and autonomy for individuals on the other descending from this point there are also issues concerning potential violations of individuals privacy in search of wrongdoings that can lead to imbalance between a state and its citizenry and that need to be carefully evaluated in modern societies it is normally agreed that the state has no right to engage in selective monitoring of any citizen unless that citizen raised strong suspicions of unlawful behaviors yet the development of facial identification technology invites the active monitoring and even the fullscale mapping of lawabiding citizens in essence the pervasive wrapping of technology around innocent civilians which may contribute to undermine the basic universal right of not being investigated selectively of course face recognition technology is also used for good things for example it is widely deployed in airports where it has contributed to speed up the processing on incoming passengers by customs authorities legislation to facilitate the usage of facial recognition programs capable of integrating pictures from passports and various forms of ids into a national database which can then be consulted by law enforcement and other government agencies are being introduced in several countries across the globe however the average reader is probably less aware that such technology is also being actively rolled out in many countries especially in connection with the development of 5g networks 5g networks which possess extremely high computational power combined with the huge storage capability of modern clouds we note that biometric database screening technology is increasingly employed in this fourth step as it is believed to remove the human element from the matching process thereby maximizing objectivity and efficacy in decisionmaking biometric technology is also increasingly considered as an effective tool for dealing with security matters because of this the last decade has seen a very rapid development of biometric technologies biometric dataveillance programs as we may call them are proliferating under preemptive strategies to combatting crime and terrorism and to ensure homeland as well as international security we shall note that the us department of defense has called such approaches perhaps in a freudian slip population management2 which suggests that their potential applications may well stretch to put it mildlyto much wider realms quite possibly along the lines envisaged by foucault 3 anyhow major recent trends in biometrics typically focus on individuating behavioral kind or towards the development of multimodal biometrics a procedure which involve the combination of sensor and computing capabilities endowed with enhanced connectivity with the intent to apply such technologies in a broad variety of sectors and for a broad variety of purposes far beyond law enforcement or prevention of crimes for example latest breakthroughs in the field include the development of sensors that can capture new types of biosignals or braincomputinginterfaces such interfaces are reported to be able to measure neuro activity and translate it into machinereadable inputs which suggests that these devices could in the futureallow for the detection of thoughts possibly opening to the possibility of influencing operations of the human brain we wont focus on such technologies on this paper as they are mostly covered by state secrets however we would like to spend the remainder of this section on analyzing the case of face recognition technology through machine learning algorithms which is equally significant and perhaps is the one that poses at this stage at least especially given its widespread application in societythe most significant ethical and social challenges humans are very good at recognizing fellows based on facial appearance naturally then face can be considered freedom issues increasingly datafied working environments are geared toward efficiency and therefore in general terms toward reducing worker discretion in this sense a certain loss of workers freedom is inherent and perhaps even acceptable in any process not only of automation but also of standardization and compartmentalization of resources and procedures the shift from the craftsman performing the whole process of pin production to the division of labour among workers performing different tasks was famously described by adam smith in the 18th century we should now consider the peculiarity of working in an environment that extensively relies on datafication and is richly wired and interconnected across multiple domains and dimensions in such an environment the human being must be a facilitator of processes that automated systems are not yet able to do or will never be able to do for example in warehouses this happens with the substantial homologation of workers to the procedures rhythms and forms of control and evaluation that have been introduced for processes carried out entirely by industrial robots it is not intended here to make a social and political critique of this kind of evolution of the work environment decoupled from technical considerations referring to productivity gains that translate into concrete benefits for consumers in terms of product availability and low costs in our societies all workers are also consumers and this cannot be underestimated however the more we make the working environment wrapped around robots the more the risk grows that even human employees will be totally absorbed in this new production procedure which may have strong repercussions for workers this could lead to new forms of exploitation as some are afraid of yet it is not necessarily the case that this will happen in any circumstance though the logic of quantification and automation entails a modification of the workers spaces of freedom indeed it should be emphasized that two of the basic criteria of aibased approaches are predictability and certainty these criteria are structurally opposed to the classical idea of freedom which is understood as the possibility of choosing from time to time between alternative courses of action based on reason there are several areas in which workers freedom might be diminished because of the widespread implementation of ai tools and datafication in society personnel selection is one of such areas where the hiring process is progressively being managed by algorithms capable of evaluating candidates in accordance to predefined criteria which are set against the perceived compatibility of a subject for a yottabytes of images and even videos represent the ideal companion for this facial recognition technology in as much as they allow to fully exploit its potentials in richly datafied and infospheric environments in brief current face recognition technologies allow to store huge amounts of personal data coming from multiple domains and timespans to reliably access them at will at any point in time with fast algorithms specifically designed to selectively checking all the information gathered for desired purposes yet facial recognition programs are to date at leastquite vulnerable to deepfakebased attacks for examplewith static facial images4 which raise concerns about the security as well as the effective trustability of those data in addition facial recognition technologies might be combined with ai tools preprogrammed for spotting specific emotions to target minorities based on ethnicity hence they could be massively deployed to discriminate and even oppress given the pervasivity of such systems in modern infospheric societiescertain strata of any given population furthermore given the storage capabilities of modern clouds which are set to increase dramatically over the next decades who could guarantee that the biometric data stored in archives now through the extensive process of datafication wouldnt become compromising say30 years from now when certain moral values or virtuous might have changed partly or entirely who could then assure that lawabiding citizens couldnt be prosecuted in 30 or 40 years for behaviors words or actions that are completely acceptable now but may not be deemed as convenient in the future if a track record of their actions associated with their morphological traits is permanently stored somewhere given current trends on cancel culture and the corresponding emergence of dataveillance this possibility shouldnt be too hastily ruled out these are very crucial issues underlying the usage of facial recognition in biometrics mapping that promise to bear a significant ethical and legal impact on the future of our societies having briefly reviewed them we now look at another application of datafication in rich infospheric environs which include industrial automation another consequence for the workers within the wrapped datafiedinfospheric environment in which we increasingly live could be the progressive loss of the freedom to change the rules that govern the environment itself this is a discretionary activity that does not violate quality standards but allows for changes and improvements in the production process both technically and in terms of working relationships and conditions for example introducing a moment of confrontation between workers can improve both productivity and employee motivation if however the procedures do not allow this any momentary slowdown in the process will be evaluated negatively even though it may yield better results in the long run an efficiencybound environment that monitors all processes in real time and intervenes to make them homogeneous and smooth cannot tolerate unanticipated deviations and tends to discourage or suppress them in this vein it can be considered another form of freedom the idea of selfgovernment this latter entails an overall ability to do and not to be governed by alien forces and the selfmastery ability that sustains the full optionality these two accounts of freedom are logically separated and can vary independently of one another now suppose a situation in which we have a high level of optionality but an environment in which there is a predominance of heteronomy in this situation options would be left open to agents but the agents would not be free by simply having a set of options open since the algorithms would be in a position to filter the choice environment thus in wrapped datafiedinfospheric working environments there may be cases with high optionality but with low autonomy for example soft control mechanisms over workers routine including persuasive popups ads or nudging techniques have been employed by uber for steering drivers to have diverse booking options and more flexibility some have noted that this can lead to power asymmetries and structure control over workers this is not only the case in strictly structured fields of work such as logistics but also in fields where ai is only now appearing such as medical diagnoses marketing or the entertainment industry in all these cases workers freedom in decisionmaking might be reduced in parallel with the possibility to exercise their creativity as we shall see in the next section if in many areas the human contribution cannot be dispensed with one issue related to the progressive depersonalisation of the worker within a datafied environment is that of the loss of the possibility of cultivating and exercising those characteristics in humans that have been shaped specific task there is already a rather large literature on the possible biases introduced by such programs these biases depend on how the programs were designed and on the type of data on which they were fed and trained typical examples of bias introduced by personnel selection programs trained on time series or previous informal criteria adopted by companies involve decisions unfavourable to women ethnic minorities or social groups that have been historically disadvantaged or excluded to be sure discrimination in the workplace has always existed and power relations between firms and individual workers have always been highly unbalanced and asymmetrical a new sensibility in recent decades however has brought new attention to the issue and has made it possible to reduce systematic bias in selection and various types of abuses yet the introduction of algorithms that are considered more efficient and unbiased may if not properly supervisedrisk introducing the very same systematic discrimination that we strove to fight in recent decades in addition this new sort of potential systemic discrimination may be far less detectable than the one which has historically affected less advantaged groups contributing to this trend will be the growing need to adapt all procedures related to the entire production processes to the automation typical of increasingly aimanaged work environments in this sense control surveillance and the system of incentives and sanctions will also have to conform to quantification and datafication the workers margins of freedom will then likely be reduced as result of the need to conform to strictly quantitative criteria in their actions and in light of the need to be evaluated with tools that prioritize objectivity and efficiency ironically such algorithms are already actively used in the criminal justice system of certain countries indeed it is hard to see why we could rely on programs that assess the appropriate sentence for an offender or the possibility of recidivism of the same after a certain period of imprisonment and not do so for labour disputes another issue relevant to the economic field and to the workers freedom concerns the possibility of being evaluated and judged by peers and not by ai algorithms it is generally agreed that there is a duty of dignity to be accorded to human beings who should be treated as unique individuals defined by personal traits and not as a set of data unified by the attribution to a first and last name this duty of dignity seems to be threatened by the widespread adoption of such technologies 1 3 text on most of dennetts corpus with the aim of seeing whether the resulting program could answer philosophical questions similarly to how dennett himself would the result was that philosophy experts were unable to clearly discriminate between the answers given by dennett and answers given by gpt38 the two examples we discussed above are just paradigmatic instances of an ongoing revolution focussing on the creative possibilities of ai the topic of creativity and its definition is one of the most complicated in the field of psychology but it has to do with the ability to produce something that is new and useful in other words what is creative is the result of a process that is not necessarily reducible to the mechanics of deterministic reasoning usually within creative acts one cannot identify a precise concatenation of stages but rather perceives holistically the emergence of the result in contrast as far as ai creativity is concerned the operation of the algorithm is potentially transparent that is reducible to a finite number of steps and its success relates either to the direct liking of a human viewer or in its appropriateness one may wonder whether we will end up delegating all creative tasks to algorithms especially in wrapped and datadriven environments where ai can deploy its engineering capability to the fullest degree and if this is the goalwhether human creativity at work will be less and less used is this a likely scenario and what consequences might it entail firstly one may ask whether lowcost aiproduced creativity is sufficient to meet the needs of consumers and the resolution of problems that may arise from time to time todays computers are composing music that sounds more bach than bach turning photographs into paintings in the style of van goghs starry night and even writing screenplays the key point however seems to be this every relevant problem that is more than just a procedural query has to do with humans and their complexity for example there is a need to not only save energy and reduce climatealtering emissions but there is a necessity to do this in tune with the desires and goals of people living in that specific area with a specific culture and specific values by natural evolution and that ai tends to counteract or suppress for example sociality and relationships the ability to frequent natural and not just artificial environments other activities including those oriented to a relevant concrete and visible purpose these aspects are related to physical and mental wellbeing which go beyond the immediate gains that the new aibased economy may bring about in terms of physical security education income or general wealth humans are proactive creatures who deeply fear loneliness boredom and feelings of worthlessness in general the sense of agency and being held accountable for their actions is something that underlies freedom as a value as a property that gives meaning to existence from a phenomenological point of view creativity recently an american artist won the first place in the emerging artist divisions digital artsdigitallymanipulated photography category at the colorado state fair fine arts competition 5 his winning image titled théâtre dopéra spatial was made with midjourney 6 an artificial intelligence system that can produce detailed images when fed written prompts the affair caused controversy because the jury evaluated the work without considering that it was produced with an ai system even though the artist openly declared that he had used an ai tool to generate the image upon submitting his work after the artist got the prize he was inundated with criticism from numerous colleagues who deemed it inappropriate to compete with a work made that way its like admitting robots to the olympics was one of the comments there are numerous programs that allow people to create images based on verbal instructions such programs draw on vast image repositories and modify or mix preexisting figures based on users inputs until now they were considered curious pastimes but their entry into competitions and the art market could revolutionise the criteria of creativity the way it is evaluated and the role of human beings in contributing to societys creative processes another experiment sparked discussion in early 2022 two scholars have with daniel dennetts permission and cooperation finetuned gpt3 the autoregressive language model that uses deep learning to produce humanlike 5 last accessed april 2023 6 last accessed april 2023 7 last accessed april 2023 1 3 datadriven environments invites an evaluation of criteria of efficiency timeliness and replicability as central to the production process and as particularly valued for what they entail on the wealth and welfare side of consumers and of society as a whole the socalled instrumental reason that is adjusting means to predetermined ends to achieve the best possible outcome may thus become the benchmark for the entire economic sector in principle humans are still responsible for decisions concerning the ultimate goals and ultimate choices but easily find that in the wrapped and datafied microenvironments the whole process revolves around the optimal management of quantitative aspects that can be handled by ai speculations about algorithms taking over and altering the purposes for which they were created currently remain science fiction scenarios however what we may witness in the short term is a culture that may be affected by being increasingly placed in the onlife dimension typical of personal devices characterized by speed real time everbetter performance and minimization of waiting time or expectations this has its counterpart in the impatience with slowness and qualitative aspects with a prevalence of phenomenal aspects over cognitive ones which distinguish each individual consciousness qua basic feeling of existence as a background that qualifies all our waking states seems to be exhibited by at least some living species and as far as we know especially by human beings this is a feature that cannot be replicated or simulated to datein artifacts which however can be partially exhibited in software as a selective intelligence sometimes superior to that of human beings this is demonstrated by the ability of computers to defeat humans in chess and even in go these examples show that appreciation for highly developed forms of intelligence also favours the illusion of seeing consciousness where there is none and not seeing consciousness where instead it exists if we pursue forms of intelligent functionalism we might end up morally devaluing the criterion of the presence of consciousness in favour of the presence of intelligenceor at least of full consciousness associated with the ability to exercise intelligent functionalism one can of course argue in favour of an ethical position of this kind but it is not easy to do so without completely giving up moral intuition even in rationally supervised forms in fact moral intuition is what seems to and the same goes for creativity if we delegate the entire creation and all marketing of saya business to a highly efficient algorithm will socalled creative workers lose their role and over time we will have no more reserves of human creativity this seems to be related to a certain approach maintaining that a parallel computer is capable to produce in ways that are not yet well understood and that exceed the serial capabilities of an analogic computer however recent progress on evolutionary computation especially those grounded on populationbased search techniques seem to suggest the possibility for ai tools to find creative solutions to very practical problems of the real world evolutionary computation especially if complemented by deep learning can process data both synchronically and diachronically it has been observed that populationbased search methods based on evolutionary computation can scale better than other machine learning approaches this suggests that soon we should see many applications of these ai tools to problems directly involving human creativity in numerous fields such as engineering healthcare finance or even in agriculture there is thus a question of whether the gradual reduction of the creative roles entrusted to humans in highly datadriven environments will lead to an increase in overall system efficiency and increasing consumer satisfaction or whether instead it may leave uncovered an important part of the innovation that proceeds with the single unpredictable insights of a few individuals of genius in addition the relative untapping of the creativity of workers who have become executors of the new ideas produced by automated systems could induce a lowering of the motivation and mood of workers themselves who will become less and less involved in the production processes therefore unable to devise answers even to decisions that for now are still entrusted to humans efficacy and instrumental reason issues the goal of efficiency as mentioned above drives the creation of new environments in which aibased technology may prevail it is not necessary to refer to marxs works to consider how relevant the means of production and the relationships between workers and production processes typical of a given era can be in shaping culture and other types of relationships in society the logic inherent in the increasingly pervasive application of ai across wrapped and 1 3 of algorithmic management reduces prosocial behavior in addition negative effect occurs because the use of algorithms to manage workers leads to greater objectification of others also occurs when algorithms perform tasks together with human managers and depends on the type of management task algorithms perform being caught up in the apparent gamification of an increasing number of tasks and functions through digital technology may lead to an overvaluing of instrumental reason at the expense of a search for ends and values to which one can give motivated and thoughtful personal adherence muldoon and raekstad proposed the concept of algorithmic domination where an individual is subjected to a dominating power the operations of which are determined directly by an algorithm also gamification permits employers to intervene at a more minute level in ways that are not feasible if required to be undertaken by a human supervisor in this scenario the business sector seems to be destined to be increasingly pervaded by ai producing quantifiable guaranteed and predictable results is one of the main goals of deeply wrapped datafied environments a goal that tends to leave no room for uncontrollable and uncontrolled personal paths such a scenario we maintain requires careful ethical evaluation and constant scrutiny to avoid that a single efficientistic view may prevail conclusion as ai becomes ubiquitous in society possibly leading to the formation of increasingly intelligent biotechnological unions there will likely be a coexistence of a plethora of microenvironments wrapped and tailored around robots and humans the key element of this pervasive process will be the capacity to integrate biological realms into an infosphere suitable for the implementation of ai technologies this process will likely require extensive datafication this trend can help to meet an increasing number of needs of a growing share of the population by improving the efficiency of production processes and introducing into them elements of quantification predictability reproducibility and minimization of error and imperfection all this however can also trigger unintended and suboptimal consequences in this paper we have considered four such consequences that seems to be crucial for decisionmaking processes in future human societies dominated by ai technologies the datafication required to realize the quantification and application of ai resources implies increasing control of the provide us with the basic preconditions of moral reasoning that is the fact of sharing at least some of the basic values of the subjects involved the latter fact is mainly due to the fundamental quality of living beings consciousness and consciousness is something that intelligent artifacts seem to lack even though they can mimic moral reasoning at a cognitive level one consequence of this shift toward quantification efficiency speed and continuous connection is the projection of these machine characteristics to which we have become increasingly accustomed onto our fellow human beings tolerance for those who are lower performing less able to keep up with the pace of the ai systems of which we are gradually becoming a part may be diminishing starting precisely in workplaces built around automation and possibly extending to the wider society in those contexts predictability and reliability are prioritized and measurement ranks first among the systems capabilities what does not fit within the parameters what slows down or hinders the flow of the process will tend to be pushed aside expelled or not even recruited there are several levels at which this selection based on efficiency and instrumental reason can take place there is a more trivially physical one those who cannot handle the pace of automation cannot participate in the work process people affected by different forms of illness or disability the elderly and those who fall below minimum performance standards will have difficult access to the labour market and more importantly may be seen as less useful to society at large reversing a trend toward inclusion that has been taking hold recently stypinska 2022farina and lavazza 2022a bcfarina and lavazza 2021a the same and perhaps to a greater extent may happen at the cognitive level as pointed out earlier the inability for various reasons to keep up and be deeply attuned to the wrapped around and datafied environment could lead to the marginalization of those who manifest such detachment from the new aicolonized context this is not an inevitable outcome but it is a risk that can already be glimpsed in a push for a digital uniformity that comes from the now compulsory reliance on electronic devices and indeed even social media with varying forms of indirect control and public exposure heßler and colleagues noticed that increased importance of empathy and autonomy leads to a higher degree of algorithm aversion at the same time it also leads to a stronger preference for humanlike decision support which could therefore serve as a remedy for an algorithm aversion induced by the need for selfhumanization in recent lab experiments fuchs found that the use are quintessentially social beings who are bound to have contacts with their peers to find satisfaction often in free and unstructured interactions the cancellation of these interactions can trigger a reduction in their wellbeing far greater than the support they could get from the intelligent tools located in increasingly datafied environs so as mentioned above potential risks exist that need to be addressed preemptively as they seem to be inherent in structural trends based on the widespread diffusion of ai in society it is the task of philosophy and ethics to help analyse these risks highlight their contours and propose solutions so that artificial intelligence may become a valuable complement to human activities favouring social harmony and moral good individual involved in the production process and quite possibly over her life this loss of privacy is typical of new datafied and infospheric environments where it is not necessarily pursued with the explicit purpose of monitoring the individual but rather of actively predicting her behaviour by having the individual herself interacting effortlessly with a wide range of integrated technological tools across multiple domains and dimensions this need for control may also result in a loss of freedom understood in the classical sense as the possibility of deciding between alternative courses of action indeed the worker must manifest maximally predictable behaviour for her contribution to be as effective and integrated as possible freedom in this context may become structurally endangered as an endproduct especially in production processes which are increasingly oriented toward maximal certainty another consequence of this production arrangement is the delegation of creativity to algorithms which are often presented as higher performing hence preferable to humans because unlike humansthey are not subject to quantitative and qualitative fluctuations the risk here is a loss of the reserve in terms of qualitative resource on the part of workers which in the long termcould leave some creative areas uncovered especially those where machines are not at the level of productive intelligence of humans finally a more general cultural tendency to favour efficiency and instrumental reason might assert itself because of the structural constraints that environments wrapped around ai tend to produce a less inclusive and tolerant society could be the result of our onlife characterized by immediacy and absence of expectations a world in briefwhere commonsense will leave space to pure objectivity and absolute neutrality based on algorithmic efficiency in this vein datafication points toward an automation of decisionmaking that makes it primarily efficiencydriven toward predetermined goals one strategy to rebalance this trend could be to create areas of decisionmaking that are removed from extreme datafication to allow a process of decision making driven by the choices of individuals without the close guidance of ai for we know that a strong sense of agency is inherent in human beings consisting of conscious control over their choices and courses of action the deprivation of this sense of agency usually leads individuals to a reduction of their own wellbeing if therefore the efficiency of economic organization is not to become the first and only goal of the social system with the consequences just highlighted it is necessary to prevent a form of automated decisionmaking from becoming the only method for choices in working environments and in societies in general humans manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law springer nature or its licensor holds exclusive rights to this article under a publishing agreement with the author or other rightsholder author selfarchiving of the accepted 1 3 data availability na

by the initiators of contemporary cognitive science mccarthy et al 2006 according to floridi it is sufficient to have recourse to a counterfactual which concerns human behaviour in this sense the problem of artificial intelligence is only that of making a machine act in ways that would be called intelligent if a human being behaved in the same way thus there is no issue of comparison between human intelligence and machine intelligence the only relevant issue is to perform a task successfully such that the result is as good or better than human intelligence would be able to achieve how this happens is not the central issue although it may have important consequences the outcome is this approach to ai is called engineering or reproductive it aims to reproduce the results or successful outcome of our intelligent behaviour by nonbiological means in contrast the cognitive or productive approach to ai aims to produce the nonbiological equivalent of our intelligence that is the source of the behaviour that the engineering approach aims to reproduce cf floridi 2011a b a recent interpretation of ai developments proposes to consider ai as a form of acting that does not have to be intelligent to be successful floridi 2013 floridi 2022 the basic idea is to return to how the problem of intelligence was framed mirko farina

introduction during the past few years we have witnessed a remarkable increase in the number of users in virtual worlds according to kzero 54 there were 1921 billion registered users in virtual worlds in the first quarter of 2012 more than triple the number of users in 2009 the largest segment of users is between the ages of 10 and 15 54 despite the growing popularity of virtual worlds there is no agreement on the definition andor typology of virtual worlds 20 71 the numerous contextual descriptions provided by academics industry professionals and the media have further complicated agreement on a common understanding about virtual worlds 91 one of the earliest definitions of a virtual world was that of schroeder 74 p25 who defined the virtual environment or virtual reality as a computergenerated display that allows or compels the user to have a sense of being present in an environment other than the one they are actually in and to interact with that environment years later koster 52 suggests a definition which contains many essential characteristics of a virtual world a virtual world is a spatially based depiction of a persistent virtual environment which can be experienced by numerous participants at once who are represented within the space by avatars castronova 25 adopts a more technologically oriented viewpoint and defines virtual worlds as crafted places inside computers that are designed to accommodate large numbers of people building on the definitions provided by bartle 16 koster 52 and castronova 25 and including an emphasis on the people and their social network bell 20 defines virtual world as a synchronous persistent network of people represented as avatars facilitated by networked computers against this backdrop social networking sites such as facebook and linkedin are not virtual worlds although not without its critics 19 social networking sites are defined as webbased services that allow individuals to construct a public or semipublic profile within a bounded system articulate a list of other users with whom they share a connection and view and traverse their list of connections and those made by others within the system 22 thus snss constitute virtual communities which have persistence but no sense of synchronous 20 keeping the bells 20 definition of virtual worlds in mind massively multiplayer online roleplaying games like world of warcraft or ultima online are virtual worlds this applies also for mmo games however there is a discussion about whether a distinction should be drawn between gamebased worlds and nongame worlds some researchers 51 77 argue that virtual worlds are essentially nongame environments where divergent games can be present but are not the defining characteristics of the world instead mmorpgs are subject to precise gaming rules and therefore they are essentially games even though some mmorpgs provide opportunities for social networking the game element is central to their functioning 47 the growing number of internet users and popularity of virtual worlds mean that more and more people are becoming involved in different types of virtual environments this also provides new opportunities for businesses to market products and services in these virtual worlds 38 especially if it can be exposed that product placements in virtual worlds are more effective at generating sales and brand loyalty than static marketing channels such as print and webbased advertisement 92 even though little is known how to effectively market to virtual world participant through avataroriented activities organizations and marketers should consider the online opportunities of marketing to the inhabitants of virtual worlds as the avatars of users represent prospective targets of current and future business this raises a number of interesting research and practical questions how companies can market themselves their products and services within virtual worlds environment by making sense of the unique features offered with this new medium 92 previous research has investigated online interaction in different types of virtual communities such as textbased 10 and networkand small groupbased virtual communities 11 30 on the other hand research has also investigated several highinteractivity online venues and lowinteractivity online venues 13 participation has also been examined in special contexts like software user groups 12 and from educational perspectives 93 viewing the phenomenon through the lens of social psychology this study examines the underlying motives of users for participating in virtual worlds utilizing an applied version of the frameworks presented by dholakia et al 30 and bagozzi and dholakia 11 12 these frameworks were developed to examine user motivations and behaviors in virtual worlds and are related to the model of goaldirected behavior 69 participating in virtual worlds is perceived as intentional social action influenced by several social determinants such as attitude subjective norms perceived behavioral control enjoyment entertainment value ease of use and social identity in the current study authors adapt the bells 20 view of virtual world which builds on synchronicity persistence network of people avatar representation and facilitation of the experience by networked computers the authors investigate the users of 2d virtual world called moipal aimed at users between the ages of 10 and 15 moipal is not a mmorpg in a sense that users story or narrative unfolding within the strict constraints of the rules and goals set by the designers instead moipal has the elements of both a fictional and physical world and exists primarily as a place for social interactions to occur however moipal is not based on a social platform like facebook and therefore it is not a social game authors identify moipal as a virtual world environment which can be classified within the broad domain of massively multiplayer online games it can also be tagged with the label multiuser virtual environment 62 moipal offers its players a virtual world environment to do everything from playing minigames to meet new and existing virtual friends to exploring many public spaces available to them moipal experience consists of many parts which are all inextricably linked apparently the sims online 60 has been a role model for moipal moipal was launched in october 2007 there were around 120 000 users in moipal at the end of the year 2008 moipal was shut down in september 2011 moipal is free to play but registration is mandatory at the initial signup each player selects the look and style of an avatar called pal from a wide range of options including gender hair and skin color clothing facial characteristics and body type pals are automatically given a personal home upon signup and invited to personalize it with a variety of furniture and accessories like rugs lamps posters and plants pals residences are located in the virtual world called pal city the city provides pals dozens of different places to visit and opportunities to carry out wide variety of tasks pals can visit for instance a horse stable library cinema film studio radio station city hall restaurants museums art gallery and holiday resort by completing tasks related to different places pal can earn palmoney to buy new furniture or clothing from divergent shops located in a shopping mall called pal store the tasks are extremely diverse ranging from eating pizza at joes pizzeria dancing at cube club having snowball fights in iceland training karate at dojo to feeding dinosaurs at museum of natural sciences for nurturing social interactions moipal provides communication opportunities such as chatting and sending palmail to others the number of friends is not limited in moipal many pals also create a group or community around a certain topic such as horse riding rock star or fashion like minded friends were then invited to the group nonmembers are able to request invitation by moimail besides the parties pals could arrange for their friends plenty of attractive events are organized around pal city these include a fashion event at the beach silent movie festival at kino lumiere cross stich exhibition at art gallery 44 and palympics sport events in sport field pals could play several minigames in moipal such as moipal racing where a player can drive a car with a side scrolling view the car can be driven across a track and the driver has to avoid hitting pumpkins and other obstacles on the track other minigames include karate moiband jump rope palping locomotion moipets just to mention a few in the next section we review the relevant literature to support the development of our hypotheses this is followed by a discussion of the studys methodology we then continue with the presentation of the results finally we draw conclusions from the study outline its main limitations and offer ideas for further research in this area goaldirected behavior vs experiential service use although bagozzi and dholakia 9 state that consumer behavior is predominantly goaldirected because goods and services are purchased with a certain goal in mind it is important to note that not all consumer behavior is based on this utilitarian and informationprocessing view as noted by holbrook and hirschman 39 using the information processing perspective to explain consumer behavior might not always be the appropriate choice in settings which include playful leisure activities such as gaming 67 according to this experiential view of consumer behavior consumption is viewed as a subjective state of consciousness that includes various symbolic meanings and hedonic responses as pointed out by holbrook and hirschman 39 it is important to recognize and also to contrast the two views of consumption the informationprocessing and the experiential view as this paper is interested in volitional behavior in an experiential service setting in which consumer behavior is driven by pleasureseeking enjoyment and fun intrinsic motivational factors such as enjoyment are expected to have a stronger effect on intention and behavior than extrinsic motivational factors like perceived utility prior research has modeled participation in virtual communities and the associated behavior from the viewpoint of goaldirected behavior 10 12 47 69 which suggests that desires predict intentions and the traditional antecedents of the theory of planned behavior namely attitudes perceived behavioral control and subjective norms influence intention through desires too the model of goaldirected behavior 69 has since been revised and applied in many studies in this case we consider applications that discuss intentional social action in the context of groups 8 virtual communities 10 30 and online venues 13 nysveen et al 67 p 336 who studied antecedents to mobile service usage argue that experiential services are characterized by ritualistic orientation and hedonic benefits derived from the use of the service whereas goaldirected services are characterized by instrumental orientation and utilitarian benefits related to the use of the service on this basis we now present a framework combining aspects of goaldirected behavior and experiential service use conceptual model and hypotheses building on the research on both goaldirected behaviors 10 12 30 and experiential service use 67 we propose the following framework to capture the antecedents of intention and behavior in the context of virtual worlds characterized by hedonic pleasureseeking motives in the next sections we discuss the model in more detail develop the hypotheses and review relevant literature to support them ease of use perceived ease of use refers to the degree to which a potential user of a certain technology expects the target system to be free of effort 28 29 ease of use is one variable introduced by davis 28 under the technology acceptance model an adaptation of the theory of reasoned action 34 however tam focuses precisely on explaining purposive behavior in the context of technology use tam also posits that two beliefs perceived usefulness and perceived ease of use influence computer acceptance through attitude in the following sequence first the design features of a certain technology affect a persons perceptions of its usefulness and ease of use consequently the person forms a certain attitude toward using the technology finally attitude produces behavioral response that is actual system use the effect of perceived ease of use on information system acceptance and use has been studied extensively in the tam research domain for a review see 50 ease of use has been found to explain a considerable amount of the variance in attitude in experiential service settings ease of use has been found to have a significant association with attitude toward use and intention to use but its explanatory power is not very strong with regards to either 67 in this study the concept of ease of use is a somewhat complicated because easeofuse may not exactly reflect the motivation of online games users authors acknowledge that without usability no one can play a game make it is too usable and its no fun 55 p 319 however in the case of online gaming acceptance hsu and lu 42 found that ease of use appeared to be the key determinant to predict online game play instead of usefulness in addition hsu and lu 43 have shown that perceived ease of use appears to have significant effects on both perceived enjoyment and preference to participate in online game communities they found in their study that easytouse interface enhance enjoyment and encourage people to reparticipate on the contrary difficulties of use make people resist ease of use h1 the relationship between enjoyment and intention is supported by many studies particularly with reference to hedonic information systems 1 46 81 84 davis et al 29 argue that users who get enjoyment from using an information system are more likely to form behavioral intentions compared with other users who do not experience as much enjoyment perceived enjoyment is also shown as a significant predictor to the intention to use virtual worlds 66 75 therefore we propose that h2c enjoyment is positively related to intention attitude toward use and attitude toward advertising in general attitude toward a certain behavior such as using a system or service is positively related to intention to engage in that behavior 2 in computermediated environments many studies state that attitude towards using a system has been found to be the strongest determinant of intention to use that system 28 67 with respect to social communication behavior online chang and wang 26 show that a more positive attitude towards the use of online communication tools corresponds to a greater behavioral intention to use them their results show that behavioral intention is influenced by perceived usefulness flow experience and attitude towards use the factors jointly explain 80 percent of the total variance in behavioral intention of which attitude alone explains 56 percent in the same vein nysveen et al 67 propose that attitude toward using mobile services is a strong determinant of intention and usage in addition moon and kim 63 argue that attitude toward using the web has a strong influence on behavioral intention on this basis we propose that h3 attitude toward use is positively related to intention to use attitude toward advertising can be defined as a learned predisposition to respond in a consistently favorable or unfavorable manner to advertising in general 57 p 53 research on attitude toward advertising has concentrated mainly on three areas attitude towards ads 57 59 perceptions of ads in general 33 and brand attitude 58 64 scholars have shown increasing interest in attitudes toward online advertising since its emergence on the internet studies have investigated for instance the perceived value of web advertising 32 different online advertising formats 24 and attitudes toward online advertising 73 attitudes toward online advertising have been found to be related to the informativeness and enjoyment of the advertisements 32 73 attitude toward advertising is a strong determinant of for instance purchase intentions 57 59 attitudes toward advertising are also found to determine behavioral responses in online 24 and mobile environments 48 82 the empirical evidence from prior studies about advertising in virtual worlds is virtually nonexistent however some studies are conducted in social networking sites for instance kelly et al 49 networking environment in their study many participants indicated that advertising on their online social networking sites was acceptable because it kept the use of site free of charge this may apply also for advertising in virtual worlds thus we suggest the following hypotheses h4 attitude toward use is positively related to attitude toward advertising h5 attitude toward advertising is positively related to intention social identity social identity theory is a socialpsychological perspective developed by tajfel and turner 79 80 it defines how people classify themselves and others into various social categories the social classification comprises two functions the first function gives the means for a person to define others by cognitively segmenting and ordering the social environment surrounding them second social classification helps individuals to define themselves in the social environment 6 originally the model of goaldirected behavior 69 included only one social variable namely subjective norm however the construct of social identity was added to the model by bagozzi and dholakia 10 the purpose in adding the variable was to make the model suitable for examining group actions dholakia et al 30 state that social identity captures the main aspects of the individuals identification with the group in the sense that the person comes to view himself or herself as a member of the community and feels that heshe belongs to it bagozzi 8 states that social identity evolves through selfcategorization processes that define how members think and feel about themselves how other ingroup and outgroup members are perceived and how one acts in relation to ingroup and outgroup members bagozzi divides social identity into three components selfcategorization affective commitment and groupbased selfesteem these were later redefined into cognitive affective and evaluative social identity 11 12 cognitive social identity refers to selfawareness of membership in a social group selfcategorization is related to affective social identity that presents the emotional feeling of belonging within the group while evaluative social identity refers to a persons positive and negative value connotation related to group membership that is collective selfesteem research has tested the validity of these measures 14 21 dholakia et al 30 completed a study of social identity in the context of networkand small groupbased virtual communities their model tested the motivational antecedents and mediators of group norms and social identity forms they hypothesized that higher levels of value perceptions lead to a stronger social identity regarding the virtual community the results of their study supported the hypothesis and revealed that purposive and entertainment value determined social identity in the relevant context against this backdrop we propose that social identity is comprised of cognitive affective and evaluative social identity 11 12 and hypothesize that h6 social identity is positively related to intention h7 social identity is positively related to behavior subjective norms intention and behavior the second determinant of intention in the theory of planned behavior is subjective norm which refers to the influence of ones personal community on the specified behavior 2 bagozzi and dholakia 11 note that group norms might be an important aspect of social influence in small group brand communities and therefore call for research on the effect of subjective norms on intention in a virtual community context the members subjective norms affecting the intention to perform a certain behavior might be the approval or disapproval of the other members according to ajzen 3 normative beliefs are the antecedents of subjective norms if a person assumes his or her referents think he or she should perform a certain behavior the person will perceive social pressure to do so on the other hand if a person supposes his or her referents would disapprove of the behavior the person will have a subjective norm applying pressure not to perform the behavior in question therefore subjective norm is a social factor that affects a persons intention to behave in a certain manner a number of studies indicate that the influence of peers on behavioral intention related to entertainment services is stronger than the influence of other subjective norms such as parents or comparative referents 35 61 peer influence has been a significant predictor of intention and behavior in the mobile entertainment services setting 17 48 72 in addition subjective norms have been found to predict user behavior in online games 42 blogs 41 and virtual communities 27 recent literature has also found subjective norms to be a significant factor in the user adoption of virtual worlds 18 45 as a result we put forward the following hypotheses h8 subjective norms especially peers are positively related to intention methodology the data was collected from the users of a virtual world called moipal the survey was promoted via a banner advertisement in the gaming world the players were encouraged to click on the banner and complete the questionnaire as an incentive to answering the survey the respondents were entered into a lottery for a gaming console notes on the questionnaire form advised respondents that the purpose of the study was to examine behavior and attitudes in the context of virtual communities the respondents were asked to devote about ten minutes to completing the survey form as regards the research ethics the fact that a majority of the moipal users are underage was taken into account when designing the survey first the survey was completely anonymous to further ensure anonymity moipal user name ie pals name of the respondents was not requested at any point in the survey secondly with the exception of the background questions on gender and age no questions about the respondents offline lives were included in the survey a total of 319 acceptable responses were received in evaluating the response rate in this kind of online survey setting we compared those who clicked the link to the number of completed questionnaires by this count the response rate was close to 90 percent a total of 86 percent of the respondents were females the mean age of the respondents was 143 years these demographics are in line with the demographics of the registered gamers potential nonresponse bias was also examined by comparing early to late respondents 5 in terms of demographics the groups do not differ from each other but in terms of the study constructs the early and late respondents differ in their intention and behavior the results of the mean tests indicate that early respondents have higher intentions to use and are more active users of virtual worlds than late respondents this finding was expected as those who answer surveys first usually represent the most enthusiastic user groups on this basis we argue that as the survey reached the majority of the active users of the virtual world as nonresponse occurs mostly among those who are less active gamers therefore nonresponse bias should not be considered a major weakness of the study potential common method variance bias was reduced and examined in various ways as suggested by podsakoff mackenzie lee and podsakoff 70 first at the data collection stage the respondents identities were kept confidential item ambiguity was reduced and the items were mixed in the questionnaire second in the data analysis stage we examined common method variance bias through harmans one factor test and the partialcorrelation technique the one factor solution p 00 rmsea 146 was inferior to the hypothesized factor structure in addition the partialcorrelation technique was used to further assess method bias as a marker variable we used the item there should be no advertising in the virtual world adding the marker variable to the model showed no effects on the observed relationships on the basis of these two tests it seems that common method variance bias is not a problem in this study measurement scales all the items were measured on sevenpoint scales with a do not know option in some questions a semantic differential scale was used instead of a likerttype scale in measuring attitudes items were adapted from bagozzi and dholakia 10 11 cognitive affective and evaluative social identity constructs were all measured with two items each adapted from bagozzi and dholakia 11 and dholakia et al 30 in measuring ease of use we adapted a three item scale from davis 28 and davis et al 29 enjoyment was measured with a three item scale taken from nysveen et al 67 in measuring attitudes toward advertising in the virtual world we used a semantic differential scale adapted from ajzen 4 subjective norms were measured on a three item scale taken from ajzen 4 and bagozzi and dholakia 11 intentions and behavior were both measured with items adapted from bagozzi and dholakia 10 and dholakia et al 30 convergent and discriminant validity the measurement model showed acceptable fit p 00 rmsea 060 srmr 043 cfi 987 ifi 987 rfi 971 the fit indices associated with the cfa exceeded acceptable thresholds 23 44 only the chisquare value was problematic but researchers have suggested looking at other fit indices like the rmsea value if the chisquare test is not passed 31 83 the rmsea statistic for the measurement model was below the cutoff criteria of 08 indicating a relatively close fit of the model 23 the cronbachs alphas were larger than or equal to 72 following dholakia et al 30 composite reliabilities were calculated for two item scales all crs were larger than the recommended cutoff criteria of 60 15 therefore the scales show sufficient internal consistency the indicators in the model loaded highly on their hypothesized constructs and were significant in addition all the average variance extracted values were over 50 on this basis the confirmatory factor analysis shows acceptable convergent validity discriminant validity was assessed by looking at the correlation among the constructs and square roots of ave values all the ave square root values were higher than the correlations among constructs indicating acceptable discriminant validity 36 structural model assessment and hypotheses tests the structural model fit was acceptable p 00 cfi 0984 nfi 972 nnfi 0982 ifi 0984 srms 07 rmsea 064 44 23 hypothesized path loadings their respective tvalues and r2 values are shown in figure 2 of the nine hypothesized relationships six turned out to be statistically significant h1 contended that there is a positive and direct relationship between ease of use and attitude no support for the relationship was found there are two possible explanations for this first this insignificant path might be explained by the strong relationship between enjoyment and attitude studies have found that in experiential settings enjoyment plays a stronger role ease of use r 2 32 attitude r 2 73 this paper is available online at doi 104067s071818762013000100002 than ease of use in determining attitudes and behavioral intentions 67 second in technology acceptance research the effect of ease of use on attitude and intention is often weaker than the effect of usefulness as the effect of ease of use is mediated through usefulness 50 in line with the literature 1 85 86 94 we find strong support for h2a which proposed that enjoyment is positively related to ease of use to test the reversed path a competing structural model was estimated the competing model showed a significantly worse fit than the hypothesized model on this basis it seems that in experiential settings perceived enjoyment has a significant impact on perceived ease of use and not vice versa with respect to h2b the path shows that enjoyment is positively related to attitude this path is extremely strong and indicates that enjoyment is a stronger determinant of attitude than is perceived ease of use this finding is supported by the literature which has found that enjoyment plays an important role in user acceptance of technology especially in the case of hedonic systems 78 there is no evidence to support h2c which proposed that enjoyment is positively related to intention this finding echoes venkatesh et al 90 who found no support for the direct relationship between perceived enjoyment and behavioral intention however that study supported the view that the effects of enjoyment are fully mediated by perceived usefulness and perceived ease of use h4 arguing that attitude toward use is positively related to attitude toward advertising was supported no support was found for h3 which argued that attitude toward use is positively related to intention to use in contrast with the findings of prior studies on virtual world usage 45 76 there was a nonsignificant effect of attitude in predicting the intention to participate into virtual world environment however mäntymäki and salo 66 made similar findings in their study conducted in social virtual world called habbo hotel in the line with mäntymäki and salo 66 we suggest that a potential reason for a nonsignificant effect may be that since attitudes develop over time their role is less salient with young people alternatively it is also possible that intentions to use virtual worlds are driven by affective emotional impulsive or habitual factors rather than attitudes h5 contended that there is a positive and direct relationship between attitude toward advertising and intention to use no support for the relationship was found one potential explanation for this may be advertising avoidance it may be that young people pay little or no interest in advertising in virtual worlds like they do in online social networking sites 49 in such a setting attitudes toward advertising may be less established and thus not exerting a strong influence on behavioral intention the next hypotheses proposed that social identity is positively related to intention and behavior both hypotheses receive significant support from the data and are thus confirmed we found no support for h8 which argues that subjective norms are positively related to intention finally there is strong evidence supporting h9 which contended that intention is positively related to behavior that path is strong and significant the nonsignificant direct effect of subjective norms on intention to participate in virtual worlds was counterintuitive and contrary to recent literature which indicate that subjective norms are a significant factor in the user adoption of virtual worlds 18 45 however the effect of subjective norms on intention has been found to be somewhat inconsistent 40 87 88 for instance liang and yeh 56 found in their study that subjective norm had no significant effects on the continuance intention to use mobile games in addition in their examination of ecommerce adoption pavlou and fygenson 68 did not find that subjective norms predicted either the intention to seek information online or the online purchase intention recently using data gathered from 3265 survey participants in a social virtual world called habbo hotel mäntymäki 65 found no effect of subjective norms on continuous use intention on social virtual world interestingly in his study the research setting and profile of respondents were very similar to the current study respondents were female dominated and the majority of respondents were between the ages of 10 and 15 in the line with mäntymäki 65 we suggest that a potential reason for nonsignificant effect of social norm may be the fact that the normative influence is not particularly salient in predicting virtual world use empirical studies have rather consistently found the influence of subjective norms to be less significant in the continuous phase of technology diffusion or where the use of the technology is voluntary 53 89 alternatively as participants in virtual worlds can interact with other people who just happen to be present in the virtual environment while not knowing them in real life and without necessarily forming personal relationships as a result anonymity inside the virtual world may reduce the salience of normative influence competing models two competing models were tested competing model 1t measured social identity as first order constructs competing model 2 was run without the social identity constructs competing model 2 the second competing model was run without the social identity constructs the model fit was acceptable p 00 cfi 0983 nfi 972 nnfi 0980 ifi 0983 srms 07 rmsea 069 this model confirms the links between enjoyment and intention to use attitude and intention and subjective norms and intention that were not established in the hypothesized model but were proposed in the literature 50 63 67 hence our three models show that the addition of the social identity construct in technology acceptance models has an effect on the other established causal relationships for example between attitudeintention and subjective normsintention discussion consumers are increasingly using virtual online games to spend time and interact with other users the objective of the study was to examine this issue from the viewpoint of users intentions to use experiential virtual game services the developed framework showed that social identity is the strongest determinant of intention and behavior in the study setting social identity outweighs the effect of attitudes enjoyment and subjective norms in explaining intention to use a gaming service furthermore the empirical test of the model successfully validated the multidimensional view of social identity our findings further indicate that affective social identity is the strongest indicator of a persons social identity outperforming the effects of cognitive and evaluative social identity affective social identity also has the strongest association with intention to use a game service and behavior theoretical contributions in line with the theory 8 11 the most notable finding of this study was that social identity is a strong antecedent of intention and behavior in the social virtual world context our findings also demonstrate that social identity outweighs the effects that enjoyment attitude toward use and subjective norms have on intention we showed that social identity consists of three components and these functions are important in determining a persons intention and behavior in a gaming world in line with the theory 11 the most influential component was found to be affective social identity followed by evaluative and cognitive social identity previous studies have identified similar results bagozzi and dholakia 11 found in their study of both harley davidson brand communities and nonharleydriving club members that affective social identity was the strongest part of social identity while the evaluative component was somewhat less strong and the cognitive component the least strong they also noticed that customer communities organized around small groups resulted in greater social identification than similar communities of customers organized around a more general topic in line with bagozzi and dholakia 11 then it can be concluded ease of use 79 17 that customers in small group brand communities are more homogeneous in their psychographic characteristics and therefore have greater social identification thus the strength of social identity in this study may be explained by the psychographic similarity of the examined virtual world participants in summary it seems that the finding that social identity is a strong antecedent of intention is more robust when interaction in the group is dense andor organized around a specific theme or setting 11 13 the strength of affective social identity indicates that a persons intentions to use virtual world may be predicted from his or her feelings of belonging to the group thus if a person feels that he or she belongs to a group in the virtual world he or she is more likely to visit that world affective social identity also showed a direct relation to behavior this suggests that a person attached to the group to which he or she belongs is more likely to perform direct behaviors evaluative social identity is another important antecedent of behavior therefore the more important and valuable member of the group the person perceives him or herself to be the more likely he or she is to perform behaviors in the group in contexts in which social identity is not present behavioral intentions can be predicted from attitudes subjective norms and enjoyment in other words these constructs become significant predictors of intention and behavior when social identity is not included in the models or its role is minimal this kind of situation may occur when a person interacts with people that he or she does not know very well for example when joining a new discussion or interest group within the virtual world because the group members are just starting to get to know each other social identity and especially the emotional attachment to the group has not yet strengthened instead the members attitudes toward using the service and their perceptions of enjoyment in using it may be better predictors of whether they take part in discussions in the future subjective norms may also influence a persons intentions thus if the individual member of the group supposes that the other members think that he or she should for example take part in later group discussions he or she will perceive social pressure to do so another important finding is the role of enjoyment as an antecedent of attitudes in line with the literature 1 29 46 47 63 84 90 94 the links between enjoyment and ease of use and enjoyment and attitude were strong suggesting that attitude is influenced by perceived enjoyment thus a person who finds participating in the discussion group enjoyable for example is more likely to have a positive attitude toward the service the link between intention and behavior was strong in all model tests this link has been studied extensively in the prior literature 3 11 13 this study confirms that intention is also an important antecedent of behavior in the social virtual world context managerial contributions our study shows that participation in virtual worlds can be predicted from intention which can in turn be predicted from social identity the importance and dominance of social identity were prevalent and this construct outweighs all other constructs tested moreover comparing this finding to the prior literature shows that the role of social identity as an antecedent of intentions seems to be higher when interaction in the group is dense and also organized around a specific theme or setting from a managerial viewpoint this implies that developers of virtual worlds should consider building themebased virtual worlds which are designed to promote a particular type of content among a community or provide more opportunities for themebased group formation among the participants of virtual worlds we have identified the following important characteristics for developing virtual worlds and a persons social identity within them first developers of virtual worlds should promote the development of social identity among users that is a part of ones selfconcept deriving from the knowledge attached value and emotional significance of a certain membership of a social group 79 in other words developers should enable and encourage users to get to know each other make friends and form communities and teams to work together on solving a problem or completing a certain task to support the feeling of belonging within the groups which refers to the affective side of social identity the developers and administrators of virtual worlds should allow groups to interact without restrictions for example by allowing the users to interact vividly both verbally and nonverbally in addition a highly personalized graphical user interface and making it possible to design group logos for example would support social identity formation in the virtual world context the results can also be viewed in the light of marketing communications the hypothesized link between attitude toward advertising and intentions was not significant which indicates that a persons intention is not affected by his or her attitude toward advertising in the virtual world from the advertising point of view this finding suggests that regardless of how disruptive sensitive harmful or beneficial advertising in the virtual world is it has no direct relationship with intention to use the service for advertisers this finding could have both positive and negative implications as the users do not change their intentions on the basis of advertising on the service marketers may be launching ads perceived as disruptive these kinds of ads can be for example popups or floating ads however effective marketing in virtual worlds might just call for more sophisticated forms of advertising as social identity was the central determinant of intention and behavior marketing should support the development of the users social identity by reinforcing the users perceptions about their belonging to and importance in a group this type of advertising may involve games that require players to form social groups another important finding for marketing communications is that perceived enjoyment affects both the perceptions of ease of use and attitude toward using study limitations and future research the empirical assessment of our framework should be interpreted in light of several limitations arising from our sample common method bias and direction of causality first our study used a convenience sampling method which yielded a sample that is very much dominated by females and the young one can expect that preteens responses to surveys might be superficial however we found no biases in the answers due to respondents age therefore the results cannot be generalized to other populations to be more certain on possible answer bias a comparison sample should be collected second although common method bias was minimized its impact on survey study results could only be completely ruled out if longitudinal data were used third the direction of our causal relationships is based on theory rather than on mathematical caveats however we were able to also contribute to the discussion around the direction of causality between the constructs enjoyment and ease of use the limitations and findings presented offer important opportunities for further research we propose researchers further validate the links between social identity and the other constructs considered in the study specifically prior studies have not conceptualized and therefore not tested the association between social identity and enjoyment or social identity and attitude as theories have not examined these aspects before further work is needed to capture the links between social identity and the other constructs research has mostly concentrated on modeling the links between social identity and intention 11 13 in addition we propose more research on the concept of social identity in experiential service settings previous studies have merely modeled social identity in the context of goaldirected behavior and not in experiential services including pleasureseeking and hedonic user experiences 11 13 finally although this research has incorporated a variety of constructs into the developed framework it seems that other factors may also exert an influence as such the exploration of differentiated service dynamics in alternative contexts seems a potentially fruitful avenue for research finally it would be interesting to develop better understanding of how to grow the user base in virtual worlds especially how can new users be attracted and what are the key issues at this stage this calls for more research prior to exposure to the virtual world and prior to the social influence exerted by other users of the virtual world

this study develops a framework for understanding user intentions and behaviors within a virtual world environment the proposed framework posits that the intention to participate in virtual world is defined by a persons 1 social identity 2 attitude toward using the service 3 subjective norms 4 attitude toward advertising on the service and 5 enjoyment the proposed model is tested using data n319 from members of the virtual world environment the results support the multidimensional view of social identity and show a strong positive association between social identity and intention and social identity and behavior and further confirm the intentionbehavior link moreover the results indicate that social identity outweighs the significance of a persons attitude and relevant subjective norms in explaining intention and behavior the results also indicate that enjoyment strongly explains both ease of use and attitude

introduction the rapid increase of global mobility that has characterized the mature phase of the globalization process in the past couple of decades has also as a consequence led to the escalation of overtourism issues in many global tourism destinations and most notably in major art and heritage cities despite massive flows of tourists clearly benefit the local economy they also pose a major threat to both the livability and in some cases even the sustainability of cities that are literally consumed by a level of human occupancy they werent designed or intended to host in barcelona where the number of overnight stays escalated from 17 millions in 1990 to more than 8 millions in 16 years overtourism is one of the key causes of an environmental pollution emergency in addition to the most renowned tourist locations the geography of overtourism is also rapidly expanding due to the global visibility acquired by some cities for having been the shooting location of successful tv series as in the case of dubrovnik for game of thrones however an increasing number of critical voices are questioning this trend locally as well as internationally for residents overtourism may have dramatic consequences housing for permanent residential use becomes increasingly scarce and expensive services catering to the needs of locals become rarer more difficult to reach and again more expensive the constant noise and the overcrowding of streets and local transport can be a source of considerable stress for working people families with small children and the elderly in cities like venice the number of bedandbreakfasts and flats for shortterm tourist occupancy has nearly doubled in the space of just one year as a consequence residents are evicted by landlords who find way more profitable to rent to tourists in florence for instance between october 1 2017 and june 30 2018 as many as 478 residents who couldnt keep up with the rising rents had to leave their homes including lifetime ones 209 living in the historical center 71 in the unesco area and 198 in other areas of the city more generally the socalled airification has been identified as a disruptive force that is literally hollowing out cities such a state of things does not come as a complete surprise to the tourism studies literature although early warnings were appropriately sent as in the seminal paper by van den borg et al they have not succeeded in convincing local policy makers to devise appropriate countervailing strategies and to take action now that the negative effects of the phenomenon are becoming indisputable however some cities are starting to react aggressively amsterdam has banned the concession of new licenses to business within the historical city core that offer goods and services targeting tourist demand as a way to curb the disneyfication of the city bruges has strictly limited the maximum number of cruise ships that may be hosted at its ports docks on a daily basis and has limited its own tourismrelated advertising in major nearby cities venice has implemented a very severe set of restrictions to many different kinds of tourist misbehavior sanctioned with heavy fines ten major european heritage cities such as amsterdam barcelona berlin bordeaux brussels krakow munich paris valencia and vienna have jointly signed a letter to the new eu commission asking for severe limitations to the further expansion of airbnb and other holiday rental websites however it is not easy to go against such a powerful trend despite that the current covid19related crisis that has caused a temporary collapse of the tourism industry worldwide will probably provide overcrowded tourist cities with an unexpected opportunity to prevent the eventual return to the old normal once the pandemic is over the vested interests that rely upon the extractive logic of the mass tourism economy are a major local consensus pool and exert powerful political pressure on the other hand the needs of tourists and residents significantly differ and this is likely to spark conflict between different local stakeholders depending on the extent to which they benefit from tourism whether or not a city eventually gets colonized by the tourism economy or manages to find a reasonable compromise can therefore be the result of a very complex interplay of factors it is therefore of particular importance to study under what conditions such interplay leads to different longterm scenarios thus enabling public decision makers to better understand not only the nature of the problem in order to imagine and test possible solutions but also the critical conditions that regulate the emergence of possible outcomes merely proposing plausible or just solutions is not enough we also need to assess whether such solutions would work and under what circumstances once they are actually implemented in principle solutions that are more desirable in abstract terms need not be the ones that work best as cities are very complex dynamical systems the pursuit of the public interest which in this case identifies to a significant extent with that of city residents whose right to the city should be the object of special consideration and protection needs to be supported by evidencebased policies building upon a sound understanding of the underlying economic and social dynamics the aim of this paper is that of studying a simple dynamic model that analyzes the effects of the tension between residents and tourists in the social usage of city resources we focus on the interplay of the essential factors behind such tension the substitution between residentoriented and touristoriented facilities and shops the congestion of city space from overtourism but also the experience value of cities as related to the effective presence of residents as a source of authenticity given that the escalating tourist flows are literally preying on the citys resources from the residents viewpoint it is natural to think of modeling such dynamics with the predatorprey framework in mind we introduce an expanded variant of the predatorprey dynamics which yields more complex dynamic behavior than the original one and allows a better analytical treatment of the main factors at play the models structure is easily interpretable but the corresponding dynamics are not obvious in particular we show that the actual dynamic trajectories of the system may be very different for relatively small changes in the key parameters this implies that even relatively small differences in local conditions and in policy actions may cause divergent outcomes with substantial differences in terms of their social desirability our results should be read as a cautionary tale against delayed or unsystematic action in curbing the social costs from overtourism intervening too little or too late or not focusing on the truly critical parameters might lead to disappointing results the remainder of the paper is organized as follows section 2 offers a brief review of the main issues discussed in the overtourismrelated literature section 3 presents the model section 4 contains the main results section 5 discusses the results and concludes a technical appendix closes the paper literature review one vastly debated issue that clearly relates to overtourism is that of residents attitudes toward tourists there is a rich literature that explores this topic but most of it has dealt with minor or even marginal tourist destinations rather than with overcrowded tourist attractors lin et al focus upon the process of value cocreation through social interaction between tourists and residents in a chinese sample and find that the positive economic benefits from tourism may also positively affect the life satisfaction of residents mathew and sreejesh working on a sample of three indian tourism destinations highlight the relationship between responsible tourism and perceptions of sustainability of the tourist destination in promoting the perceived quality of life of residents on the other hand boley et al show that although destinations that place more emphasis on sustainability tend also to be the more sustainable perceptions of actual sustainability by residents tend to be low rasoolimanesh et al show that for two unesco heritage sites in malaysia one of which located in an urban context and the other in a rural one there are nuanced differences between the urban and the rural site in terms of the impact of residents perceptions on the support for tourism development or lack thereof but also substantial homogeneities therefore when tourism is still in a developing phase the evidence of the benefits from tourism development can be a main driver of support from residents and this effect may even cut across major territorial divides such as the urbanrural one as shown by stylidis et al and wang and chen a central mediating role in residents perceptions of the impacts of tourism is perceived place imagea dimension that is tellingly significantly compromised in destinations affected by overtourism but can be improved by an increased tourists presence in developing destinations it is no surprise that literature reviews of this research field lament the excessive narrowness of focus of most research as well as its reliance on specific quantitative techniques that are good at highlighting specific effects but often fail to deliver the big picture for instance almeida garcia et al argue that the current literature on residents perception of tourism significantly underplays the role of key historical cultural and social factors in shaping a specific destination and its response to tourism moreover the nature of the ecological interactions between the residents and tourists populations may make a big difference and has an intrinsically dynamic nature and if this is true in general it is even truer for overcrowded destinations and the possible scenarios may be very different from one another for instance touristic congestion may be the result of a sudden boom or of a gradual steady increase the pervasive presence of tourists in the urban space may have become a deeply ingrained feature of the local culture or be an outcome of recent tourism development strategies the availability of space and the impact of building density may be not particularly problematic for urban livability or rather extremely critical and exacerbated by tourism flows and so on just to limit ourselves to a few obvious examples segota et al show for instance that the informedness and involvement of residents in the local management of tourismrelated issues significantly impacts their perceptions in the expected direction a rare example of a study on the acceptability of crowding perceptions by residents in a global tourist destination such as bruges carried out by neuts and nijkamp moreover shows that the actual negative perception of crowding varies widely across residents depending on individual characteristics and is not found in the majority of the sample however the situation might have changed now in the light of further recent accelerations of tourism flows in many heritage cities as possibly signaled by bruges current deadvertising on the tourism market despite this overtourism and its policy implications are still relatively poorly covered in the literature with the consequent risk of failing to fully appreciate the complex social conflict issues that can emerge and deflagrate in the absence of proper policy strategies and management at the city level the key critical aspect which is amplified by overtourism but already apparent in developing destinations even in the case of positive residents perceptions is the impact of tourism on local culture and behaviors whose effects can only be appreciated in full in the mediumlong run of course culture and behaviors are inevitably bound to change anyway independently of tourism but the changes induced by tourism might eventually clash with the developmental priorities and goals of local communities on socioeconomic inequalities on community empowerment and so on especially critical is the evaluation of residents perceptions in developing countries affected by substantial socioeconomic issues analyses that rely on an exclusively tourismcentric perspective are likely to overlook the most critical dimensions ribeiro et al s analysis of the development of protourism behaviors of cape verde islands residents is an example in this regard nunkoo and gursoy instead consider in the case of mauritius the role of local identity in the orientation of residents support for tourism but interestingly point out how even the emergence of a supportive orientation need not reflect into a significant shift in attitudes thus underlying the complex functioning of community identity as a regulator of cultural and social change on the other hand tourism itself is constantly raising the bar as to the level and depth of interaction with local social life and customs that tourists expect to reach as a quintessential aspect of their experience to the extent of becoming cocreators of the experience itself prebensen and xie show for example that the level of tourists participation under the form of mastering and cocreation in experience tourism significantly enhances their value perception paulaskaite et al highlight how tourists increasingly expect to spend their time at the destination living like the locals therefore transforming local identity itself into a commodity that can be purchased at will such issues are relevant for all kinds of tourist destinations but they are especially problematic in overcrowded ones overtourism shifts the focus of residents perceptions on critical aspects such as the pressure of tourism flows on the local system the threats to ecological sustainability and the role of media and social media in particular in causing tourist congestion peaks on an almost instantaneous basis in other words the aspect of overtourism that is seen as the most socially alarming is its capacity to put under stress at an unprecedented scale and pace the homeostatic mechanisms of local systems on many different levels economic social cultural logistical and so on overtourism magnifies many of the most critical features of tourism to an extent that strains local governance and regulatory capacity however its effects may be more critical on certain dimensions rather than others when such impact is perceived as disruptive by local communities social protest ensues once a perceived saturation level is reached a vicious circle can take over as residents classify as threatening by default any tourism event that causes local congestion irrespectively of its quality importance and expected longterm benefit for the city this kind of vicious circle may mutually reinforce with others eg the one causing the erosion of local services quality in overcrowded tourism destinations such social dynamics are difficult to manage at all levels and even large digital tourism platforms may find it hard to function well when the effects of digital influencing upon spatial patterns of tourism congestion spark social controversy such new systemwide challenges may be effectively tackled only through tailored sophisticated forms of local cooperation between key stakeholders and of smart governance the model the literature briefly discussed in the previous section shows how the problem of overtourism in the more general context of the residents perceptions of the social and economic impacts of tourism is generally focused on the analysis of specific case studies and on the measurement of perceptions and attitudes by means of suitable psychometric tools in this paper we take a different route as a contribution to a comprehensive approach to the smart governance of overtourism dynamics that of characterizing such dynamics in terms of an explicit mathematical model the ambition of the model is not to provide a detailed realistic representation of overtourism in all of its multifaceted dimensions but to examine what are the basic conditions that may favor or prevent its onset paying special attention to a basic phenomenon the competition between residentoriented and touristoriented services for the limited spatial and material resources of the city as we have seen from the literature review a detailed modeling of such dynamics would involve many different variablesplace identity social perceptions local culture historical trajectories and many moreand this would easily make an explicit dynamic analysis intractable due to the number of potential variables implied however simplifying the model to its essentials has the advantage of providing some insight that may help focus upon the possible dynamic regimes that may prevail providing policymakers with some important indications for policy design we choose as our conceptual benchmark the classical lotkavolterra predatorprey model which has been the object of countless applications in a variety of different fields and of mathematical generalizations of all kinds due to its optimal combination of simplicity of structure and richness of dynamic behaviors in our case the predatorprey logic is somewhat ingrained into the nature of the problem we want to analyze as one thinks of overtourism as the process through which tourism flows literally capture the local system reshaping it according to their necessities on the other hand even a basic description of the overtourism problem urges us to depart from the basic formulation of the predatorprey model to better take account of some essential specificities in particular the model we propose has the following structure ẋ r ax bx c ẏ s dx y ex f y where x is the level of the resident population and y is the level of the tourist population all parameters are positive let us now see in some detail the rationale behind the equations the basic premise of the model is that there is an implicit competition between residents and tourists for the availability of services and resources that respond to their specific and partly mutually incompatible needs in particular there are two threshold values of x and y x and ȳ respectively beyond which the local level of residents is large enough to warrant a satisfactory provision of resident specific services and resources we call such thresholds the relevance thresholds when one population crosses its relevance threshold the local economy becomes increasingly respondent to that populations needs and this positively influences the dynamics of such population these two effects are captured respectively by the two terms x x and y ȳ so the level of the resident population is positively depending on whether the residents are above their relevance threshold and negatively depending on whether the tourists are above their relevance threshold in this latter case however the size of the effect is scaled by the level x of the resident population the larger the pool of residents the more an abovethreshold level of tourists makes competition for scarce space and resources more sustained increasing the negative impact of tourists on the resident population parameters b and c measure the relative size of the two effects moreover the dynamics of the resident population also linearly depends on the actual level of the resident population as the choice to live in a city is characterized by some amount of inertia due to a variety of factors such as relocation costs habit cultural and affective reasons jobrelated reasons and so on as to the tourist population it positively benefits from the crossing of its own relevance threshold as already anticipated and the effect is measured by the parameter e moreover its dynamics are negatively influenced by tourism congestion an effect whose size is measured by the parameter f finally the tourist populations persistence in the destination also depends and in a positive way on the level of residents as measured by the parameter d insofar as the resident population is small the city basically turns into a theme park devoid of any specific authenticity and vitality to become a mere entertainment district that maximizes tourismrelated profit this effect as already hinted at in the discussion of the previous section therefore captures the experience economy dimension as tourists do not simply ask for entertainment but also value opportunities of meaningful interaction with locals finally parameters r and s measure the exogenous components of the rates of growth of the resident and tourist populations respectively the system of equations above can be conveniently rewritten as follows ẋ r c x x bx y ẏ s e ȳx x y f y in our analysis we will refer to as the default formulation of the model existence and stability of the stationary states to analyze the dynamic behavior of the model we start by posing a a b ȳ c b b c x r a b ȳ c c e ȳ e d d s e ȳ e f d e the complete taxonomy of possible dynamic regimes is illustrated in the following proposition we will see how even a relatively simple model like the present one can generate a rich array of dynamic behaviors depending on the prevalence of certain constellations of conditions rather than others proposition 1 under the assumption that all parameters of the system are strictly positive the following dynamic regimes can be observed if b 0 ie x r c then at most two stationary states exist in particular if either d b e or e d b holds a unique repelling stationary state p exists in the appendix if b min d e two stationary states p 1 and p 2 with x 1 x 2 and y 1 y 2 may exist where p 1 is always a saddle point whereas if d e then p 2 is a repeller and in the appendix if d e then p 2 is either a repeller or an attractor if b 0 a unique stationary state exists if d e it is a either a repeller or an attractor while if d e it is an attractor proof see appendix to explain the meaning of proposition 1 let us start by understanding better the interpretation of the new composite parameters a b c d and e the parameter a measures the relative size of the parameters that positively regulate the growth of the resident population vs the parameter b that negatively affects it in particular the growth of the size x of the resident population depends positively on the parameter a on the parameter c we can therefore intuitively interpret a as a measure of residents resilience as for b it positively depends on the relevance threshold of the resident population the larger it is with respect to r and with respect to the parameters that positively influence residents resilience the larger b b can therefore be intuitively interpreted as a measure of residents susceptibility the higher b the more demanding for the residents community to fulfil the conditions for the prevalence of a residentoriented local economy likewise c can be interpreted as a measure of tourists susceptibility as c is larger the higher the threshold of relevance for tourists e ȳ and the smaller the combined strength of the experience value parameter d from visiting the city plus the impact e of crossing the relevance threshold on the availability of touristoriented services and resources d can be seen as the citys intrinsic attraction value for tourists as it equals s scaled by the relevance threshold for tourists finally e measures the tourists relative congestion effect expressed by the congestion parameter f scaled by the combined strength of the experience value and resource and service availability effects for tourists at this point we are ready to illustrate the findings in proposition 1 the results are organized around the sign of b that is whether or not the residents susceptibility problem occurs which implies a relatively high relevance threshold for the residentsoriented local economy to kick off in the case of a positive level of residents susceptibility that is b 0 we have at most two stationary states that can be potential equilibria for the dynamics a first subregime relies on two possible conditions at which of the two possible stationary states only one exists and is repulsive that is the dynamics never settle down to a given state the two conditions are d b e and e d b in the first case we have a condition where the congestion effects is particularly high with respect to residents susceptibility and to the intrinsic attraction value for tourists this is for example the case of a relatively small city where despite the comparatively modest attraction value congestion is a problem and tourists can crowd out residents relatively easily in the second case we have to the contrary a situation where congestion is relatively unimportant and residents susceptibility is comparatively high in presence of a relatively substantial attraction value this is for instance a scenario that could describe a relatively large city with high carrying capacity and culturalamenity value where there is real competition for local resources and services between residents and tourists these two conditions may therefore span very different cases a second subregime contemplates again the existence of two possible stationary points one of which is always a saddle that is a state where a unique converging trajectory exists and all the other ones diverge the key condition for the second subregime is that b be smaller than both d and e given that b is constrained to be positive the condition requires that both the congestion effect and the intrinsic attraction value are relatively high an example here is that of an established tourism destination with severe congestion problems where however the issue of resource accessibility for residents is relatively less binding possibly due to a large diversified local economy that can accommodate local demand an extra condition regulates the dynamic properties of the second possible steady state according to the relative size of the two potentially dominating effects if the dominant effect is congestion the second stationary state is locally unstable if instead the dominant effect is the intrinsic attraction value the second stationary state may either be locally unstable or locally stable that is may attract all local trajectories and emerge as a stable state when residents susceptibility is not a major concern the dynamic regime is much simpler in this case the stationary state is always unique moreover if congestion prevails upon intrinsic attraction this state may be either attracting or repelling if the opposite is true and intrinsic attraction prevails the stationary state is always attractive an example of this latter condition is a worldrenowned tourist destination with a large carrying capacity that can manage congestion and where the competition between residents and tourists for local services and resources is not binding proposition 1 tells us among other things that the dynamics we are studying is not in many cases conducive to a stable equilibrium state and is rather characterized by more complex longrun behaviors the stability properties of the stationary states do not give us enough information to understand what such dynamic behaviors will look like as they only provide insight about what happens close to them however the structure of stationary states is an important piece of information and in particular it is interesting to ask how the number and stability properties of the stationary states vary depending on the levels of specific couples of parameters such as the relevance thresholds for residents and tourists given our focus on overtourism and its possible impacts in all the analysis that follows the choice of parameter values for the simulations has been made in order to select cases that enable us to illustrate clearly and in a compact way the dynamic properties of the model figure 1 illustrates the bifurcation diagrams obtained by varying the relevance threshold y panels and show how the coordinates x and y of stationary states vary in response to variations in y the lp point separates the interval of y values where no stationary state exists from that in which two stationary states exist the point h indicates the hopf bifurcation value of y dashed continuous and dotted lines represent saddle points attractive and repulsive stationary states respectively the conditions under which a hopf bifurcation occurs by varying the parameter y computed according to the criterion proposed by liu are given in the appendix in panel of fig 1 we show how through the hopf bifurcation a family of limit cycles emerges notice that an increase in the parameter value y leads to an increase in the magnitude of the limit cycles in fig 2 we show for a specific set of parameter values the bifurcation diagram that illustrates the existence and stability of the stationary states as the two relevance thresholds vary figure 2a provides the full diagram whereas fig 2b presents an enlargement of the rectangle area where the most finegrained structure is found as we can see the bifurcation diagram contains here all seven possible scenarios for the stationary states where in fig 2 the apexes a r denote respectively regions where two stationary states exist of which one is a saddle and another an attractor regions where two stationary states exist and are in particular a saddle and a repeller regions where one stationary state exists and is an attractor and regions where one stationary state exists and is a repeller the h curve is the hopf bifurcation curve whereas the lp curve is the one that separates the region without stationary states from the region where at least one stationary state exists the hopf bifurcation curve h separates the regions where an attractive stationary state is found from those where a cycle emerges as shown in more detail in fig 2b in the simulations below we find that the attractive cycle is stable and the corresponding stationary state consequently becomes unstable figure 2c instead reports the bifurcation diagram in the space where we study how the structure of stationary states varies with the parameters that measure the strength of resource provision when residents cross their relevance threshold again the bifurcation curve h and the lp curve delimit the areas where one of the stationary states changes its local behavior from repulsive to attractive and where stationary states exist vs fail to exist from these figures we see how in the case of the bifurcation diagram for the relevance thresholds there is a vast region where stationary states do not exist for most values of the relevance threshold for residents if the relevance threshold for tourists is small enough that is when tourists are substantially favored in their capacity to access local resources with respect to residents the dynamics fails to settle on a stationary state however when the relevance threshold for residents is very low even for relatively high levels of the relevance threshold for tourists a stable stationary state emerges that is when residents succeed in getting access to the local resources the system has a chance to stabilize itself but when the relevance threshold for tourists or even both thresholds become very high so that it is difficult for both populations to gain easy accessibility to local resources there is no chance that the system may settle down to a stable equilibrium in the case of the bifurcation diagram in the space the pattern is more complicated and the existence of stable stationary states here relies on more specific combinations of the two parameters in general when c is very high that is when the access to resources beyond the relevance threshold has a big positive impact on the population of residents no equilibrium exists whereas for smaller values of c a stable stationary state can emerge again when both parameters are large no stable stationary state can be found remember that these bifurcation diagrams are drawn for a given choice of numerical values of all the other parameters and that they change as any one of the other parameters varies to get a better understanding of what the actual trajectories of the system look like we report a few examples of phase diagrams for a specific choice of parameter values in fig 3 in particular we keep the values of all the other parameters but the relevance thresholds as in fig 2 and we set a specific value for x 4 letting ȳ vary the four cases correspond respectively to points from the white yellow indigo and orange regions of fig 2b for ȳ 08 for most initial conditions the system converges toward states where the resident population goes extinct and only a stable level of tourists is observed this is a full disneyfication scenario where the city turns into a tourist theme park where the eventual level of tourists depends on initial conditions as it could be expected this is due to the fact that the relevance threshold for tourists is very low with respect to that for residents and consequently tourists take over local services and resources expelling the residents however for very low initial levels of tourists and high enough levels of residents there are also trajectories where residents take over the city letting tourists go extinct or remain present at very low levels as the relevance threshold ȳ grows to 11 making access to resources more demanding for tourists we witness the emergence of a stable attractor where residents and tourists stably coexist in the long term approaching this state through a cyclical adjustment path whose basin of attraction is delimited by the yellow region outside this basin depending on the initial level of tourists vs residents we find as before that either tourists take over entirely or residents do entirely or partially as ȳ is brought further up at 13151 the stationary state becomes unstable and cyclical behaviors emerge within the yellow region whereas outside the region one still observes as before depending on initial conditions the eventual takeover of tourists or the emergence of a state with high levels of residents and some tourists finally with ȳ at 135 the system is destabilized the stationary state is unstable and the trajectories may entail big oscillations where despite that both the noresidents and prevailingresidents longterm states can materialize as before it is also possible that the limit state is reached through expanding fluctuations in particular it is interesting to observe that as the conditions for accessibility of resources for tourists become more demanding as ȳ increases the resulting dynamic behaviors do not simply favor residentsrather what we observe is an increase of the systems dynamic variability with the eventual emergence of cyclically diverging behaviors where big changes in the levels of residents vs tourists are observed in time in fig 4 we highlight a different phenomenon namely how the size of the basin of attraction of the stable stationary state varies with the variation of ȳ for a given value of x we now fix x 22 and choose the values of ȳ in order to always remain within the yellow region of fig 2b where a stable stationary state exists as we see in fig 4a as ȳ increases the size of the basin of attraction of the stable stationary state significantly increases in fig 4b we analogously set ȳ at a constant value 12 and let x vary in this case as with the increase in x access to resources becomes less and less easy for residents the size of the basin of attraction of the stable stationary state gradually shrinks maintaining a viable access to resources for residents therefore causes as one might expect a dynamic stabilization of the system figure 5 reports yet another angle of analysis namely how the coordinates of the stationary state vary with ȳ for a given level of x and of e the other parameters are still kept at the usual values we see that as ȳ increases the stationary state entails smaller equilibrium levels of both tourists and residents however for a given ȳ increases in x imply lower levels of tourists at the stationary state this pattern of course only informs us about the composition of the stationary state but not about its stability properties or if attractive about the size of its basin of attraction in fig 5b as it could be expected as c grows we see that the stationary state entails lower and lower levels of tourism all other things being equal beyond a certain threshold for c the steady state level of tourists keeps declining even when e increases whereas below the threshold an increase in e causes a corresponding increase of the level of tourists at the steady state we have checked the robustness of our simulation results through further extensive numerical tests that are not reported here for brevity and which confirm our analysis discussion and conclusions we have built a simple model to study the conditions for the emergence of overtourism through mathematical simulation of a predatorpreyinspired dynamical system the core element that drives our dynamics is the competition for the accessibility of resources and services between residents and tourists a feature that is typical of overtourism and is mainly responsible for its most disruptive effects the model has been further enriched with a few elements that capture effects such as tourist congestion or the experience value for tourists deriving from the interaction with residents or from the intrinsic attractiveness of the city even if studying the model in its most essential form the dynamic analysis is challenging our model shows that under suitable conditions overtourism may emerge to the point of causing a full disneyfication of the city with the eventual extinction of all residents and its final transformation into a tourist theme park however also the reverse option is possible with tourists disappearing from the city or reaching a stable level without taking over the local economy of course in addition to these extreme cases the possibility of a stable coexistence of residents and tourists is also possible but equally possible are more complex dynamics that may entail stable cyclical oscillations or wide variations in the relative levels of the populations of residents and tourists the outcome that is eventually reached depends on a very complex constellation of parameters each of which plays a specific role that can however be fully understood only by means of a thorough analysis what we have learnt from this study is that in a nonlinear setting acting on specific parameter values may cause counterintuitive effects as we have seen some cities have decided to tackle overtourism by restricting tourists access to local services and resources in our model this basically amounts to raising the relevance threshold of tourism as it makes the conditions for access to touristspecific resources more demanding however this does not necessarily entail the eventual reduction of the number of tourists or even the reaching of a stable stationary state where the number of tourists is under control it may happen instead that the main effect of raising the threshold ȳ is destabilizing the system for instance by causing the emergence of large oscillations in the levels of residents and tourists this means that contrary to commonsense approaches it is important to understand how certain measures affect the whole structural organization of the local economy the interplay with factors such as congestion intrinsic attractiveness or experience value can generate complex dynamic effects that influence the existence and stability of stationary states and more generally the dynamic behavior of the system it is interesting to notice that in determining the existence and stability properties of the stationary states of the model certain composite parameters play a more substantial role than others in particular residents susceptibility is the key parameter in determining the dynamic regime that prevails whereas residents resilience and tourists susceptibility play practically no role although it is far from excluded that they may play a role in the dynamic behavior of the system far from equilibrium the central point seems therefore to be the conditions for access to local services and resources by residents promoting residents access does not merely amount to restricting access to the same resources to tourists lowering residents susceptibility might be a better strategy and also a source of stabilization of the system this goal may be reached for instance by providing better social and welfare services to residents by supporting social entrepreneurship that better addresses critical local needs by improving the quality of key resident services such as kindergartens or retirement houses and so on what is important to stress is that in a nonlinear system even relatively small changes may make a big difference for better or for worse and therefore building models that allow to estimate the likely impact of policy measures as an essential support tool for public decision making becomes crucial it is unlikely that overtourism will be successfully dealt with by cities through the implementation of occasional measures without a clear evidencebased strategy that is informed by a solid knowledge of the underlying system of structural interdependencies not unlike what happens in the management of ecological systems our study has clear limitations due to the extreme simplicity of the model that disregards many potentially relevant factors in particular the role of residents and tourists expectations and attitudes that as we have seen is an important aspect in the current evaluation of the social and economic impacts of tourism could also be modeled with all the ensuing complexities arising from cultural transmission effects misperceptions and biases manipulation of consensus and so on another important limitation is that an empirical estimation of the values of the model parameters is not simple and would call for a sophisticated nonlinear econometric analysis data availability is also demanding as ideally very long time series of residentstourists populations of cities with significant or potential overtourism issues would be required the nonlinearity features of the model would imply that even relatively small estimation errors might have big consequences on the projected dynamics yielding potentially misleading indications the present paper has therefore mainly a conceptual value in drawing attention upon the dynamic complexity of the socioeconomic dynamics of overtourism and the ensuing necessity to carefully assess the longterm effects of policy changes even when they intuitively seem to respond effectively to outstanding issues curbing tourist congestion through the reduction of commercial licenses for tourismrelated businesses for instance looks like an appealing solution but its longterm consequences might be more complex than one could expect depending on the overall structure of the local economy and its ecosystemic interdependencies in its current form our model is not tailored to guiding policy design choices a task that requires suitably calibrated empirical models but we hope that this first study may inspire further more sophisticated analyses that will serve in turn as a guide for the construction of policy oriented tools we look forward to this promising perspective we obtain 9173884257 0 and therefore condition 2 holds finally at ȳ ȳh we have dt d ȳ 1292610372 0 so that a hopf bifurcation occurs at the parameter value ȳh 1309562086 existence and stability of stationary states in order to study the existence of the stationary states we rewrite the system so the isoclines 0 and h 0 of the dynamical system become y g a x y h c x d x e 7 it is easy to check that the above functions are two hyperbolas with the following properties i the function y g presents an horizontal asymptote at y a a vertical one at x 0 and its graph crosses the xaxis at x b sign ii the function y h presents an horizontal asymptote at y c a vertical one at x e and its graph crosses the xaxis at x d remark 1 the graphs of g and h can have at most two intersection points and therefore at most two stationary states exist furthermore under the assumption that all parameters of the system are strictly positive it is easy to check that the inequality a b is always satisfied overlapping the pairs of fig 6ac ad and bd we obtain all possible intersections between the two isoclines as shown in fig 7ag this proves the claim about the existence of the stationary states of proposition 1 in order to study the stability properties of the stationary states we compute the jacobian matrix of the system evaluated at the stationary state p j b bx f e f e we know that the signs of the determinant d give us the stability properties of the stationary state in particular if d 0 then the stationary state is a saddle point if d 0 and t 0 the stationary state is a repeller point we prove the result for the subregime 0 b e d in proposition 1 shown in fig 7d the other claims for the other subregimes can be proven in the same way we observe that the slopes of curves g 0 and h 0 are given by m g y a x m h y c x e at any given stationary state p in this respect we rewrite the determinant as d b f e x m h since y a 0 y c 0 x e 0 the stability analysis can be developed as follows i at the stationary state p 1 the curves g 0 and h 0 are both increasing and the slope of g 0 is greater than that of h 0 then the determinant d is strictly negative and the stationary state is a saddle ii at the stationary state p 2 the curves g 0 and h 0 are both increasing and the slope of h 0 is greater than that of g 0 then the determinant d is strictly positive and the stationary state is either a repeller or an attractor depending on the sign of the trace t appendix hopf bifurcation the jacobian matrix of the system evaluated at a stationary state p is given by liu derived a criterion to prove the existence of a hopf bifurcation without using the eigenvalues of the matrix j according to lius criterion if the stationary state p depends smoothly upon a parameter p ∈ and there exists a parameter value p h ∈ such that the characteristic equation of j λ 2 t λ 0 satisfies the conditions publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

overtourism is an increasingly relevant problem for tourist destinations and some cities are starting to take extreme measures to counter it in this paper we introduce a simple mathematical model that analyzes the dynamics of the populations of residents and tourists when there is a competition for the access to local services and resources since the needs of the two populations are partly mutually incompatible we study under what conditions a stable equilibrium where residents and tourists coexist is reached and what are the conditions for tourists to take over the city and to expel residents among others even small changes in key parameters may bring about very different outcomes policymakers should be aware that a sound knowledge of the structural properties of the dynamics is important when taking measures whose effect could otherwise be different than expected and even counterproductive

background womens highrisk fertility behaviour which is defined by narrow birth intervals high birth order and younger maternal age at birth have been associated with negative health outcomes for both the mother and the child 12 maternal hrfb is a biodemographic risk factor that impedes the achievement of lower maternal and child morbidity and mortality 3 4 5 6 7 some demographic variables such as womens age parity and birth spacing are the crucial parameters of measuring hrbf including tooearly or toolate childbearing short birth intervals and a higher number of live births 3478 although the total fertility rate of bangladesh declined from 37 in 1995 to 204 in 2020 9 remarkably the rate of teenage pregnancy is about 35 and 15•1 gave birth less than 24 months interval in bangladesh comparing with many developing countries bangladesh has the highest rates of adolescent fertility with 82 births per 1000 women as of 2019 where over 50 percent of adolescents gave birth between the years 1519 10 several studies identified that early or late motherhood is associated with hypertension premature labor anemia gestational diabetes diabetes obesity pregnancy related complications higher rates of caesarean and operative deliveries and unsafe abortions 1112 childbearing at an early age is connected to a growing risk of intrauterine growth restriction child undernutrition preterm birth and infant mortality on the other hand late motherhood is related to preterm births intrauterine growth restriction stillbirths amniotic fluid embolism chromosomal abnormalities and lowbirthweight newborns 1213 hrfb in mothers also associated with the neonatal mortality while a study in india identified causal effect of birth spacing on neonatal mortality 14 and also childbearing at teenage was also found to be linked to neonatal mortality 15 some previous studies established a relationship between numerous hrfbrelated parameters and their detrimental effects on maternal and infant health 781617 women who start having children at an early age often have more children 18 and this is also associated with adverse maternal infant and child health outcomes 19 one the other hand short birth intervals 20 and higher birth order 21 may also aggravate the infant and child mortality although such evidence supports the consideration of different exposures to highrisk fertility behaviors as a highpriority maternal and child health concern very few studies in bangladesh have evaluated factors related to hrfb in women of reproductive age therefore in order to develop effective prevention programs for the region a clear understanding of the determinants and potential risk factors for maternal highrisk fertility behavior among bangladeshi women is required there is however a dearth of literature examining the risk factors for hrfb in bangladesh to date most of the studies on hrfb in bangladesh focused on identifying the relationship between hrfb in women and maternal and child health outcome 71722 based on these considerations this study aimed to identify the associated factors of hrfb in women identifying such determinants will be crucial for formulating evidencebased programs in bangladesh especially targeting the significant risk factors methods data sources the study relied on data from the bangladesh demographic and health survey 201718 the national institute of population research and training of the ministry of health and family welfare of bangladesh used a twostage stratified sampling approach to conduct this crosssectional study the outcomes of our study were assessed using a total sample of 7757 women the study included evermarried women aged 1549 who were not pregnant currently and had at least one child before the survey unmarried and pregnant mothers with incomplete bmi information were excluded as the sample the description about the data collection procedures and sampling frame are detailed in the original report 23 outcome variable the outcome variable for this study took into account maternal highrisk fertility behaviour developed using the definition of the bdhs 23 the study considered three variables to define the highriskfertility behaviour maternal age at the time of delivery birth order and birth interval the presence of any of the following conditions was termed as a single highrisk fertility behaviour mothers age less than 18 years at the time practicing islam as core religion age above 35 years having normal childbirth having above 3 children having unwanted pregnancies and not using birth control methods were at increased risk of having hrfb as a result of the studys findings interventions are urgently needed to prevent highrisk fertility behaviour among bangladeshi women aged 15 to 49 years of childbirth mothers age over 34 years at the time of childbirth latest child born less than 24 months after the previous birth and latest childs birth order 3 or higher multiple highrisk categories are made up of two or more aforesaid conditions highrisk fertility behaviour was defined as the presence of any of the four conditions listed above for final analysis independent variables the researchers reviewed the most recent relevant articles to determine the independent variables the selected sociodemographic and economic variables included in the analysis are place of residence administrative division religion age age at marriage education access to television body mass index current working status partners education partners occupation reproductive factors birth order antenatal care seeking and current use of contraceptive methods types of childbirth place of childbirth pregnancy wanted statistical analysis the frequency and percentage of the selected attributes were determined using descriptive statistics the pearsons chisquare test was performed to show the association between the outcome variables and the specified independent variables at the bivariate level finally the factors related to highrisk fertility behaviour were determined using a logistic regression analysis with significant components at the multivariate model these analyses included both unadjusted odds ratios and adjusted odds ratios along with 95 confidence intervals multicollinearity among covariates was checked for all models using variance inflation factors which were determined to be the modest with vif ≤ 2 for all covariates statistical package for social sciences was used to conduct all statistical analyses ethical consideration dhs data is available in the public domain and is freely available to anyone who makes a reasonable request the entire study protocol was approved by the bangladesh ethics committee and icf international thus we did not need any additional ethical approval the bdhs 201718 report contains details about the ethical approval 23 results background characteristics and prevalence of hrfb the final study included 7757 women who had given birth within the previous five years the median age of the respondents was 250 years more than half of the women aged 15 to 24 years most women lived in rural areas and overwhelmingly large number of them were muslims over half of the women finished secondary education and 628 were unemployed the worst situation was found in the rural areas for both the single and multiple hrfb about 467 of respondents from rural areas had single hrfb compared to 117 from urban areas similarly 245 of women from rural areas were at multiple hrfb which was only 44 among women from urban areas figure 2 demonstrates the prevalence of hrfb across different administrative divisions of bangladesh the highest prevalence of single risk fertility behaviour was found in dhaka followed by chottogram division however the highest rate of multiple hrfb was found in chottogram division reproductive characteristics and highrisk fertility behaviour most women have had a recent normal childbirth and 543 have given birth at a healthcare center of the total mothers a significant portion completed anc followup for their recent pregnancy factors associated with highrisk fertility behaviour both univariate and multivariate logistic regression models were used to identify potential risk variables however because this model was controlled for confounding effects of covariates we only used the adjusted results to interpret the findings the women who were muslims having higher risk of fertility behavior than that of other religion hrfb was found 19 less common in younger women and 642 times more likely in women over 35 years women who had normal childbirths possessed higher hrfb compared to those who had a caesarean section women who had unwanted pregnancies were 1079 times more likely to have highrisk fertility than women whose pregnancies were desired women who did not presently use contraceptive methods were 137 times more likely to have hrfb compared to their counterparts the odds of hrfb disproportionately distributed across the divisional regions on the other hand women aged 25 to 34 having secondary and higher education level partners higherlevel education reduced the odds of high hrfb discussion this study showed that 677 of women had hrfb of which 456 were in single highrisk category and 221 women have had multiple highrisk categories this high prevalence rate demonstrates that hrfb are all too common in bangladesh potentially endangering the health of the countrys women we found that women who were muslims age above 35 years having normal childbirth having low literacy level having unwanted pregnancies not using birth control methods were at increased risk of having hrfb when compared to women who have never had any formal education those with a higher level of education had a lower likelihood of highrisk fertility behaviour this result was supported by the previously conducted studies 22 25 26 27 the reason for this could be having no formal education impacts on work status and leads to lower income and independence all of which affect in this study visiting anc was found to be facilitating factor for reducing the odds of high hrfb this is probably due to the fact that antenatal care provides opportunities to reach pregnant women with a variety of interventions that may be essential to their health and wellbeing 2829 thus they were more likely to receive information regarding importance of routine checkup maternal nutrition delivery complications and risk of having hrfb on the other hand women who did not have anc followups for their recent children had more probability to engage in risky reproductive behaviours family planning for extending the time between births was discussed during postnatal care counseling as a result decreased anc seeking during pregnancy may have a role in hrfb another important finding from this study is women who had a history of caesarean delivery were less likely to have highrisk fertility behavior there are some other studies related to the association between type of delivery and subsequent fertility 3031 which have similar results the reason behind this may be women who have their babies by cesarean section were less likely to have more children than women who have their babies vaginally and also cesarean section delivery was followed by a higher likelihood of actively contraception after that birth which may lead to low odds of hrfb this study revealed that hrfb was more likely to occur among women who had never taken contraception compared to those who used which is in line with previously did studies elsewhere 3233 one of the goals of contraception is to increase the birth interval and reduce unplanned pregnancies women who had unwanted pregnancies were more likely to engage in highrisk reproductive behaviour than those who had previous desired pregnancies it may be the result of not using contraceptive methods by the women who experienced unwanted pregnancies this result also corroborates with a study conducted in nigeria 25 moreover religious belief also did affect maternal hrfb our study revealed that the women who were muslims have increased odds of hrfb compared with other religious believers this finding was in line with an indian study 34 where the author argued that muslim women are less willing to use contraceptive methods family planning and they prefer temporary methods over sterilisation these could be plausible reasons why muslim women in bangladesh were at higher risk of having hrfb evidence suggests that maternal age of 3549 have the higher odds of hrfb than their counterparts similar result was found in other study where the author concluded that pregnancy at later stage is associated with significant increases in maternal risks and complications 3536 which leads to adverse outcome for both the mother and the child furthermore highrisk fertility behaviours were found more than double among women in rangpur a northern region in bangladesh compared to the women who live in sylhet this is probably due to the fact that women in remote locations may stay behind in terms of utilizing reproductive health services such as anc poor family planning adopted rates related to religious beliefs and community attitudes as well as having poor literacy levels however this inequity in utilizing reproductive health facilities among different regions in bangladesh should be minimize to reduce the odds of hrfb this analysis may lead to important inferences that may help to lower maternal highrisk fertility behaviour and can be useful and relevant in areas where hrfb is ubiquitous the strengths and limitations of this study have been wellrecognised the study employed the recently published bdhs 201718 data which had a large country representative sample size allowing the findings to be more generalisable moreover appropriate statistical technique applied in the analysis can be used to find probable components and their relationships however the study has some limitations for instance due to crosssectional data outcomes and predictors variables were collected at a point of time therefore causality cannot be established in addition some important factors such as dietary factors physical activity and maternal comorbidity histories are not taken into consideration due to unavailability in the original dataset but these factors may have been associated with hrfb conclusions this study highlighted the pervasiveness of maternal highrisk fertility behaviour among bangladeshi reproductive aged women several significant protective factors such as maternal and partners higher education were associated with lower hrfb in contrast being muslims age 35 to 49 years having normal childbirth having unwanted pregnancies and not using any birth control tools may increase risk of having hrfb for women thus findings from the study identify the need to develop an intervention especially focusing on bangladeshi muslim women aged 3549 years to reduce highrisk fertility behaviour furthermore the government of bangladesh and stakeholders should work jointly to prevent early marriage of women and to enhance awareness and proper education to reduce the highrisk fertility behaviour competing interests none of the authors declares any conflict of interest

background we aimed to determine the factors that increase the risk of hrfb in bangladeshi women of reproductive age 1549 yearsthe study utilised the latest bangladesh demographic and health survey bdhs 201718 dataset the pearsons chisquare test was performed to determine the relationships between the outcome and the independent variables while multivariate logistic regression analysis was used to identify the potential determinants associated with hrfb results overall 677 women had hrfb among them 456 were at single risk and 221 were at multiple highrisks womens age 3549 years aor 642 95 ci 3951042 who were muslims aor 552 95 ci 2251352 having normal childbirth aor 147 95 ci 122169 having unwanted pregnancy aor 1079 95 ci 5671864 and not using any contraceptive methods aor 137 95 ci 124181 were significantly associated with increasing risk of having hrfb alternatively women and their partners higher education were associated with reducing hrfba significant proportion of bangladeshi women had highrisk fertility behaviour which is quite alarming therefore the public health policy makers in bangladesh should emphasis on this issue and design appropriate interventions to reduce the maternal hrfb

introduction over the last two decades online practices of death mourning and memorialization have grown into a vibrant field of interest and research studying the intersection of death and digital media sheds light on novel commemorative practices affective performances and oscillations between personal and public spheres as such it contributes to our understanding of social practices of remembrance underlined by the questions who is worthy of remembrance and why and how are they remembered a major site of online mourning and memorialization is the social networking site facebook the oscillations between personal and public spheres are integrated into facebooks internal logic and infrastructure as a multifunctional platform facebook brings together several distinct communication channels also known as subplatforms facebooks three main subplatforms are profiles groups and pages profiles are personal accounts that represent the user as an individual groups allow interaction of several users usually around a specific shared interest and pages serve as public channels allowing a more unidirectional communication with broad audiences the official aim of pages is to serve businesses communities organizations and public figures who seek to increase their digital presence and connect with audiences and fans it is an essentially public subplatform that is visible to anyone on facebook by default and may have an unlimited number of followers pages administrators manage the interaction with the followers and the content on the page interestingly users commonly employ pages in a memorial capacity and create pages to memorialize and publicize ordinary people in this article we look at memorial pages that are dedicated to ordinary people who died in nonordinary circumstances our data consist of 18 cases all of whom are israeli the aim of this study is to examine the practices involved in creating and maintaining memorial pages from the theoretical perspective of the social capital approach we explore how creators of memorial pages view the role of the page their motivations and their relations with different audiences such as strangers we further analyze how admins interact with their network of followers and the various resources associate editor katy pearce they accumulate through this processfrom economic capital and practical support to solidarity and emotional support literature review online mourning and memorialization online practices of remembrance and memorialization emerged in the mid1990s initially in the form of virtual cemeteries and private web memorials this first generation of digital practices as walter terms it changed surprisingly little compared to earlier offline practices it was only in the early to mid2000s with the rise of social media that things have significantly changed social media and social network sites in particular afford new means for grieving and commemorating and influence the experience of death both online and offline brubaker et al identified three expansions of death and mourning that snss afford and facilitate a spatial expansion in which physical barriers to participation are dissolved a temporal expansion that refers to the immediacy of information enabled by snss and a social expansion that results in a context collapse and the inclusion of the deceased within the social space of mourning the intense social nature of social media is shaped by its inherent features of sharing performance and interaction sharing can be appreciated through different logics while on snss the primary logic is communicative and not distributive on snss sharing is telling where fuzzy objects of sharing are nonetheless associated with giving and caring these sharingtelling practices involve multiple modes and strategies of selfpresentation identity negotiation and performance which inevitably lead to intensified engagement and participation this is true also of mourning and memorialization contexts where engagement and participation can be viewed as a demonstration of communality and social support alternatively engagement and participation may also indicate social pressure and competition over who has the most significant contributions or the right to portray the deceased social dynamics and engagements are complex determined in part by the specific media platform and its affordances studies of mourning and memorialization examine various social media platforms including myspace youtube instagram twitter andtiktok however the most dominant platform both in terms of research and of user practices is facebook the vast number of dead users along with the various practices and rituals that living users perform qualifies facebook as a current center of gravity for the discussion of online mourning and memorialization mourning and memorialization on facebook studies of mourning and memorialization on facebook point at multiple practices and uses such practices may chronologically commence with death announcements and the posting of information about memorial services to subsequent and more continuous practices such as visiting the deceaseds profile and posting messages as a way to commemorate express emotion and remember special occasions an additional common practice which lies at the heart of our current study is the creation of memorial pages these pages may be dedicated to individual subjects groups of people animals and things such as places they enable parasocial copresence and continuing bonds as well as public presence of the deceased and engagement with strangers rossetto et al point to three themes or functions that mourning and memorialization on facebook possess news dissemination preservation and community news dissemination describes sharing or learning information about a death through facebook preservation refers to the continued presence of the deceased and maintaining communication and connection with them lastly the community theme refers to the connection and communication with people other than the dead it includes connecting with other mourners seeking and offering social support and expressing ones feelings and thoughts while at the same time facing a challenge to privacy one way to face this privacy challenge and negotiate boundaries is through facebook subplatforms in a study of mourning and memorialization practices across facebooks subplatforms navon and noy outline a spectrum that ranges from private to public and accordingly from a more personal sphere of mourning to a larger and more institutional sphere of memorialization located on one side of the spectrum profiles are characterized by expressive and emotive communication hence turning with time into personal mourning logs on the bereaveds profile and online mourning guestbooks on the deceaseds profile located on the spectrums other side pages possess a distinctly public quality and serve as online memorialization centers where the deceased becomes an icon and is portrayed in one dominant way finally groups are positioned inbetween possess a hybrid nature and combine selfexpression and emotional sharing along with more public aspects this results in groups affording the revival of onceprevalent bereaved communities the triadic spectrum we outlined corresponds with the three levels of social death that refslund and gotved have put together first the individual level focuses on the personal loss second the community level revolves around an extended network relatives neighbors colleagues and other acquaintances of the deceased and third the cultural or public level refers to the death of people not personally known according to the authors this level generates memorial practices that relate to the way of death or how they were appreciated in life similarly walter suggests the concept of public mourning pertaining to either highstatus figures or to ordinary people who die in tragic circumstances in this study we examine the latter we look at public memorial pages created in memory of ordinary people that nonetheless generate public mourning analyzing facebook memorial pages marwick and ellison discuss the publicizing of the deceased in terms of impression management strategies and conflicts among users they focus on context collapse negotiation of visibility and the four characteristics of social media persistence replicability scalability and searchability they conclude with a recommendation for future research that will employ qualitative methods to explore how creators of memorial pages view the role of the page their motivations and their view of different audiences such as strangers our current research does precisely that and seeks to provide answers to these questions however while marwick and ellison frame their investigation in terms of context collapse we suggest viewing facebook memorial pages via the social capital approach we focus on admins practices which result in the accumulation of social capital social capital and social media defining the term social capital is challenging in part because it has received multiple definitions during the last few decades kritsotakis and gamarnikow observe that defining social capital is rather problematic williams adds that it is a contentious and slippery term and xu et al conclude that it is an encompassing yet elusive construct one of the influential formulations of social capital was proposed by bourdieu as part of his conceptualization of different types of capital and related systems of exchange for bourdieu the distribution of the different types and subtypes of capital at a given moment in time represents the immanent structure of the social world in line with his practicecentered approach and his dialectic view of the structureagency relations bourdieu puts much emphasis on the role of constant social interaction in maintaining social structures he accordingly sees social capital as potential resources which are linked to possession of a durable network of more or less institutionalized relationships another oftcited and productive definition emerges from putnams view of social networks from the perspective of political science and civic engagement putnam draws a distinction between two main types of social capital bridging and bonding the first describes broader more diverse and inclusive relations which are often more tentative while the latter concerns more exclusive relations which are less diverse and more cohesive the two concepts echo granovetters famous observation concerning weak ties versus strong ties in a related manner williams notes that strong ties supply a getting by type of network while weak ties supply a getting ahead social environment he further suggests that different types of social networks can predict different types of social capital more recently xu et al conclude that social capital consists of both social networks and resources derived from social networks hence we now turn from describing network characteristics to describing measurements of their outcomes or resources williams operationalizes measures of assessing social capital outcomes by addressing the two types of social capital putnam discerned as per bridging social capital he developed a questionnaire based on several criteria one of which is contact with a broad range of people as per bonding social capital he builds on several dimensions including emotional support and the ability to mobilize solidarity xu et al found that network features specifically tie strength and communication diversity result in different levels of emotional practical and informational support theories of social capital have been studied extensively in relation to social media so much so that they are recognized as a leading area of interest in the field one stream of scholarship has explored the effect of social media affordances on social capital outcomes the term sociotechnical capital captures these relations arguing that individual users enjoy a greater ability to accrue social capital in the age of social media as it becomes easier to maintain and create new connections indeed studies have found a positive association between the usage of snss and perceived access to social capital resources ellison and vitak observe that recent studies further examined the specific kinds of activities that are predictive of social capital and not only general measures of use they point to two main factors that appear to be most significant to social capital gain the size and composition of the network and how users communicate with that network that is patterns of interaction they stress that social capital is derived from interactions with ones network in this article we view social capital as potential resources that are produced through interactions in a structured social network these resources may possess bonding or bridging social capital qualities including emotional practical and informational support rather than looking separately at resources or network characteristics our focus is on social capital processes that is the relations between the social network and the outcomes or resources that emerge from it while some existing literature examines these relations and processes we add a third element namely the social network platform this concerns how specific affordances enable and motivate social capital processes and how users utilize affordances to position themselves and others in ways that encourage accumulation positioning is constitutive of social capital processes and in line with our platformcentered approach we take it to include users practices of discursive positioning and the positioning that the platform itself performs within this framework we look at pages affordances as well as users practices and activities discourse and patterns of interaction together the findings provide fruitful insights into social capital processes memorialization practices and public remembrance on snss method sampling the research sample includes 18 facebook pages which we observed during three years 1 all the pages were created in memory of ordinary people who died in nonordinary circumstances typical examples include a woman who was murdered by her male partner a highschool student who committed suicide as a result of cyberbullying a female backpacker who died in a bus accident during a trip to nepal victims of terrorist attacks and fallen soldiers table 1 presents key details of all the cases including the cause of death to stress none of these commemorated individuals were public figures or known publicly the cases include 12 men and 7 women ranging in age between 15 and 55 with an average of 256 the pages were created between january 2011 and october 2016 and are all in hebrew all the translations are ours data collection procedures employed facebooks search bar we looked for keywords and phrases related to death and memorialization while using facebooks filter to specifically reach pages because the display of facebooks search results is managed by unclear criteria we conducted multiple searches which led us to different lists of pages to further offset facebooks unknown algorithmic preferences we did not always sample the pages from the top of the result list after collecting the data we selected pages for analysis based on the intensity sampling method intensity sampling focuses on the relevance of specific cases their expected contribution to the research and the extent to which they offer insights into our field of research in order to strengthen the datas heterogeneity we selected diverse cases in terms of age gender cause of death sociocultural background etc as indicated earlier pages are visible and available to anyone on facebook which made the work of accessing all the contents posts and comments on each page relatively easy since we are particularly interested in the admins roles and communicative practices our analysis focuses on posts and not on comments still the comments provided complementary material that enabled a better understanding of the larger picture including the dynamics among users and between the users and the admins analysis between june 2018 and march 2021 following the data collection phase we conducted ethnographic fieldwork based on the principles of digital ethnography siding with varis we see ethnography not primarily as a data collection practice and not so much as a set of methods and techniques but as an approach that is methodologically flexible and adaptive it does not confine itself to following specific procedures but rather remains open to issues arising from the field as such we do not employ a prestructured qualitative analysis procedure but address discursive concepts such as positioning and participatory dynamics following romakkaniemi et al we link the frames of positioning and social capital taking positioning as both a theoretical and methodological framework we identified and analyzed positioning levels and positioning strategies which we refer to as technodiscursive practices we were sensitive to relations between actors as established through positioning keeping in mind that the way individuals are positioned in social structure can be an asset in itself and social capital is conceptualized as that asset examining positions and positioning we highlighted different roles different acts of participation and levels of engagement and commitment which together amount to participatory dynamics between the network members we applied these discursive concepts more closely to several dozen posts from each page from which the examples below are taken in terms of research ethics we now turn to address the processes of accessing analyzing and representing data from these memorial pages in a scoping review of 40 empirical papers myles et al aimed to situate ethics in online mourning research they suggest that terrain accessibility constitutes a determining factor in ethical decisionmaking including data anonymization they further refer to the difference between a facebook page and a facebook profile in terms of the nature of the online setting yet they emphasize that ethical decisions should not rely on technological arguments and affordances but rather on an actual ethical reflection in line with markham they invite researchers to think contextually about ethics and conclude that ethical judgments could only be made in context in the context of the current study we believe that the activity on the memorial pages in our sample possesses a distinct public quality nevertheless to ensure anonymity we changed the names of the deceasedthe memorial pages and since we translated all the quotes from hebrew they could not be located via search varis highlights the difference between early research of technologically mediated communication that centered around things or texts and later research that examined actions and situated practices this shift builds on a new understanding of discourse as a socially contextualized activity in this perspective context and contextualization are critical issues that should be investigated rather than assumed varis suggests two contextual layers that digital ethnographies of communication need to investigate the first is media affordances and the second is onlineoffline dynamics we implemented these two layers as part of our analysis as for the first layer we pursued an ethnography of affordances identifying and investigating different affordances that admins use when creating and maintaining a page and how features such as likes shares and following shape discourse and dynamics on the page in line with klastrups and kern and gileguis study of facebook memorial pages we also examined the about section of each page and analyzed the textual data therein the about section serves as the pages visiting card it displays its basic information in part provided by facebook and in part by the admins this includes the current number of people who like and follow the page its category contact info and a short introductory text up to may 2020 during our data mining stage the about section also included the page creation date and in most cases a team members title which shows the admins in the updated version this information was removed a new section called page transparency was added in an effort to increase accountability and transparency of pages yet the information provided in this new section is actually more limited when compared to the previous version a page history title presents the creation date however a new title people who manage this page does not reveal names and profiles as it used to in the past but rather only the primary country location of the admins this update reinforces previous observations about the vagueness and anonymity of pages administrators and puts into question facebooks declared efforts to increase transparency specifically examining memorial pages marwick and ellison likewise observed the difficulty to ascertain who created the page and their motivations for doing so in the current study we try to answer these questions based on the team members data we collected before the facebook update a textual analysis of the about texts and the ethnography we conducted as for the second layer onlineoffline dynamics indeed turned out to be an important part of our analysis the memorial pages in our sample are all created in memory of actual people and the life they lived offline or their offline death story as opposed to studies of memorial pages that included pages dedicated to fictional characters places or things moreover the activity on these memorial pages involves production promotion and documentation of a rich variety of offline events as will be discussed shortly in the findings section below we discuss the pages names their categories about texts admins and followers count along with the analysis of adminsfollowers interaction and the activity on the pages findings and discussion page name the first finding we discuss corresponds with the first step of creating a page supplying the page name typically the page name consists of two verbal elements the first element concerns one of the following phrases in memory of or remembering which is formative because it designates the meaning of the page as a memorial site the second element is the deceaseds full name which appears in all the cases supplying the deceaseds full name contributes to a more formal and respectful tone it accords well with cases in which the dead have served in the military or in a police unit where their rank appears next to their name as part of the page title in this vein several titles include an english translation or the ending the official page of serving to establish a sense of formality authority and recognition of the page and of the deceased supplying the deceaseds full name may also suggest that page creators do not expect or assume that all visitors know the deceased personally or beforehand one way or another a norm seems to be emerging in regard to naming memorial pages which is based on the evocation of one of the two phrases together with the deceaseds full name page category community public figure interest right below the page name the page category appears in grey and in smaller letters a page category describes what type of business organization or topic the page represents when creating a page facebook affordances allow users to type freely in the page category text box while receiving help from facebook in the shape of prompting or introducing to the user existing categories according to the letters she types these potential categories may seem like helpful suggestions but in fact the user must choose one of these preexisting options in other words defining a category is a necessary step in creating a page on facebook which can be done only according to a pregiven list that the platform provides the list of available categories that facebook offers comprises over 1500 possibilities which include for example 12 types of tour agencies 15 subcategories of pet services 28 different types of chinese restaurants and a similar number of beverage shops however none of the categories or subcategories offered in the detailed list relates to memorialization nor to synonyms or related terms this raises interesting questions how carefully does facebook select form and shape pages categories and uses how do users act within this framework of affordances and more practically which categories do users employ in memorial pages when such elementary categories are missing altogether our the interest category includes sports visual arts and the like in the context of memorial pages however the meaning of these categories is negotiated they do not reflect the meaning facebook provides but instead the interpretations that usersadmins ascribe in line with their goals to engage interest in the page to create a large community that recognizes and remembers the deceased and to turn herhim into a public figure this finding demonstrates an interactional view of affordances as a relationship and negotiation between the interface and the user rather than merely a property or a feature of the interface itselfan entanglement of policy and practice in the words of arnold et al users take the freedom to interpret facebook categories creatively in order to contend with restrictions put forth by the platform they might not have absolute freedom to choose the page category but they enjoy the freedom which they exercise to choose how to interpret and use it this finding also reveals an emerging norm concerning the socially accepted way of naming and categorizing memorial pages this norm hints at admins underlying motivations for creating and maintaining a memorial page admins concealed identity four cases in our sample appeared with users as team members in three of these four cases the surname of the admin user was identical to that of the deceased yet the specific kinship was unspecified this relation has not been revealed in the about text as well but a review of the posts along the pages tells us that two are mothers of the deceased one is a sister and one is a cousin in two other cases the introductory text in the about section refers to the page admins though in an unspecified way the page is moderated by the loving family and the page is moderated by friends from naariah city and by nurits brothers finally in three additional cases we were able to deduce who runs the page by looking at the posts over time as the information was not provided in the about section in one case the admin is the deceaseds daughter who often signs posts as daddys girl in a second case it is the sister who frequently mentions her name uploads photos of herself and shares posts from her personal profile on the page in the third case family pictures appear frequently and most of the posts end with the designation the family but no further information is provided about the specific admins overall in all the nine cases we detailed above the admins are selfidentified as relatives of the deceased and in the rest of the cases it is unclear who created or manages the page in other words in most cases it is difficult to determine who the admins are admins motivations and collective discursive positioning of the deceased in more than half of the cases admins describe in the about section the reason for which they have created the page the accounts they supply share similar motifs we opened this page to keep the spirit of alive this page was created for the memory of and this page is in his memory and to inspire his legacy in other words the goal of the page as stated by the admins is to have the deceased remembered publicly more precisely it is to make the deceased remembered and recognized by as many people as possible beyond the circles of relatives and acquaintances who knew her when she was alive in most of the cases admins use the about text as a space to write about the deceased and provide basic information that should presumably be known to acquaintances for example age at death date and cause of death a list of family members who are left behind or a short biography in line with the formal register these brief biographies are often written in an informative and factual manner consider the following example such texts supply a brief overview of the deceaseds life story highlighting his exemplary military service and heroic death the death story is charged with a deeper meaning relating to honor sacrifice patriotism and recognition that aims at transforming it from a personal death story to one that is collective and anchored in the public sphere hence the detailing of the number of people who attended the funeral stressing the deceaseds contribution to the state or society adds both moral and collective values to the act of remembrance to those publicly and collectively engaging it and thereby also to the memorial page itself this finding echoes harjus observation of a stance of moral superiority that users construct in relation to public mourning of a celebrity on youtube the question at heart is a moral and sociocultural one namely who is worthy of public remembrance according to harre ´ moral questions are integral to discursive positioning the positioning theory claims that every thought expression and social action in and among groups take place within shared systems of belief about moral standards and about the distribution of roles rights and duties similarly giaxoglou describes affective positioning as semiotic and discursive practices whereby selves are located as participants producing one another in terms of roles our findings point at heroic and sacrificial discursive positioning in all the cases in which the deceased served in the military or the police for example her death saved many lives and taking the shot in his own body yoni prevented multiple deaths these and similar texts portray the ultimate sacrifice paid by the deceased evoking a sense of patriotic gratitude in one case in a page dedicated to the memory of shlomo levi the about text opens with this brief introduction gal levia son brother friend worrier here the discursive positioning reflects a scale that ranges from the personal through the familial to the social and the institutional in another case even though the deceaseds cause of death was suicide and he did not fall in the line of duty his rank plays a salient role on the about it says this page intends to commemorate the legacy of the officer the policeman and the beloved person major general eytan bar the admin of the page is selfidentified as the deceaseds daughter who regularly signs her posts with the words daddys girl yet the focus lies with his public role and contribution the goal is to form his memory as a respectable individual who has served the country and the society well collective and often heroic discursive positioning also appears when the deceased was not a soldier nor held a formal institutional role in these cases as well admins highlight the social importance of the deceased or the death story and the collective values it embodies such is the case in the page in memory of talya nadav talya died in a car accident abroad involving negligent dui by two israelis who avoided prosecution the admin stresses the relevance of the tragic death story to the general public we need your support after a year and ten months they the perpetrators are still walking free they deserted talya who died and fled mexico we begin a struggle to bring them to justice enter the link and donate for justice for talya nadav for us for everyone because we all travel abroad us our children our friends we might all find ourselves in a similar situation the page remembering talya nadav with a smile march 9 2017 this example demonstrates how the admin discursively positions the deceased and the death story as a matter of collective interest she builds on the shared value of justice to mobilize social engagement and support in the form of crowdfunding the deceased becomes a symbol yet this is achieved not by appealing to themes associated with national sacrifice and gratitude as in the case of the soldiers but by appealing to a sense of social responsibility these dynamics resonate with walters observation that in contemporary cultures celebration of vulnerability victims are now as or more likely to be commemorated as heroes furthermore even when death is not framed in terms of victimhood admins still position the deceased as a valuable collective symbol they do so by portraying her special virtues and unique character in the case of osnat shemesh a backpacker who died in a weather related bus crash in nepal the admins state weve chosen to take the life according to osnat and turn it into legacy into a will here too the deceased is elevated as her life is presented in hindsight as embodying shared values with which the audience can identify themes concerning national sacrifice and collective gratitude are altogether absent yet the deceased is framed as a collective symbol admins supply quotes by the deceased which they frame as a motto or a legacy and share stories about her life and highlight her virtues these acts of discursive positioning serve to supply an account for the reason that that specific person is worth remembering the page followers count admins efforts to increase the network if someone is worth remembering herhis memorial page should be worth following the followers count shows how many users are following a page in quantitative terms this index measures circulation and exposure ie the size of the network in qualitative terms the followers index helps assess the pages popularity and social impact and the social capital that page admins have come to possess the average number of followers on the pages we sampled is 13k ranging between 12k to 403k explicit efforts to gain followers likes and shares appear in all 18 cases pursued through repeated and explicit requests by the admins in one case admin offers a small token in the shape of bracelets to new followers enter the osnats butterflies facebook page like the page and you can get free bracelets we warmly ask that you like the page osnats butterflies and request that the bracelets will be sent to you the page osnat shemesh the sun will never set july 11 2015 the butterfly bracelets are part of a social initiative propelled by this pages admins for promoting good deeds and giving in the spirit of pay it forward this initiative was established in memory of osnat shemesh the backpacker who died in nepal and had a butterfly tattoo on her shoulder osnats butterflies page has over 33k followers and the social initiative it promotes has reached over 40 countries worldwide the goal of the page is to increase public awareness and support for the project by documenting and posting butterflies paintings and bracelets around the world alongside moving stories about osnat shemesh in this way the page accomplishes the goals of memorial pages as implied in the categories we discussed above building a community engaging interest and turning the deceased into a public figure the idea of publicizing the deceased is exemplified quite clearly also in the following post taken from a page in the memory of police assistant commissioner eytan bar as indicated earlier bar ended his own life in the wake of an investigation he was under the admin of the page is his daughter youre all invited to like and share the page in memory of our father so no one will forget this angel who wholeheartedly gave his life to the country the page in memory of acop eytan bar july 26 2015 this short message performs the transition from a personal loss to one that is collective and public such texts hint at the perceived connection that users make between online participatory acts such as follow like and share and participatory acts of a cognitive or emotive nature like memory recognition and esteem the admin uses the conjunction word so to form a causal connection between likeshare and a public memory between visible online engagement and cognitive or emotive implications offline page activity initiatives and events the page likes that we examined offer only a glimpse of how admins can evaluate the activity of their audience in the case of facebook memorial pages the activity extends beyond the online sphere and involves production promotion and documentation of offline initiatives and events the initiatives vary reflecting the sociocultural differences found in our sample which in turn reflect preexisting memorial practices in israeli society some cases have a more spiritual or religious orientationinauguration of a torah scroll and other jewish rituals in other cases there are sporting eventsracings soccer tournaments mass zumba workouts and yet others take the shape of intellectual or educational activitiestalks at schools mind sports olympiad etc we can therefore see that in most cases the admins promote multiple events and initiatives throughout the year which make the page active constantly rather than only around a single annual memorial event the frequent activity on the page serves to maintain an ongoing interaction with the network and to establish the page as an appealing and vibrant site despite the differences in terms of content we found several similarities in the ways admins communicate and promote these initiatives first the format in 89 of the cases event announcements take the shape of a photoa professionally designed flyerand not a textual post the flyers are visually stylized and convey an impression of a formal invitation the second similarity concerns addressivity or who the posts address these invitation posts are directed at the general public calling for as many people as possible to join the communityturnednetwork and partake in its activities third in most of these posts similar keywords are used evoking themes that concern respect recognition and togetherness consider these examples we invite you all to come watch and participate in the heritage of our father it is important for us that a large crowd will show up so that it will be respectable the tournament will take place in modiin and silicone bracelets will be sold for 10 shekels 3 usd with the inscription love thy friend as thyself in the spirit of eytan bars path we will donate the money to the same places that our father used to support we are looking forward to seeing you spread the word the page in memory of acop eytan bar june 12 2017 both examples include the words honor and respect the notion of respect is significant and the crowd plays an important role in its amassment indeed the presence of a large crowd is the very mechanism through which respect and honor are generated and publicly assessed hence the address is directed at the general public and you all moreover the second example ends with the directive spread the word explicitly seeking to reach beyond the page followers the admin makes use of the network alongside the platform affordances in order to reach as many people as possible to generate large attendance and to amass respect as part of the production of multiple memorial events and initiatives admins often address the followers with various requests for resources and participatory actions these actions range from physical attendance through volunteering and contributing ones skills and knowledge to purchasing memorial merchandise and donating money requests for resources include as we can see economic capital but also practical support which is appreciated as a form of social capital resources the extensive memorial activity and the involvement or harnessing of wide crowds in its production fulfill the three goals of memorial pages we detailed earlier community interest and public figure these three common categories of memorial pages can be seen as reflecting three aspects or dimensions of the same process in this process users create and maintain memorial pages which come to serve as mechanisms for the accumulation of social capital resources these categories are interrelated and represent different aspects or stages of the same process this process entails the assumption that at stake here is a collective interest which results in attempts at creating a community and establishing the deceased as a public figurein fact turning the deceased into a public figure builds on the size of the community and the degree of its members engagement and interest the ongoing activity on memorial pages including the positioning of the deceased and the various online and offline events are all put in the service of the same three goals or stages in this process building a community engaging interest and ultimately positioning the deceased as a matter of public interest in other words as a public figure worth remembering memorial merchandise economic and social support the second example above draws attention to another widespread practice we observe in our data namely selling merchandise in memory of the deceased in 61 of the cases in our sample this practice appears to be popular and in some cases several types of merchandise are sold through the page the examples vary tshirts baseball hats bumper stickers memorial candles and recently also face masks puts it apropos her discussion of celebrity commemoration on youtube materiality anchors meanings this finding is significant because branded merchandise is generally associated with celebrities and not with ordinary people designing and selling merchandise in memory of an individual therefore convey a message that heshe was a famous person or should be famous posthumously furthermore since nearly all sold merchandise are wearable they promote offline public display of the deceased and enhance her status as a public figure this closely relates to our earlier finding about the frequent employment of the public figure category and confirms our argument about the underlying motives and goals of admins of memorial pages the admins use the memorial page to promote distribute and sell this merchandise and in line with the moral discursive positioning on the page they add a moral value to those products and to the act of buying and using them consider these two examples wearing the bracelet commits the wearer to maintain the values you the deceased represents and in this way to become a better person and 10 shekels for your contribution and involvement in the observatory project in memory of ofek so friends share and get yourself a new bracelet for a worthy cause 2 the purchase of memorial merchandise emerges as a value laden moral action because the deceased is consistently portrayed as a special person whose story carries social meaning and significance and bears moral value the money that is collected is directed to worthy and charitable causes such as donations and participatory actions such as buying memorial merchandise supports the admins the support that admins receive is twofold it is financial but also social and emotional the action of purchasing a memorial merchandise reflects both interest and involvement and enhances the sense of recognition with regards to the social significance of the deceased the admins are well aware of these meanings and in response express their gratitude readily and frequently as we show below expressing gratitude from followers to partners alongside the multiple repeated requests and invitations that page admins direct at the page followers they also make sure to thank them devotedly in doing so the admins tone is rather informal personal friendly and enthused they routinely express gratitude and show their appreciation to followers and their engagement every action counts from like and share through money donations to physically attending eventsadmins show that no activity goes unnoticed they highlight the importance of these actions as not merely helpful but truly vital for the memorial page and its moral goal followers thus become an integral part of the page and its activity or in other words they are repositioned as partners indeed sometimes admins note this explicitly we are grateful for having such partners as yourselves at stake here is a significant status promotion for the followers which is pursued visa vis facebooks affordances and hierarchical terminology admins who manage approve curate edit and produce content and followers who consume it by symbolically upgrading the followers to the status of partners admins imbue the followers with a sense of importance and enhance their commitment and engagement with the page in this way they encourage the followers to contribute more more likes content resources and engagement the following example nicely captures this circle of encouragementengagement here in relation to the inauguration of a torah book wow how exciting thanks to you we achieved the goal with every passing day the hug we received grew greater and greater thanks to you to your shares to your devotion more than 100000 shekels were raised in the last couple of days for the commemoration of ofek the page in the memory of ofek noy hyd september 8 2016 communication here seems spontaneous and informal and while the accomplishment is framed as mutually achieved gratitude is clearly expressed and extended to the followers followers engagement is described as a hug a nonverbal act that indexes affection support and closeness thus admins discursively position the followers who are otherwise strangers as helpful in extending love and support this finding resonates with stage and hougaards discussion about caring crowds in which love and care are not only expressed through words but also through material practices in the cases they observetwo public facebook groups that were created for two children diagnosed with cancercrowdfunding was a dominant practice that was motivated and energized by sharing the personal stories of illness and suffering alongside gratitude expressions by the parents who run these groups in the following example the mother of osnat shemesh nicely illustrates how to direct attention to the followers when you experience the most excruciating pain possible you hold on to any bit of light like a wounded animal it seems like this is the only way to survive in the last couple of months family and friends have completely embraced us and i will forever owe them my life and my sanity i want now to talk about the people we dont know about bits of light that radiate from people who never knew us or osnat these people who send us comforting messages strangers who took time off their everyday routine to all these beautiful souls we wish to say thank you thanks for seeing us thanks for taking time off for us thanks for helping us regain our faith in goodness the page osnat shemeshthe sun will never set december 25 2014 emphasizing the pain this admin is experiencing enhances the moral value of the followers benevolent participatory actions the admin a bereaved mother mentions and thanks family and friendsthen directs special attention to other people she pursues this by the metadiscursive statement i want now to talk about through which she signals a thematic shift to what will be the focus of her message namely to those who deserve the utmost gratitude these are strangers users with whom she is not familiar who showed showed interest and took time off and who served as an audience and a network the admin describes the visitors and the followers of the page as radiating bits of light and as beautiful souls who help restore faith in goodness posts of this type confirm the moral value that engaging the page carries framing it as a socially valued action this is a result of the social solidarity and support that followers direct at the admins often bereaved users in pain and of the fact that memorialization is generally held as a sociomoral project more so when the deceased is consistently portrayed as a hero a special person a respectable public figure worth remembering such expressions point at how admins acknowledge having received emotional support from their network of followers recall that putnam and williams associated emotional support and mobilization of solidarity to bonding social capital that is to interactions that are typical of strong ties and closer relationships interestingly our findings suggest that such resources may also be obtained through what we can call bridging relations and interactions with a broad network of mostly strangers admins explicitly and repeatedly link emotional support to such parameters as engagement with the page the economic capital gained through the network and the practical support followers provide conclusion in this article we explored facebook pages created in memory of ordinary people with the aim of raising social awareness and public remembrance of their death we offered a new perspective on these memorial pages and suggested viewing them through the scope of the social capital approach in line with existing literature our findings demonstrate that the most significant factors of social capital processes are the size and composition of ones network and the patterns of interaction we identified different communicative practices that admins pursue in the aim of reaching an audience increasing the size of their network and enhancing its activity and engagement in addition we analyzed how admins interact with their networka multilayered communication that serves the multiple functions they seek to accomplish on the one hand admins use a formal register and the notion of respect is salient as they try to establish a sense of formality authority and recognition towards the deceased and the page on the other hand they use a highly personal enthused and emotional register partly because of the engaging effect of affective performances and partly because of the affectladen quality of digital mourning practices when a user performs an increased emotional sharing it activates reactions of the networked audience in the shape of an exchange of emotional and support resources which have been shown to reinforce tie strength in a discussion on networked emotions and sharing loss online giaxoglou et al observe the increasing mobilization of emotion as a commodity and sabra further notes that the potential for economic and emotional capitalization is integrated into the facebook platform our findings flesh out these observations by showing how admins carefully and strategically select where and when to use a formal and factual register and when to use a more personal and friendly emotional tone like share and remember the expected engagement and with it requests for resources that admins post range from online participatory acts to purchasing memorial merchandise donating money physically attending events contributing ones skills to the production of initiatives and so on the accumulation of resources through the page is a social capital process par excellence a process in which ordinary users become admins and create their own network gradually expand it and harness it by employing platform affordances to achieve their goals network members are mostly strangers while previous studies note that strangers are unwelcomed on facebook memorial spaces our study suggests that strangers are more than welcome and are deeply appreciated in an effort to portray the deceased as a public figure and to establish a state of public remembrance admins address the largest audience possible pages as opposed to other facebook subplatforms afford this publicity and capitalization which users acknowledge and take advantage of from the very early stages of creating and naming the page this complements studies that have examined social capital processes on facebook and relationship maintenance behaviors of existing connections here we examined the creation maintenance and strengthening of new connections with strangers or parasocial relations corroborating previous observations of memorial pages which gather strangers rather than friends however despite existing literature that links between strangers and weak ties and bridging social capital outcomes in the case of the memorial pages we studied broad networks of followers that consist mostly of strangers in fact facilitate bonding social capital outcomes such as solidarity and emotional support admins recognize this support and pursue a circle of encouragementengagement that motivates participatory activities limitations and future directions this study has several limitations that future studies can address first due to the relatively small sample size we could not draw conclusions relating to the connections or correlations between the cause of death and the activity or dynamics on the page second future studies may examine the collectivization of personal mourning and related social capital processes on other platforms with different affordances and dynamics we believe that much of the transferability of these insights rests on platforms public quality or publicity finally while we focused on memorial pages future research can explore social capital processes on pages in different contexts and themes future research may also focus on social capital in relation to special users such as admins who employ special affordances and pursue special practices data availability the data underlying this study will be shared on reasonable request to the corresponding author

this study focuses on users practices involved in creating and maintaining facebook memorial pages by adapting the theoretical perspective of the social capital approach it examines 18 pages in israel which are dedicated to ordinary people who died in nonordinary circumstances we employ qualitative analysis based on a digital ethnography conducted between 2018 and 2021 our findings show how memorial pages serve as social capital resources for admin users admins negotiate facebook affordances when creating designing and maintaining such pages they discursively position the deceased as a respectable public figure worth remembering and their followers who are otherwise strangers as vital partners in this process the resources followers provide range from economic capital and practical support to solidarity and emotional support finally we point at the perceived connection users make between visiblemeasurable online engagement like share follow and cognitive or emotive implicationspublic memory recognition and esteem

introduction health i the state of an animal or living body in which the parts are sound well organized and disposed and in which they all perform freely their natural functions in this state the animal feels no pain this word is also applied to plants ii sound state of the mind natural vigor of faculties iii sound state of the mind in a moral sense goodness health as defined in scientific dictionary 1863 1 viewed through the prism of life and ways of living health is an expansive term which has longsince defied concrete definition in 1946 the world health organizations constitutional statement 2 maintained that health is complete physical mental figure 1 highlevel wellness is applicable to organizations communities nations and humankind as a whole in an era of gross environmental concerns and a crisis of noncommunicable diseases personalized medicine must be increasingly viewed in the context of planetary health image by author slp remarkablyeven without our current sophisticated understanding of biodiversity losses environmental degradation climate change and resource depletiondunn underscored that highlevel wellness is predicated upon the health of the earths natural systems 5 in other words discussions of highlevel wellnesswhether for person or civilizationmust always consider the environment and this must include broad aspects of the natural environment on which humans depend dunn was underscoring the principles of what is now termed planetary health the term planetary health popularized in the 19801990s underscores that human health is intricately connected to the vitality of natural systems within the earths biosphere coincident with the rise of environmentalism preventive medicine and the selfcare movements of the 1970s the artificially drawn lines between personal public and planetary health began to diminish 67 dunns concept of highlevel wellness was referenced in articles which discussed a different philosophical framework through which individual community environmental and planetary health can be better understood in a broad and integrated fashion 8 highlevel wellness is applicable to organizations communities nations and humankind as a whole in an era of gross environmental concerns and a crisis of noncommunicable diseases personalized medicine must be increasingly viewed in the context of planetary health image by author slp remarkablyeven without our current sophisticated understanding of biodiversity losses environmental degradation climate change and resource depletiondunn underscored that highlevel wellness is predicated upon the health of the earths natural systems 5 in other words discussions of highlevel wellnesswhether for person or civilizationmust always consider the environment and this must include broad aspects of the natural environment on which humans depend dunn was underscoring the principles of what is now termed planetary health the term planetary health popularized in the 19801990s underscores that human health is intricately connected to the vitality of natural systems within the earths biosphere coincident with the rise of environmentalism preventive medicine and the selfcare movements of the 1970s the artificially drawn lines between personal public and planetary health began to diminish 67 dunns concept of highlevel wellness was referenced in articles which discussed a different philosophical framework as the global health burdens have shifted from infectious to ncds greater emphasis has been placed on the healthmediating role of social determinants lifestyle and the total lived environment the health implications of anthropogenic threats to life within the biosphere cannot be uncoupled from discussions of the individual community and global health recent endeavors such as the lancet commission on planetary health 9 and the canmore declaration 10 have reemphasized that public health biopsychosocial medicine and planetary health are oneandthesame roadmap to the current review here in our narrative review we will revisit dunns highlevel wellness and explore its place in the emerging planetary health paradigm first we discuss some of the origins of the highlevel wellness concept and describe how it manifests in contemporary clinical care next we examine the concept of planetary health its historical origins and the global movement which now considers the health of civilization and the earths natural systems as inseparable with this background in place we argue that the concept of highlevel wellness provides an essential framework for health promotion and clinical care in the modern landscape it allows scientists of diverse fieldsno matter how reductionist the scope of their inquiryto see the largescale relevancy of their work it provides healthcare providers a broader vision of human potential with individuals as living embodiments of accumulated experiences shaped by natural and anthropogenic ecosystemsrather than a vision limited to a neutral diseasefree set point dunns highlevel wellness and planetary health requires discourse concerning values our connectedness to one another our sense of purposemeaning and our emotional connections to the natural world highlevel wellness also demands discussion of authoritarianism social dominance orientation narcissism and other barriers to vitality of individuals communities and the planet finally we emphasize that experts in environmental health promotion and lifestyle medicine are ideally positioned to educate and advocate on behalf of patients and communities helping to promote vitality and safeguard the health of person place and planet highlevel wellness wellness is conceptualized as dynamica condition of change in which the individual moves forward climbing toward a higher potential of functioning highlevel wellness for the individual is defined as an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable within the environment where are functioning this definition does not imply that there is an as the global health burdens have shifted from infectious to ncds greater emphasis has been placed on the healthmediating role of social determinants lifestyle and the total lived environment the health implications of anthropogenic threats to life within the biosphere cannot be uncoupled from discussions of the individual community and global health recent endeavors such as the lancet commission on planetary health 9 and the canmore declaration 10 have reemphasized that public health biopsychosocial medicine and planetary health are oneandthesame roadmap to the current review here in our narrative review we will revisit dunns highlevel wellness and explore its place in the emerging planetary health paradigm first we discuss some of the origins of the highlevel wellness concept and describe how it manifests in contemporary clinical care next we examine the concept of planetary health its historical origins and the global movement which now considers the health of civilization and the earths natural systems as inseparable with this background in place we argue that the concept of highlevel wellness provides an essential framework for health promotion and clinical care in the modern landscape it allows scientists of diverse fieldsno matter how reductionist the scope of their inquiryto see the largescale relevancy of their work it provides healthcare providers a broader vision of human potential with individuals as living embodiments of accumulated experiences shaped by natural and anthropogenic ecosystemsrather than a vision limited to a neutral diseasefree set point dunns highlevel wellness and planetary health requires discourse concerning values our connectedness to one another our sense of purposemeaning and our emotional connections to the natural world highlevel wellness also demands discussion of authoritarianism social dominance orientation narcissism and other barriers to vitality of individuals communities and the planet finally we emphasize that experts in environmental health promotion and lifestyle medicine are ideally positioned to educate and advocate on behalf of patients and communities helping to promote vitality and safeguard the health of person place and planet highlevel wellness wellness is conceptualized as dynamica condition of change in which the individual moves forward climbing toward a higher potential of functioning highlevel wellness for the individual is defined as an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable within the environment where are functioning this definition does not imply that there is an optimum level of wellness but rather that wellness is a direction in progress toward an everhigher potential of functioning highlevel wellness therefore involves direction in progress forward and upward towards a higher potential of functioning an openended and everexpanding tomorrow with its challenge to live at a fuller potential and the integration of the whole being of the total individual body mind and spirit in the functioning process highlevel wellness is also applicable to organization to the nation and to as a whole halbert l dunn md phd canadian journal of public health 1959 11 in two notable papersboth published in 1959 311 biostatistician and public health physician halbert l dunn conceptualized the idea of highlevel wellness for humankind and civilization atlarge maintaining that wellness is not just a single amorphous condition but is rather a fascinating and everchanging panorama of life itself inviting exploration of its every dimension 3 in this context he included population pressures rising rates of mental and functional illnesses and the rapid speed of technological growth moreover he stated it is probably a fallacy for us to assume as so many of us have done that an expansion in scientific knowledge can indefinitely counterbalance the rapidly dwindling natural resources of the globe 3 in other words dunn was acutely aware even in 1959 that the ability to obtain highlevel wellnessat individual and civilizationwide scaleswas predicated on the health of the planet highlevel wellness is applicable not only to the individual but also to all types of social organizationsto the family to the community to groups of individuals such as business political or religious institutions to the nation and to as a whole for each of these aggregates it implies a forward direction in progress an openended expanding future interaction of the social aggregate and an integrated method of functioning which recognizes the interdependence of with other life forms halbert l dunn md phd 1966 12 dunns context for highlevel wellness was beyond even national boundaries in the era of rapid change no longer could health be viewed as exclusively a local phenomenon the effects of these changes ripple outward to all parts of the physical environment affecting the entire ecology on which man is dependent and also penetrating into the deepest recesses of his inner world 13 the search for highlevel wellness in life cannot be separated from our individual and collective mode of living or lifestyle to understand such connections dunn advocated for educational efforts to develop interest in biology on a vast scale so that it would become of major interest to all this would mean acquiring a deep interest in lifein the life process itself 14 related to this dunn emphasized a need to understand how human attitudes to other forms of life are formed the prerequisite to individual and societal highlevel wellness dunn contended is the maintenance of a sense of purpose and opportunities for creative expression on the other hand he argued that the barriers to highlevel wellness include authoritarianism clinging to dogma and lack of critical analysis skills he encouraged health and medical bodies to selfreflect barriers to highlevel wellness dunn argued are manifest in uncritical allegiance to teams in political economic occupational academic and other professional and social spheres in particular the inability to adjust beliefs and communication based on advancing knowledge is a major impediment dunn maintained that global wellness in the modern era is predicated upon providing opportunities to see common ground teaching children critical appraisal skills and learning the value of listening to opposing views while searching for points of mutual agreement dunn proposed a universal philosophy of living which focused not on what individuals were against but rather what they would be for a philosophy which will permeate the minds and hearts a philosophy which men and women of good will regardless of race creed and nationality can be for a unifying type of philosophy which can be embraced and lived by all within their own cultural background 15 he also called for greater research investments to be directed toward an understanding of the social biochemical physiological and psychological pathways to the goal of highlevel wellness dunn maintained that highlevel wellness was itself a way of lifea lifestyle which involved a sense of purpose and meaningone which maximized the odds of achieving the fullest potential in its simplest form highlevel wellness equates to vitality humans can experience the upper ranges of wellness when there is a feeling of zest in life abundant energy a tingle of vitality and a feeling of being alive clear to the tips of your fingers however dunn cautioned that in 20th century modernity zest was being confused with something that gives us a very momentary lift 14 in the 21st century the iron pyrite of zest and aliveness is alltoooften sold to the public in the form of energy drinks 16 vitality has since become a measurable psychological construct and the subject of intense research scrutiny several vitality scales have been validated and researchers have linked vitality to various healthrelated outcomes for example vitality is emerging as a surrogate marker of reduced risk of ncds psychological wellbeing and better lifecourse health 17 18 19 20 21 in line with dunns commentaries vitality is captured on scales as approaching life with excitement and energy feeling vigorous and enthused living life as an adventure feeling alive and activated zest for life it is unclear if vitality is a cause or consequence of a healthy diet exercise social support and other lifestyle habits such as spending time outdoors in natural environmentsit is likely a mixture of contribution and cause 22 23 24 25 the concept of highlevel wellness may be identified in socalled blue zones where longevity chronic disease resilience and quality of life are found in tandem preventive medicine public and planetary health the term planetary health emerged from the annals of preventive medicine health promotion and the environmental health movement in 1972 physician ecologist frederick sargent ii md advocated for a greater understanding of the interrelations between the planetary lifesupport systems and health 26 in 1974 soviet biophilosopher gennady tsaregorodtsev called for novel and integrative approaches to planetary public health 27 he also advocated for a greater understanding of the biopsychosocial needs of humans in the context of ecosystems at microand macroscales both writers underscored the urgent need for informationgathering and actionable steps in relation to the human health sequelae of environmental degradationthe focus on preventing unanticipated consequences of humaninduced changes to the natural environment on the environmental side of health work of multidisciplinary scientists was folded into definitions of health by environmentalists and various advocacy groups for example in 1980 the environmental group friends of the earth expanded the world health organization definition of health to include ecological and planetary health inputs health is a state of complete physical mental social and ecological wellbeing and not merely the absence of diseasethat personal health involves planetary health 28 at the same time these sentiments were echoed within the growing holistic health movement of the 1980s which argued for greater attention to prevention a different philosophical framework through which individual community environmental and planetary health can be better understood in a broad and integrated fashion 8 nursing a profession which has been unified by deeper understandings of the words health and care was progressive in underscoring planetary health the health of each of us is intricately and inextricably connected to the health of our planet 29 by the early 1990s leaders in nursing advocated for a need to understand health as a reintegration of our human relationships with nature openness to natures healing power broader ecologicallyinformed perspective on health 30 by the mid1990s the wellness movement had according to experts in health education added a sixth dimension of health environmental or planetary health this dimension involves both micro and macro environments 31 health education textbooks maintained that we must now view health as the presence of vitalitythe ability to function with vigor and live actively energetically and fully vitality comes from wellness a state of optimal physical emotional intellectual spiritual interpersonal social environmental and even planetary wellbeing 32 viewed this way the word health cannot be disassociated from the words equity access and opportunity it is also important to point out that the planetary health movement which began in the 1980s was an extension of indigenous knowledge and ideation scholars have underscored that indigenous cultures have longsince understood that human health and planetary health are the same thing 33 for example lori alvord md the first conventionallytrained female navajo surgeon in the united states stated i cannot think of a single thing that would be more important to us than to have a pure environment for our health human health is dependent upon planetary health and everything must exist in a delicate web of balanced relationships 34 an understanding of the links between human and planetary health among indigenous peoples is a product of emotional bonds with the natural environment and effective transgenerational knowledge transfer 3536 indeed the ecopsychology movement of the early 1990s advocated for a planetary view of mental health to live in balance with nature is essential to human emotional and spiritual wellbeing a view that is consistent with the healing traditions of indigenous peoples past and present 37 in sum the environmental health preventive medicine and wellness movements of the late 20th century often included a planetary health perspective however it must be recognized that the foundations of the contemporary planetary health concept are a product of indigenous science and medicine and longstanding awareness that human health is dependent upon the vitality of the natural environment 38 in the context of highlevel wellness preventive medicine is tasked not only with helping to prevent the path to specific diseases but to prevent departure from vitality we turn now to examine the accelerating pace at which the term planetary health has moved into the glossary of science and medicine planetary health moves to mainstream even with all our medical technologies we cannot have well humans on a sick planet planetary health is essential for the wellbeing of every living creature future healthcare professionals must envisage their role within this larger context or their efforts will fail in their basic objective although until recently healthcare providers could ignore this larger context such neglect can no longer be accepted thomas berry 1992 39 although the term planetary health was used frequently by various experts researchers clinicians academics and advocates only recently has the concept entered the lexicon of mainstream science and medicine in 2015 the rockefellerlancet commission on planetary health published its landmark report the expansive documentwhich covered political economic and social systemsformally defined planetary health as the health of human civilization and the state of the natural systems on which it depends with its stated goal to find solutions to health risks posed by our poor stewardship of our planet 9 as a crude measure of the reports impact results of a pubmed search for planetary health demonstrate that over 70 of the citations have been published post2014 the commission report financially supported by the rockefeller foundation has already been cited over 300 times on google scholar it has also spawned a dedicated lancet planetary health journal there is little doubt that the commission report and the efforts of other groups have moved planetary health into widespread discussion the contemporary planetary health concept is meant to break down silos and galvanize research efforts so that there is greater awareness of how specific pieces of research work toward solving the grand challenges of our time planetary health is of course the terrain of environmental impact assessments and strategic environmental assessments climate indicators and toxinbased units of analysis however in 2018 one of the leading voices in the current planetary health movementlancet editorinchief dr richard hortonunderscored that it is so much more planetary health at least in its original conception was not meant to be a recalibrated version of environmental health as important as environmental health is to planetary health studies planetary health was intended as an inquiry into our total world the unity of life and the forces that shape those lives our political systems and the headwinds those systems face the failure of technocratic liberalism along with the populism xenophobia racism and nationalism left in its wake the intensification of market capitalism and the states desire to sweep away all obstacles to those markets power the intimate and intricate effects of wealth on the institutions of society the failure of social mobility to compensate for steep inequality the decay of a tolerant pluralistic well informed public discourse the importance of taking an intersectional perspective rule of law elites the origins of war and the pursuit of peace problems of economicsand economists 40 we agree with this sentiment indeed the future of planetary health in the context of preventive medicine and environmental health requires a greater understanding of a planetary health psyche by this we mean deeper insight into the ways in which emotional bonds are developed between person and place and the collective cognitions and behaviors which have resulted in environmental degradation and anthropocene syndrome in the first place 41 this goes far beyond the now extensive research showing the health benefitsphysical emotional cognitive social and spiritual healthof contact with natural environments 4243 the preventive form of planetary health is now an imperative as stated by harvard psychiatrist john e mack we must develop a relational psychology of the earth which allows us to tell unpleasant or unwelcome truths about ourselves to explore our relationship with the earth and understand how and why we have created institutions that are so destructive to it we in the west have rejected the language and experience of the sacred the divine and the animation of nature our psychology is predominantly a psychology of mechanisms parts and linear relationships we have grown suspicious of experiences no matter how powerful 44 the development of emotional connections with the natural worldand healthrelated associations with such emotional bondsis now a measurable construct in the form of nature relatedness 45 nature relatedness scales are a means for researchers to evaluate individual levels of awareness of and fascination with the natural world nature relatedness scores encapsulate the degree to which individuals have an interest in making contact with nature while this body of research is far from robust the available evidence indicates that nature relatedness is positively associated with general health mental wellbeing empathy proenvironmental attitudesbehaviors and humanitarianism 46 47 48 49 50 51 the challenge for global researchers is to develop a more sophisticated understanding of how nature relatedness fits into the planetary health imperative how is nature relatedness fostered and how is it influenced by cultural experience and socioeconomic variables 5253 what are the biological underpinnings of nature relatedness in relation to noncommunicable disease 54 how does it influence environmental behaviors and the politicaleconomic viewpoints outlined by horton 55 are high levels of nature relatedness a burden in some cases for example in cases where environmental degradation and biodiversity losses are immediately apparent 56 it might be expected that rapidly changing environmental conditions would provoke distress humanity is facing colossal interconnected global challenges it is now abundantly clear that humancaused climate change represents a threat to all of humanity extreme temperature and weather events degraded air quality and the spread of diseases via food water and alterations to the life of vectors are now a reality 57 climate change does not stand alone as a looming public health threat it is coupled with environmental degradation biodiversity losses grotesque health disparities the global spread of ultraprocessed foods and what has been described as a pandemic of noncommunicable diseases 41565859 the burden of these global threats is shouldered by the socioeconomically disadvantaged only recently have researchers begun to tabulate the ways in which environmental degradation takes its toll on mental health in areas where environmental degradation has already been significant researchers see a worsening of mental healthdescribed by some as ecological grief 60 there is an urgent need to study the ways in which climate change and environmental degradation not only contribute to ncds but also how they contribute to mental stress and diminish vitality 61 62 63 planetary health vs authoritarianism more than ever before medicine science and health are political discussions 64 65 66 67 a rapid change in communication technology and social media has accelerated the ability of misinformation to spread globally we have now entered a strange era dubbed posttruth 68 a time when it is no long tenable to be on the sidelines as a health care spectator however in comparison to other professions and even the general population us physicians show low levels of civic participation 6970 recent elections in north america and europe have underscored the ways in which public health is threatened by political authoritarianism 7172 however authoritarianism and social dominance orientation are not constrained to the political arena and politicians rather they can be found in many contemporary social structures including those associated with westernized medicine 73 and science 74 in his writings on wellness dunn underscored that authoritarianism is a significant barrier to global wellbeing in order to remedy this he encouraged greater inclusion of political science in health research and education he also advocated for a greater understanding of leadership styles as influence on the health of groups and broader awareness of the ways in which scientific findings are selectively misused in particular he was concerned about the abuse of science by sociallydominant political elites and those with biased interests in the outcomes during dunns time the research on authoritarianism was still in its infancy today this area of research is far more robust and it is much easier to determine the ways in which it interferes with health authoritarianism is described as expecting or requiring people to obey favoring a concentration of power limitation of personal freedoms scores on authoritarianism scales are associated with stigmatization of outgroups a rigid adherence to mainstream convention and broad aspects of prejudice 75 76 77 authoritarianism predicts intolerance to diversity and differing cultures aggression toward outgroup members and hypervigilance to threats against nonconformism it is also associated with a cognitive style devoid of finegrained discourse and nuance outgroups are labeled in simplistic allornone fashion 78 social dominance orientation is a related psychological construct that is characterized by attraction to hierarchy and areas of prestige found within social systems sdo scales capture beliefs regarding the acceptability or entitlement of highstatus groups to dominate other groups and attitudes toward maintaining social and economic inequality higher scores on sdo scales are associated with lower empathy and less concern for matters of social justice and inequalities 79 conversely these individuals are hypervigilant to threatsreal and perceivedthat might compromise privileged status and its benefits 80 researchers have shown that higher sdo predicts prejudice and diminishes awareness that power gained from the dominant social position is being used for personal gains 8182 the overlaps between sdo and authoritarianism have been consistently noted such that researchers refer to the combination of sdo and authoritarianism as the lethal union the relevancy of authoritarianism and sdo to planetary health is now obvious authoritarianism andor sdo predict denial of the seriousness of climate change lower levels of environmental concern and a hierarchical anthropocentric view of nature 83 84 85 86 87 many public health professionals are keenly aware of the threats posed by political authoritarianism indeed recent elections in north america and europe have been a catalyst in emphasizing the importance of political science in personal public and planetary health 88 empathic caring civilminded professionals that fill the ranks of global healthcare are obligatory humanists because so many health threatsthose linked to ecosystems and the biosphere and infectiousncds alikeare oblivious to national boundaries humanist healthcare professionals are in turn obligatory antinationalists thus public preventive and environmental health is built upon vigilance for political authoritarianism it is understood that the misguided actions of any one nation or even one individual can conspire against all of humanity however this does not mean that sdo or institutional authoritarianism is a problem to which science and medicine is immune on the contrary research shows that authoritarianism andor sdo may be uncomfortably high among students at entrance to medical schools increased through medical education and reinforced at the institutional levels of medicine 89 90 91 92 93 94 medicine in general and the technical medical disciplines such as surgery in particular maintain high levels of perceived status 91 that is a problem not only for clinical care but also for building the public trust in science and medicine atlarge research is beginning to tease out the motivations of students who enter medical school as they relate to money and status and connect these to characteristics such as low agreeableness and intolerance of opposing views 95 since experimental studies show that manipulating social status and power increases social dominance and that sdo can be provoked by status reminders and cues such as money 819697 medicine may need to look inward and examine its commitment to the principles of planetary health indeed contemporary research supports dunns contention that individual authoritarianism is a barrier to the collective action required to support the core tenets of planetary healththat is it blocks social rightsbased movements 98 as discussed in detail elsewhere 73 entering medical school with a high desire for social status or with higher baseline levels of authoritarianism and social dominance orientation than societal normsand to have such characteristics amplified through medical training and institutional structuresis at the heart of hortons plea 40 for a planetary health agenda designed for meaningful change how can science and medicine challenge an unhealthy status quo if it is unwilling or unable to confront its own contextual power hierarchies 99100 these are concerns which permeate healthcareatlarge higher sdo is associated with an unwillingness to engage in interprofessional education 101 this is likely to reflect more generalized shifts in societal goals and value systems away from meaningful life philosophy towards an emphasis on financial wealth as the dominant measure of success 102 conclusions the contemporary concept of planetary healthwhich has its roots in the late20th century preventive medicine and environmental health movementsemphasizes that health equates to vitality at scales of person place and planet it asserts that preventive medicine is a broad term one which extends to the planets natural systemsthe ecosystems and biodiversity upon which our own vitality depends planetary health is an adisciplinary unifying concept which allows researchers working in seemingly disparate branches of science and medicine to understand the relevancy of the toil provided by each group specifically we must advance the cause of planetary health by demonstrating a willingness to engage with and promote other disciplines to this end there are now encouraging examples of collaborative initiatives between health providers regenerative agriculturalists and local communitiesnotably developing regions of the worldwith demonstrated communitywide benefits for health wealth employment and environmental sustainability 103 these integrative models provide a path forward for ensuring the health of people and planet in the context of planetary health the urgent task for preventive medicine and environmental health is to provide deeper insight into the ways in which we develop relationships with nature and how we feel think and respond to the natural world this includes the biological social political and economic underpinnings of nature relatedness and its impact on vitality at all scales it includes a more finegrained understanding of what prevents the planetary health goals set forth by the who and the lancet commission on planetary health report 9 from our perspective this means further study of authoritarianism and social dominance orientation vis à vis the structuresincluding those found in politics science medicine and elsewherewhich either support the status quo or provide meaningful solutions to planetary health objectives this applies equally to the injustices and inefficiencies of global systems such as food and international trade systems which also serve to undermine health and equality through biased authoritarian and neoliberal ideologies 104105 the idea that threats to the health of the person the place and the planet are distinct from each other is a mirage this false notion has been challenged by environmental health and preventive medicine for decades we have moved past the point at which such discourse is merely intellectual fodder we argue that in 2019 one simply cannot claim to be a health care professional without advocating forcefully for the planet there are no healthy people on an uninhabitable planet and we are fast heading there if its true goals are realized environmental health and preventive medicine at the planetary scale will as jonas salk implored in 1984 place emphasis on the idea that we should want those who follow us to look back on us as having been wise ancestors good ancestors 106 author contributions slp developed the commentary project oversight and research analysis acl provided the research analysis and developed the historical aspects of the manuscript dlk is responsible for the commentary oversight research interpretation critical review of manuscript and input of public health perspectives all authors contributed to the development and review of the manuscript all authors read and approved the final manuscript the artwork was created by slp

experts in preventive medicine and public health have longsince recognized that health is more than the absence of disease and that each person in the waiting room and beyond manifests the socialpoliticaleconomic ecosystems that are part of their total lived experience the term planetary healthdenoting the interconnections between the health of person and place at all scalesemerged from the environmental and preventive health movements of the 19701980s roused by the 2015 lancet commission on planetary health report the term has more recently penetrated mainstream academic and medical discourse here we discuss the relevance of planetary health in the era of personalized medicine gross environmental concerns and a crisis of noncommunicable diseases we frame our discourse around highlevel wellnessa concept of vitality defined by halbert l dunn highlevel wellness was defined as an integrated method of functioning which is oriented toward maximizing the potential of individuals within the total lived environment dunn maintained that highlevel wellness is also applicable to organizations communities nations and humankind as a wholestating further that global highlevel wellness is a product of the vitality and sustainability of the earths natural systems he called for a universal philosophy of living researchers and healthcare providers who focus on lifestyle and environmental aspects of healthand understand barriers such as authoritarianism and social dominance orientationare fundamental to maintaining transgenerational vitality at scales of person place and planet

background men tend to eat less healthfully than women eating fewer fruits and vegetables 1 2 3 more red and processed meat 24 and greater amounts of processed discretionary foods 3 4 5 these differences contribute to gender inequalities across a range of adverse health outcomes including obesity 6 diabetes mellitus 7 and coronary heart disease 8 socioeconomic inequalities in diet are well established 9 10 11 men and women experiencing socioeconomic disadvantage tend to have eating behaviours not conducive to good health 9 10 11 compared with more advantaged adults those who are disadvantaged tend to eat fewer fruit and vegetables 912 and less fibre 9 disadvantaged adults also consume more fat skip breakfast 9 and eat fast food more frequently 13 education was selected as an indicator of socioeconomic position because it is a strong determinant of future occupation and income reflects knowledgerelated assets and other intellectual resources and has been strongly associated with dietary intake in previous studies 14 the social ecological model which recognises that individuals are embedded within larger social systems provides a useful framework for investigating determinants of behaviour according to the model behaviours are determined by the interactions of individuals and their social and physical environments 15 while correlates of womens eating behaviours are well characterized 16 17 18 19 20 influences on mens eating behaviours are less well understood and are likely to differ from those that influence women 2122 while some sex difference in intakes may be attributable to biological factors it is likely that a range of other factors at the individual social and environmental levels are also implicated for instance social norms related to masculinity may lead men to perceive that consumption of certain healthy foods and activities such as meal planning and cooking are feminine 23 and hence unmasculine 24 several potential drivers of socioeconomic inequalities in mens eating behaviours have been identified in studies focussed on singular domains of the social ecological model intrapersonal factors including nutritionrelated knowledge 25 26 27 selfconfidence problemsolving skills and the ability to process information are important for helping individuals overcome obstacles to adopting more favourable eating behaviours 25 socioeconomically disadvantaged men may also be less likely to use nutrition information and may also lack the skills or confidence to prepare healthy meals 2728 social norms particularly those related to masculinity may also contribute to socioeconomic differences in eating behaviours men who endorse dominant norms of masculinity were shown to adopt less optimal eating behaviours than their peers who endorse less traditional norms 23 young bluecollar male workers tended to show little consideration for being healthconscious resulting in consumption of diets high in saturated fats and sugars 29 those mens food practices reflected gender identity with food preparation commonly viewed as womens work bluecollar workers food choices were also influenced by poor dietary role models including peers coworkers and supervisors 29 environmental factors may also explain socioeconomic differences in mens eating behaviours such as differential access to stores selling both healthy and less healthy foods 30 disadvantaged men may be less likely to make optimal food choices due to limited access to affordable nutritious foods within the local environments where they work and live danish men with low education believed their weight gain was partly attributable to the types of foods available in their work environment 31 in new zealand the least deprived areas had 76 fewer fast food outlets than the most deprived areas and fast food outlet exposure was negatively associated with individuallevel sep indicators 30 methods to our knowledge potential explanations of socioeconomic differences in mens eating behaviours across intrapersonal social and environmental domains have not previously been investigated simultaneously further as these influences remain unexplored across multiple domains together such an approach may have yielded a better understanding of the interaction between factors from different domains as well as potentially identifying factors that may have been overlooked when domains were previously investigated in isolation how these factors may influence socioeconomic inequalities in eating behaviours among men remains unclear the present investigation aimed to qualitatively explore potential explanations for socioeconomic differences in mens eating behaviours among men with tertiary and nontertiary education this study is reported according to the consolidated criteria for reporting qualitative research guidelines 32 and was conducted in conjunction with an independent social and market research agency market solutions pl the agency was selected to assist with the study given their strong track record in conducting social science research 3334 and their familiarity with qualitative methodology and research particularly amongst socioeconomically disadvantaged groups the agency is accredited to the international iso standard for market social and opinion research and is a member of the association of market research organisations market solutions pl was responsible for recruitment conducting interviews recording and transcribing data and transmitting deidentified data to the study investigators the study investigators were responsible for all other aspects of the study the study was approved by the deakin university faculty of health human ethics advisory group all men provided informed verbal consent to participate this was recorded by interviewers at the point of first contact with the men in a password protected project database stored on a secure server recruitment procedure market solutions pl accessed telephone directories of community members in both target catchment areas including mobile and landline numbers and randomly selected mens numbers to be called by one of three male interviewers male interviewers were chosen to maximise the potential to build reciprocity between the interviewer and participant which may yield richer data than may have been gathered by female interviewers 41 men were invited to complete a telephonebased interview either immediately or at a more convenient time purposive sampling 42 based on educational attainment and city of residence was used to recruit a total of 30 men interested participants received study information via telephone and were assessed for eligibility men were offered an aus 20 voucher to a leading retailer as compensation for their time semistructured interview schedule and procedure development of questions for the semistructured interviews was informed by the social ecological model 15 and previous research examining determinants of mens eating behaviours 21232426282931 43 44 45 46 questions were primarily openended and aimed at assessing participants usual eating behaviours and perceived influences on these men were prompted to discuss food task responsibilities influences on eating behaviours and eating choices body weight masculinity social influences perceptions of other mens eating behaviours and neighbourhood availability of healthy foods interview procedure interviews were conducted by telephone in 2015 a oneonone telephone interview was chosen as men resided across a wide geographical area making facetoface interviews less feasible the interview schedule was pilot tested and refined with the first two men piloting showed no major issues with timing or questions with only minor changes made for clarification pilot data were not included in further analyses before commencing interviewers asked for permission to digitally record the interview and participants answered sociodemographic questions interviews lasted between 25 and 35 min and once complete were transcribed verbatim from the recordings sociodemographic characteristics men provided their age and highest attained level of education employment status annual household income household structure and occupation were also established data analysis qualitative description was used to build a comprehensive understanding of socioeconomic differences in influences on mens eating behaviours qualitative description aims to maximise descriptive and interpretive validity by providing an account of events that both participants and researchers would agree is accurate 4748 this methodology is more appropriate than those requiring a greater degree of researcher interpretation given the goal of the present investigation to discern potential influences on socioeconomic differences between mens eating behaviours 48 data were analysed by the lead author using thematic analysis which comprised four key steps 49 immersion in the data linebyline coding creating categories and generation of themes ls read and reread transcribed interviews to build familiarity with the data and then performed abductive thematic analysis 50 to code data using descriptive labels categories were formed by linking coded data together that related to similar concepts while keeping categories for tertiary and nontertiary educated men separate 49 based on these categories ls identified key emerging themes that were salient for men within each education level group individual influences were each classified into a separate theme findings were generated via an iterative abductive cycle moving back and forth between inductive and deductive reasoning where relationships between themes andor subthemes were identified such interactions were classified under the predominant theme that united those factors rigour was maintained via researcher reflexivity development of an audit trail by recording steps taken in the development and reporting of findings linking interpretations with the raw data by presenting participant quotes and peer debriefing with the studys coauthors throughout the analytical process an independent researcher doublecoded a subsample of interviews each coder independently and systematically employed the iterative abductive cycle described above to create categories from the data the purpose of double coding was to explore potential alternative interpretations of the data as the iterative process of crosschecking coding strategies and data interpretation by the researchers enables potential alternative interpretations to be identified and discussed serving to create a more thorough examination of the data 51 data analysis was conducted using raw transcripts entered into nvivo software results sociodemographic characteristics of the sample are shown in table 1 a range of age groups were represented with the majority aged 4554 years and employed in fullor parttime work very few men were studying unemployed or retired and none were engaged in home duties or other forms of employment most tertiary educated men worked as professionals among nontertiary educated men 50 worked as technicians and trades workers 17 worked as managers and 17 in clerical and administrative roles only one man was employed as a machinery operatordriver and none were employed as sales workers labourers or in other roles major emerging themes and exemplary quotes are presented below with results presented stratified by education level themes found to be equally prominent across both groups of men included the intrapersonallevel influences of attitudes relating to masculinity nutrition knowledge and awareness and moralising consumption of certain foods and social influences of children environmental themes discussed by both groups included availability of and access to healthy and unhealthy foods convenience and the interplay between cost convenience taste and healthfulness when choosing foods intrapersonal influences more frequently discussed by tertiary educated men within themes identified included having greater foodrelated skills but less involvement in foodrelated tasks because of time constraints almost all tertiary educated men with partners identified their partners as a positive influence on eating behaviours environmental influences more dominant among tertiary educated men included accessibility of healthy foods and perceiving healthy foods as expensive and unhealthy foods as inexpensive a number of influences within themes were more frequently discussed by nontertiary educated men including having less developed cooking skills but regular involvement in foodrelated tasks such as shopping preparing and cooking meals when compared to discussion by tertiary educated men while men from both groups recognised nutrition knowledge as an influence on their eating behaviours nontertiary educated men reported lower perceived levels of nutrition knowledge and sometimes described misperceptions related to nutrition and body weight a theme identified only among nontertiary educated men was the perception that noone influenced their eating behaviours nontertiary educated men also identified mobile worksites as an unhealthy influence on eating and discussed the need to adhere to a food budget intrapersonal influences intrapersonal influences included attitudes related to masculinity foodrelated tasks and skills nutrition knowledge and awareness and moralising consumption of certain foods attitudes related to masculinity men from both educational groups reported that they did not believe that preparing and consuming healthy food were negatively associated with principles of masculinity but rather were important for good health some tertiary educated men thought perceptions that it was unmasculine to eat healthfully had become less common over time while others from both groups thought eating healthfully actually enhanced masculinity things have changed it might just be a reflection of my own friends but i think a lot of guys i know cook more and want to eat a greater range of foods i think there is a change where guys are picking up more responsibility at home tertiary educated man i tend to think if you eat healthy it would give you a greater sense of masculinity from a male point of view nontertiary educated man foodrelated tasks and skills foodrelated tasks and skills were discussed as an influence on mens eating behaviours by almost all men from both education groups tertiary educated men reported taking part in meal planning food purchasing and preparation and adding extra vegetables to a dish to make it healthier some nontertiary educated men described themselves as expert cooks while others felt they had sufficient skills to put simple meals together both groups of men also frequently prepared their lunch for work tonight ive got leftover pasta… i just added frozen peas and some fresh asparagus which i just boiled quickly and i added it in tertiary educated man if i do prepare a meal i might make myself some bacon and eggs on toast or i might make myself a burger if the materials are here at the time nontertiary educated man men from both groups identified several reasons for cooking including sharing the workload with their partner or spouse andor because they enjoyed cooking a few of the nontertiary educated men described eating at home because it was cheaper to cook at home than to eat out some nontertiary educated men also described sharing the food preparation workload due to time constraints such that whoever in the household arrived home earliest after work or had more time did the cooking dinner time is the time that my wife sort of works a bit later and im working days and ive got time to cook til she comes home… i like the taste and i like experimenting with cooking and making a few different things nontertiary educated man nutrition knowledge and awareness men from both groups were aware of the importance of eating healthfully and thought people particularly other men were far more aware of the importance of eating healthfully than in the past and that awareness was continuing to grow over time both groups of men considered healthfulness when making food choices with many choosing foods specifically because they felt they were healthy nutrition knowledge was not determined by skilltesting questions and men were not asked to directly compare their knowledge to other mens knowledge however nontertiary educated men perceived that they had lower nutritionrelated knowledge than men with a tertiary education and sometimes described misperceptions related to nutrition and body weight steaks are probably better for me than any of the other fatty food even with sausages sometimes they can be real fatty where at least i know if a steaks done properly theres not much chance of a lot of fat still being inside of it nontertiary educated man my understanding is that fat is only stored to a point and then your body wont take anymore what we assume is eating too much fat is actually carbohydrates stored as fat… in actual fact people are not fat theyre just carrying an enormous amount of carbohydrate that theyre not using nontertiary educated man moralising consumption of certain foods men in both groups moralised consumption of certain foods based on their perceived healthfulness particularly snack foods in 1999 rozin described moralisation as the act of accreting moral value to activities or objects that were previously without moral value 52 moralising food consumption can be regarded as translating food judgements into corresponding behavioural rules for example men associated choosing good food with good health or high selfcontrol while bad food choices were linked with poor health and low selfcontrol such food judgements can be taken further to imply that certain food choices are righteoussinful or moralimmoral 53 men in both groups often described healthy food as right or sensible while consumption of unhealthy foods was construed negatively associated with feelings of guilt or viewed as terrible i always favour seafood because i tend to think its a more sensible choice… i think seafoods invariably a healthy choice nontertiary educated man social influences social influences on eating behaviours identified included the influences of partnersspouses and children and the perception that noone influenced eating behaviours partners and spouses among those men with partners more of the tertiary educated men than those with nontertiary education described believing that their partner had a healthy influence on their eating behaviours in the majority of cases partners main mechanism of influence was by acting as gatekeepers of the home food environment by controlling the healthfulness of foods purchased and preparing nutritious meals some tertiary educated men also thought their partners also verbally encouraged them to eat healthfully or that their partner was a healthy role model my wife helps me eat more healthfully … by positive reinforcement by actively seeking and assisting in healthy choices healthy recipes and healthy food tertiary educated man children among both groups of men most who had children thought their children influenced them to eat healthfully a number of fathers described choosing healthier foods in order to make them available to their children as well as to rolemodel healthy eating for their children noone influences eating behaviour several nontertiary educated men stated they did not believe anyone else exerted influence on their eating behaviours despite many of these men having partners andor children this view was not identified by tertiary educated men environmental influences environmental influences identified by both groups of men included availability of and access to healthy and unhealthy foods as well as convenience and cost availability of and access to healthy and unhealthy foods all men discussed availability of and access to healthy and unhealthy foods at home work and in the local neighbourhood as affecting food choice almost all men from both groups felt healthy food was readily available and accessible in the local neighbourhood tertiary educated men thought access to particular foods increased the likelihood those foods would be eaten therefore ready access to healthy foods would result in eating more healthfully in general a few nontertiary educated men also chose foods at home particularly snack foods simply because they were readily accessible if im in the right frame of mind when im shopping ill buy better things… ill buy more vegetables and more fruit… and if i buy it i eventually will eat it i dont like wasting stuff… just making sure that you buy more fruit and vegetables than you think you need… because theyre there you can think of things you can do with them tertiary educated man for snacks i eat anything i can get my hands on really im a bit of a human garbage disposal so theres fruits and biscuits and nuts and whateverchocolate anything i can get chips anything i can get a hold of anything in front of me nontertiary educated man some nontertiary educated men had mobile worksites and so work lunch choices were influenced by what was available in the neighbourhood surrounding their workplace ie they purchased food wherever they were located for a job not an actual workplace cafeteria im selfemployed im sort of all over the place so itd be just like a shop where i buy my lunch when at work yeah just whatevers closest nontertiary educated man convenience almost all men from both groups cited convenience as a major influence of food choice selecting foodsparticularly breakfast and lunch foodsbecause they were close to hand and quick to purchase and consume among men who purchased work lunches several from both groups considered the convenience and time it took to access food influenced their choices often leading to less healthy food purchases theres always a lot more temptation to eat junky food for work lunch because its really easy and its there and its just about everywhere that you go you can just grab it and eat it you dont have to think about it and ive noticed if you have to wait and think about it you generally change your mind tertiary educated man cost cost influenced mens food choices all tertiary educated men considered cost when choosing food and the perception that healthy food was expensive was prominent among tertiary educated men but not among nontertiary educated men tertiary educated men thought the cost of healthy food was prohibitive when doing the grocery shopping and unhealthy food items available in supermarkets were often cheap or on special its so much easier in particular this country to buy cheap takeaway than it is to buy whats often not so cheap healthy food and then do the groundwork of preparing its easier and often cheaper you walk into a supermarket and youre going to pay aus 300 for a bottle of highcalorie beverage and aus 350 for a bottle of water how is that possible tertiary educated man almost all nontertiary educated men also considered price when choosing foods with some households having to stay within a budget when they shopped for food generally we cook the cheaper cuts of meat mince and sausages… because were on a budget nontertiary educated man men from both groups talked about considering cost along with other influences when choosing foods consistently the interplay between cost convenience taste and healthfulness of foods were considered together before a choice was made among men from both groups those who prioritised health tended to consider cost as a secondary influence after health followed by convenience with taste being less important among those who did not prioritise health cost and convenience were more important over health and taste considerations probably convenience cost and health would be the main three influences to consider when choosing lunch for me its just with my work and home life having a schedule where were home with the little one at lunch time and shes having a sleep during my lunch i choose what is convenient and then other times cost its more cost effective for me to take my lunch to work with me something that i like to eat rather than have to pay 8 for a salad roll when i can make one and bring one from home and dont have to go looking for it as well tertiary educated man food definitely has to be filling because the price of food these days out is usually expensive definitely filling… you need to be content you dont want to have one hot dog and go gee im still hungry at the end of the day you might get to a place and theres only two options available so you look at that and convenience whats easy whats simple price does come into it again its hard to judge because everything that you buy these days is pricey anyway nontertiary educated man discussion the present investigation aimed to examine potential explanations of socioeconomic differences in mens eating behaviours by qualitatively exploring influences on eating among men of tertiary and nontertiary education levels salient themes among men from both education groups included influences from intrapersonal social and environmental domains influences more predominant among tertiary educated men included having more advanced foodrelated skills but relatively less involvement in foodrelated tasks compared nontertiary educated men partnerspouse support for healthy eating access to healthy foods and views relating to food cost prominent influences among men with nontertiary education levels included having limited cooking skills but more frequently being involved in foodrelated tasks and perceiving having limited nutrition knowledge when compared with discussion by tertiary educated men these men also identified more often that noone influenced their diet they had mobile worksites and adhered to a food budget neither group perceived food preparation or healthy eating to be at odds with the concept of masculinity a finding which is divergent with those of previous studies that showed men irrespective of education level or occupation considered healthy eating as feminine 215455 it may be that with increasing global recognition of the importance of diet for chronic disease prevention eating for good health has become more acceptable and normative among men since those earlier studies were published mens perceptions about masculinity described in the present investigation may also be attributed to workforce and societal changes in women and careers with fewer men being the familys primary income provider and with fewer women staying home to perform all foodrelated tasks than previously further the majority of participants in the present investigation were aged ≥45 years and may have greater awareness of the importance of health behaviours as they age and face increased risk of dietrelated disease when discussion about foodrelated tasks and skills was examined tertiary educated mens cooking skills were more developed but they had less involvement in foodrelated tasks than nontertiary educated men who had more limited cooking skills but regular involvement in foodrelated tasks these findings correspond with those reported previously for example low income us men were nearly three times more likely to be involved in meal planning and preparation compared to their wealthier counterparts 56 and norwegian men working in blue collar occupations were more likely to share food shopping and preparation with their partnerspouse compared to men in white collar occupations 57 consistent with our findings regarding education level and cooking skills when selfdescribed cooking skills were compared between swiss men those with high education levels had more elaborate cooking skills than less educated men 58 social influences on mens eating behaviours included those in their family unit or as for several nontertiary educated men no other individuals partnerspousal support for healthy eating was recognised as important by tertiary educated men in our study but not among those with nontertiary education conversely low income british men previously identified female figures as positive influences on their eating behaviours 59 similarly dutch men with lower vocational education or below stated they would eat healthfully if their spousepartner did 60 a previous australian nutrition and physical activity intervention incorporating social support by partners resulted in significant decreases in total and saturated fat consumption and significant increases in fibre intake among men and women 61 implying that greater social support from spousespartners would encourage men to eat more healthfully it is unclear why our findings diverged from these previous studies however it may simply be a function of studying different samples fathers from both education groups acknowledged the importance of rolemodelling healthy eating for their children and how this encouraged their own healthy eating previous research showed that australian childrens total fruit consumption was positively associated with that of their father 62 and thus supports observations in the present investigation that some nontertiary educated men in the present investigation thought noone influenced their diet was novel and contradictory to previous research suggestive that social support for healthy eating encouraged less educated or low income men to adhere to healthier eating behaviours 5960 on balance findings from the present investigation and previous research suggest that rolemodelling and social support are important factors for supporting men to eat healthfully and have the potential to be powerful mechanisms through which improvements in mens diets could be achieved if incorporated into future nutrition promotion initiatives for example engaging men along with their partners in intervention strategies including nutrition education and cooking classes tertiary educated men in our study considered healthy foods to be expensive however although nontertiary educated men reported having to adhere to a food budget they did not generally describe healthy foods as expensive potential explanations for this paradoxical finding could be that only six of the nontertiary educated men had low income and may have been able to afford healthy foods however previous research among socioeconomically disadvantaged men showed they did not consider healthy foods prohibitively expensive 5960 the present investigation also revealed that men chose foods by considering a number of influences in conjunction at multiple socioecological levels the observed interplay between influences on mens eating behaviours implies multiple factors shape mens dietary behaviours it also suggests employing a qualitative approach to explore influences on mens eating behaviours across the domains of the social ecological model in unison such as employed in the present investigation is advantageous this can yield a deeper understanding of how influences across domains interact and can be utilised in future to further inform research and interventions aimed at improving mens eating behaviours factors identified as potential influences on socioeconomic inequalities in mens diets in this study need confirmation in larger samples using quantitative methods acknowledging this the present investigation has elucidated key levers that could if confirmed be targeted in initiatives aimed at reducing inequalities in eating behaviours in turn ameliorating the socioeconomic gap and adverse health and economic outcomes associated with these inequalities for example strategies to promote healthy eating among nontertiary educated men could focus on developing greater nutrition knowledge improving cooking skills identifying key social supports for healthy eating and providing skills and strategies to purchase healthy foods particularly whilst at work whether at a fixed or mobile worksite and on a budget strategies that could support tertiary educated men to eat healthily could include promoting greater involvement in foodrelated tasks and education about choosing low cost healthy foods previous programs incorporating some strategies identified above have successfully promoted healthy eating among women and men 63 including those experiencing socioeconomic disadvantage 64 however given challenges in engaging men in such programs 65 policy and practice should not only focus on developing nutrition promotion initiatives aimed at improving mens diet that are custommade to specific socioeconomic groups but also incorporate specific tailoring to engage men study limitations should be acknowledged participating men may have been more interested in nutrition and health than nonparticipants resulting in possible participation bias transferability of findings may be limited by a single measure of sep being used to define the sample almost all participating men were employed and had professional occupations and only half of nontertiary educated men had low incomes more sensitive measures of education could be considered in future research further sep is not determined by education alone and is only one of many possible measures when in fact sep is best described in a more complex way by considering multiple factors such as income education and occupation simultaneously not singly as no data about mens ethnicity or culture were gathered in the present investigation it was not possible to make any observations about possible cultural variations in views between men exploring cultural differences in conjunction with socioeconomic differences may be considered in future also as more than half of participants were aged 4554 years the generalisability to men of other age groups may be limited men who identified as having a partner were not asked to disclose the sex of their partner it is unclear if study findings would vary whether the couple was samesex or oppositesex and is therefore acknowledged as a limitation nevertheless qualitative studies do not intend to focus on general sample representativeness but rather aim to generate a range of responses and hypotheses for potential follow up in future research 38 men may also have provided socially desirable responses such as stating they had more favourable eating behaviours than in reality yet participants also identified challenges faced in consuming healthy foods and openly discussed barriers to doing so suggesting that socially desirable responses were minimised further participants responses might have been influenced by being interviewed by another male views presented may have inadvertently been driven by participants perceptions of shared masculine identity with or reciprocal enactment of masculinity by the male interviewer and consequently resulting in a more idealised cultural notion of masculinity 41 however as this was not reflected in the responses observed the use of male interviewers here could be interpreted as a strength as there may have been reciprocity between the interviewer and interviewee resulting in richer data than may have been gathered by female interviewers 41 also using a oneonone telephone interview methodology may have reduced some response bias as participants may have been less affected by cues from facial expressions or perceived social desirability from the researcher eg in facetoface interviews or other participants eg in a focus group setting 6667 while using a telephone method also has disadvantages including lack of visual cues and difficulty building rapport 68 this method was deemed necessary as participants were recruited across a wide geographical area finally data analysis occurred after data collection was complete and therefore emerging themes could not be checked during the data collection process study strengths include the qualitative design which provided indepth comprehensive insights into socioeconomic differences in influences on mens eating behaviours with perspectives provided by men living in two regions of australia drawn from different educational strata a further notable strength of the study is that it provided unique insights into mens eating behaviours overall irrespective of sep conclusions to conclude the present investigation provided insights into individual social and environmental influences on the eating behaviours of men with divergent education levels expanding the knowledge base around this important topic key potential drivers of socioeconomic inequalities in mens eating behaviours were identified with potential to inform novel strategies to encourage men to eat healthfully future quantitative research is required to examine how factors identified in the present investigation are associated with mens dietary intakes across socioeconomic strata how they might explain socioeconomic differences in mens diets and the feasibility of adopting various strategies to support healthy eating among men in different socioeconomic groups drafted the manuscript all authors contributed to revising the manuscript lds had primary responsibility for final content all authors read and approved the final manuscript additional file additional file 1 table s1 semistructured interview questions investigating ns on mens eating behaviours summary of semistructured interview questions used in the present investigation abbreviation sep socioeconomic position authors contributions dc lt and kb designed the research dc lt dlo pjm fjvl and kb developed measures lds performed data analyses lds dc dlo and kb consent for publication not applicable competing interests the authors declare that they have no competing interests

background men of low socioeconomic position sep are less likely than those of higher sep to consume fruits and vegetables and more likely to eat processed discretionary foods education level is a widely used marker of sep few studies have explored determinants of socioeconomic inequalities in mens eating behaviours the present study aimed to explore intrapersonal social and environmental factors potentially contributing to educational inequalities in mens eating behaviour methods thirty australian men aged 1860 years 15 each with tertiary or nontertiary education from two large metropolitan sites melbourne victoria and newcastle new south wales participated in qualitative semistructured oneonone telephone interviews about their perceptions of influences on their and other mens eating behaviours the social ecological model informed interview question development and data were examined using abductive thematic analysis results themes equally salient across tertiary and nontertiary educated groups included attitudes about masculinity nutrition knowledge and awareness moralising consumption of certain foods the influence of children on eating availability of healthy foods convenience and the interplay between cost convenience taste and healthfulness when choosing foods more prominent influences among tertiary educated men included using advanced cooking skills but having relatively infrequent involvement in other foodrelated tasks the influence of partnerspouse support on eating access to healthy food and cost more predominant influences among nontertiary educated men included having fewer cooking skills but frequent involvement in foodrelated tasks identifying that noone influenced their diet having mobile worksites and adhering to food budgets conclusions this study identified key similarities and differences in perceived influences on eating behaviours among men with lower and higher education levels further research is needed to determine the extent to which such influences explain socioeconomic variations in mens dietary intakes and to identify feasible strategies that might support healthy eating among men in different socioeconomic groups

introduction although asian american adolescents are commonly perceived to be model minorities there has been a growing concern about delinquent behaviors in this group indeed studies have found that asian american adolescents are at least as likely to engage in delinquency as their european american counterparts the literature on this topic suggests that asian american adolescents delinquent behaviors are tied to the challenges of adapting to life in the us such as dealing with family and peer relationships in potentially conflicting mainstream and heritage cultures thus it is important to consider the psychosocial predictors of delinquency such as acculturation in order to inform future intervention efforts acculturation refers to a process through which immigrants gradually adapt their language behaviors beliefs and or values as a result of contact with the mainstream culture a significant body of work has shown that discrepancy in acculturation levels between parents and children is a significant risk factor for child maladjustment as indicated by decreased academic performance depression and delinquency longitudinal research on this links underlying mechanism however is limited also limited are studies examining withinfamily variations in the effects of parentchild acculturation discrepancy on child maladjustment the present study explores how parents knowledge of childrens daily experiences and adolescents association with deviant peers two important constructs related to delinquency operate sequentially to mediate the relationship between parentchild acculturation discrepancy and adolescent delinquency in an understudied population of adolescents in chinese immigrant families within each family the mediating pathway is tested separately for two groups of parentadolescent dyads those that are more discrepant in their acculturation levels and those that are less discrepant parentchild acculturation discrepancy as a risk factor for adolescent delinquency acculturation is a bidimensional construct consisting of orientations toward two cultures heritage and mainstream which are independent from each other children of immigrants tend to be more acculturated to the mainstream culture while immigrant parents tend to be more oriented toward their heritage culture although the alternate scenario occurs with less frequency some immigrant parents are more acculturated to the mainstream culture while their children are more oriented toward the parents heritage culture regardless of direction however discrepancies in family members acculturation levels have been linked to externalizing behaviors in children such as substance use in latino youth conduct problems in mexican youth and violence in asian american youth this might be due to the fact that as long as parents and children have discrepant beliefs values and behaviors family functions are likely to be disrupted birman found that parentchild acculturation discrepancy leads to family disagreement regardless of the direction of discrepancy therefore although the current study controls for the direction of discrepancy any form of acculturation discrepancy is considered to have a similar effect on adolescent adjustment one limitation of previous studies on this topic is their tendency to rely on concurrent data and to examine only direct correlational relationships between acculturation discrepancy and adolescent delinquency by using longitudinal data the current study takes into account the temporal ordering of variables to test the longterm effect of parentchild acculturation discrepancy on youth delinquency and to explore in greater depth the underlying mechanisms of this relationship parental knowledge and deviant peers as potential mediators parentchild acculturation discrepancy in immigrant families disrupts family functioning by increasing the incidence of miscommunication and misunderstanding theories on communication have highlighted the disruptive effect of not sharing beliefs values and behaviors people with divergent points of view can experience difficulty gaining information from each other similarly parents and children who hold culturally discrepant beliefs values and behaviors may be discouraged from communicating and interacting effectively therefore adolescents may come to feel that their parents do not know or understand their daily activities whereabouts and companions the extant literature does not directly examine the link between parentchild acculturation discrepancy and perceived parental knowledge however previous research does provide some support for such a link for example using generational status as a proximal measure of acculturation tasopouloschan et al found that second generation chinese american youth more frequently avoided discussing their activities with their parents than did first generation chinese american youth in a case study of chinese immigrant families qin found that both parents and children report that parents do not know about their childrens friends and school activities and children do not tell their parents about their experiences due to the fact that parents and children adhere to the heritage and mainstream cultures to different degrees weaver and kims study on chinese american families which used parent and adolescent reports of parental knowledge as one of several indicators of supportive parenting suggested that a high level of parentchild acculturation discrepancy may be related to less parental knowledge about childrens whereabouts companions and bedtime therefore it is possible that in families with a high level of acculturation discrepancy between parents and children adolescents perceive a lack of parental knowledge in addition within a twoparent immigrant family the child may perceive that the parent who is more culturally discrepant knows less about the childs activities whereas the other parent whose acculturation level more closely matches that of the child knows more parental knowledge has been consistently connected to fewer adolescent problem behaviors because such knowledge reduces the likelihood that the child will affiliate with deviant peers although this link between parental knowledge and adolescent delinquency has been demonstrated in the literature few studies on immigrant families have examined the factors that set this process in motion parentchild acculturation discrepancy may be an ongoing obstacle for immigrant parents when it comes to obtaining knowledge about their children which in turn places adolescents at risk for affiliating with deviant peers and engaging in delinquent behaviors withinfamily variations on the hypothesized model studies on parentchild acculturation discrepancy usually sample only one parent within a family even though twoparent families are the most common family form in the immigrant population examining the effect of parentchild acculturation discrepancy without considering the family context may yield inconclusive results as the dynamics in each of the parentchild dyads within a family are interdependent for example an acculturation discrepancy with one parent may not influence family functioning if there is a great deal of tension between the child and the other parent within a family there are likely to be differences between parents in terms of how similar their acculturation level is to that of their child in fact costigan and dokis found that fatherand motherchild acculturation discrepancy differed significantly from each other in both chinese and american orientations thus the two parentchild dyads within a family can be categorized as the dyad with a greater acculturation discrepancy versus the dyad with a smaller acculturation discrepancy a contrast effect is likely to take place acculturation discrepancy in the less discrepant parentchild dyad becomes less important whereas acculturation discrepancy in the more discrepant dyad becomes more problematic indeed literature on social judgment suggests that ones evaluation of a target is based on its relative characteristicsthat is in comparison to the reference whatever the reference might be therefore the link between parentchild acculturation discrepancy and adolescents perceptions of lack of parental knowledge may be stronger among more discrepant parentchild dyads than it is among less discrepant dyads control variables several control variables are theoretically related to the main study variables of parentchild acculturation discrepancy perceived parental knowledge adolescents contact with deviant peers and delinquency first the current study controls for family income and parental education level as the risks posed by parentchild acculturation discrepancy may be especially strong in families in which parents have fewer resources second parent gender is controlled as some parent and child characteristics are more consistently related to paternal knowledge than they are to maternal knowledge third empirical studies have found that secondor latergeneration adolescents engage in more delinquent behaviors than their firstgeneration counterparts and that boys engage in more delinquent behaviors than do girls in addition delinquent behaviors tend to increase from early to middle adolescence therefore the present study also includes adolescents generational status sex and age as control variables we also control for the direction of parentchild acculturation discrepancy and whether the moreless discrepant designation remains the same across waves present study the present study is part of a longitudinal project on chinese immigrant families data were collected first when children in these families were in their early adolescent years and again when they were in their middle adolescent years the current study has two aims first we examine the proposed mediating pathways separately among the more and less discrepant parentadolescent dyads we hypothesize that parentchild acculturation discrepancy will be related to adolescents perceiving that their parents know less about their daily experiences the perception of less parental knowledge will be associated with adolescents affiliating with more deviant peers which in turn will be related to adolescents engaging in more delinquent behaviors second we compare model paths between more and less discrepant dyads we hypothesize that model paths may be stronger for more discrepant dyads than they are for less discrepant dyads the conceptual model to be tested is shown in fig 1 which depicts both concurrent and longitudinal paths between model constructs concurrent relationships from parentchild acculturation discrepancies to parental knowledge to adolescent delinquency are tested among all wave 1 variables as well as among all wave 2 variables data on deviant peers were collected only at wave 2 and thus are tested as a wave 2 construct only autoregressive influences are controlled through paths of the same constructs across waves in addition crosslagged paths are specified for distinct constructs from wave 1 to wave 2 alternative crosslagged paths are also specified to test for a potential alternative causal direction of the proposed relationships in the model method participants participants were drawn from a twowave longitudinal study conducted in northern california immigrant parents in the current study hail from mainland china hong kong and taiwan as the study targets both parents in a family all families have two foreignborn parents who are married to one another both of whom participated in the study the current sample consists of 201 families in the first wave and 183 in the second wave adolescents were between 12 and 15 years of age at wave 1 and 1619 years of age at wave 2 females accounted for 612 of the adolescent sample at wave 1 and 601 at wave 2 median family income was in the range of 30001 45000 at wave 1 and 45001 60000 at wave 2 median education level was high school graduate for both fathers and mothers across waves procedure at wave 1 participants were recruited from seven middle schools in major metropolitan areas of northern california with the aid of school administrators chinese american students were identified and all eligible families were sent a letter describing the research project participants received a packet of questionnaires for the mother father and target child in the household participants were instructed to complete the questionnaires alone and not to discuss answers with friends andor family members they were also instructed to seal their questionnaires in the provided envelopes immediately following completion of their responses within approximately 23 weeks after sending the questionnaire packet research assistants visited each school to collect the completed questionnaires during the students lunch periods of the 47 of families who agreed to participate 76 returned surveys approximately 79 of families participating at wave 1 completed questionnaires at wave 2 at each wave the entire family received nominal compensation for their participation questionnaires were prepared in english and chinese the questionnaires were first translated to chinese and then backtranslated to english any inconsistencies with the original english version of the scale were resolved by bilingual bicultural research assistants with careful consideration of culturally appropriate meaning of items attrition analyses were conducted to compare whether demographic variables differed between families that participated at only one wave and those that participated at both waves only adolescent sex was marginally significantly related to attrition boys were more likely to have dropped out than girls 386 p 051 measures acculturationthe vancouver index of acculturation follows the bidimensional model of acculturation and was developed for use with chinese americans using a scale ranging from strongly disagree to strongly agree mothers fathers and adolescents responded to 10 questions about their american orientation and 10 questions about their chinese orientation questions asked about a range of generic behaviors without listing specific traditions or attitudes the american orientation items were the same as the chinese orientation items except that the word chinese was changed to american only those items that conformed to the common factor structure across informants and waves were used across informants and waves the internal consistency was high for both orientations parental knowledgeparental knowledge was assessed through a measure adapted from the iowa youth and families project using a scale ranging from never to always adolescents rated three items on parents knowledge of adolescents daily activities across waves the internal consistency was acceptable deviant peersadolescents reported on their association with deviant peers at wave 2 only using an abridged 7item version of a peer deviance measure previously used with asian american adolescents adolescents rated the proportion of their close friends who had exhibited problem behaviors during the past 6 months using a scale ranging from almost none to almost all the internal consistency was high delinquent behaviorsdelinquent behaviors were assessed through measures adapted from the rulebreaking behaviors subscale of the child behavior checklist one additional item is part of a gang was added using a scale ranging from not true to often true or very true adolescents rated their own problem behaviors during the past 6 months two items were dropped from factor analysis due to low factor loading the internal consistency was between 57 to 60 across waves given the low levels of delinquent behaviors reported each delinquent behavior was dichotomized such that a score of 0 reflected no delinquent behavior and a score of 1 indicated delinquent behavior whether occasional or frequent control variablesfathers and mothers reported on their family income before taxes and highest level of education attained family income was assessed using a scale ranging from below 15000 to 165001 or more the highest level of education attained by parents was assessed using a scale ranging from no formal schooling to finished graduate degree adolescents also reported their age sex whether they were foreignor usborn and whether their parents were married to one another conceptualizing moreless discrepant parentchild dyads acculturation scores of adolescents and parents were first standardized the parentchild discrepancy score was the absolute value reached by subtracting the standardized parent score from the standardized adolescent score the discrepancy scores of the two parentadolescent dyads in the same family were then compared with each other the dyad with a higher discrepancy score was assigned to the more discrepant group whereas the dyad with a lower discrepancy score was assigned to the less discrepant group these designations were done separately for each wave and separately for chinese and american orientations for the entire sample there were slightly more fatheradolescent dyads than motheradolescent dyads placed in the more discrepant group for all the designations this issue was addressed by controlling for parent gender as a covariate in the following analyses results analyses plan data analyses proceeded in three steps first we conducted descriptive and correlational analyses for model constructs and control variables second we tested our first hypothesis on the mediating pathway separately among more and less discrepant groups using structural equation modeling we examined the hypothesized paths depicted in fig 1 and the indirect effects from parentchild acculturation discrepancy to adolescent delinquency third we tested our second hypothesis on the difference between more and less discrepant groups we conducted invariance tests to compare the strength of the model parameters for more and less discrepant dyads all the steps were conducted separately for chinese and american orientations descriptive statistics and correlational analyses among model constructs table 1 displays the descriptive statistics for the raw scores from participants original reports tables 2 and3 display the descriptive statistics and correlations among the study variables for models involving chinese and american orientations respectively consistent with the hypotheses concurrent relationships and autoregressive relationships between model constructs are generally significant one notable exception is that parentchild acculturation discrepancy is significantly correlated with parental knowledge only among the more discrepant parentadolescent dyads in american orientation in addition only two crosslagged relationships are significant among the more discrepant parentadolescent dyads in american orientation a high level of parentchild acculturation discrepancy at wave 1 is related to compromised parental knowledge at wave 2 and a high level of parental knowledge at wave 1 is significantly related to less contact with deviant peers at wave 2 a potential alternative crosslagged relationship emerged as adolescent delinquency at wave 1 is significantly related to deviant peers at wave 2 for both chinese and american orientations this is the only alternative path included in the analyses of the hypothesized models described below analyses of hypothesized models structural equation modeling was used to examine the hypothesized model using mplus 611 both concurrent and longitudinal links as well as direct and indirect effects among the model constructs were tested simultaneously mplus uses the full information maximum likelihood estimation method to handle missing data so that all the available data can be used to estimate model parameters four separate models were tested separately for more and less discrepant parentadolescent dyads for both chinese and american orientations for all models the endogenous variable was adolescent delinquent behaviors and the mediating variables were parental knowledge and deviant peers adolescents age sex and place of birth as well as family income parental educational level the direction of the parentchild acculturation discrepancy and whether the assignment to the more or less discrepant group switched from waves 1 to 2 were included in all models as covariates the model fits are displayed in the last set of rows in table 4 the four models showed a fair to good fit to the data each model explained 92159 of the variance in wave 1 adolescent delinquency and 435477 of the variance in wave 2 adolescent delinquency the coefficients and confidence intervals for our hypothesized paths are also shown in the first set of rows in table 4 all the hypothesized concurrent relationships among parentchild acculturation discrepancies perceived parental knowledge adolescents contact with deviant peers and adolescent delinquency are significant in the models for more discrepant dyads in american orientation in contrast parentchild acculturation discrepancy is not significantly related to less parental knowledge in the models for less discrepant dyads in chinese or american orientation nor for more discrepant dyads in chinese orientation autoregressive influences are generally significant for parentchild acculturation discrepancy and parental knowledge however with the exception of model 4 the autoregressive influence of adolescent delinquency is not significant in addition with the exception of the significant relationship between w1 delinquency and w2 deviant peer association none of the other crosslagged paths is significant indirect effects are shown in the second set of rows in table 4 concerning our first hypothesis on mediating effects only the models for more discrepant parentadolescent dyads in american orientation yielded significant indirect effects from parentchild acculturation discrepancy to adolescent delinquency concurrently the effect of parentadolescent acculturation discrepancy on adolescent delinquency was mediated by parental knowledge at wave 1 and by both parental knowledge and contact with deviant peers at wave 2 longitudinally the indirect effect of parentadolescent acculturation discrepancy at wave 1 on adolescent delinquency at wave 2 was significant via two pathways the first pathway was via parental knowledge at both waves and contact with deviant peers at wave 2 the second was via parental knowledge at wave 1 adolescent delinquency at wave 1 and contact with deviant peers at wave 2 comparing models for more and less discrepant parentadolescent dyads concerning our second hypothesis on the difference between more and less discrepant parentchild dyads invariance tests were used to determine whether the model paths were significantly different between the two groups these were conducted separately for american and chinese orientations for each orientation data for more and less discrepant dyads were modeled within the same covariance matrix to account for withinfamily dependence a model was first fitted allowing all structural paths to be freely estimated between more and less discrepant dyads individual paths of the structural model were then constrained one at a time to determine if they were significantly different across groups the chisquare test was used to determine whether a more constrained model fitted the data significantly worse than a less constrained one for american orientation only invariance tests showed that three paths are stronger in the model for more discrepant parentadolescent dyads than in the model for less discrepant dyads the path from parentchild acculturation discrepancy to parental knowledge at wave 1 447 p 05 the path from parental knowledge to adolescent delinquency at wave 1 568 p 05 and the path from parental knowledge to contact with deviant peers at wave 2 725 p 01 discussion parentchild acculturation discrepancy has mostly been studied using crosssectional data from the adolescent and just one parent in the family usually the mother the current study used longitudinal data to examine parentchild acculturation discrepancy as an ongoing risk factor for adolescent delinquency and explored possible variations of this effect between more and less discrepant parentadolescent dyads in terms of how their different acculturation levels might affect the functions within each family group the mediating mechanism of this relationship was examined both concurrently and longitudinally for more discrepant parentadolescent dyads in american orientation the relationship between parentchild acculturation discrepancy and adolescent delinquency is mediated by adolescents perception of parental knowledge and contact with deviant peers both concurrently and longitudinally in the current study parentchild discrepancies in american orientation but not chinese orientation are indirectly related to adolescent delinquency the extant literature has been inconsistent on the question of whether orientations towards the mainstream and heritage cultures influence delinquent behaviors in adolescents from immigrant families for example le and stockdale found that asian american adolescents endorsement of both orientations was related to their delinquent behaviors in comparison juang and nguyen found that adolescents misconduct was not significantly related to orientations towards either american or chinese culture but instead to specific cultural values this finding suggests that the effects of acculturationrelated factors on adolescent adjustment may vary according to the specific area being examined it is possible that only a parentchild discrepancy in american orientation affects adolescent delinquency through the mediating pathway of parental knowledge and contact with deviant peers whereas a discrepancy in chinese orientation affects adolescent adjustment through other mediating mechanisms this possibility seems especially likely considering that the construct measured in the current studynamely parental knowledge about childrens daily experiencesis more likely to be associated with the mainstream culture than with the heritage culture future studies are needed to explore whether and how parentchild discrepancy in chinese orientation may be related to adolescent delinquency in chinese immigrant families the existing literature considers lack of parental knowledge especially adolescents perceptions that their parents lack knowledge to be a risk factor for adolescent delinquency the current study adds to this literature by identifying parentchild acculturation discrepancy as one possible origin of this particular risk factor in immigrant families further this link between parentchild acculturation discrepancy and parental knowledge may take different forms depending on the various dynamics operating within a given family in our study we compared the more and less discrepant parentadolescent dyads within each family generally the parent who is more discrepant from the child in orientation towards the mainstream culture presents more of a risk factor than does the less discrepant parent only among dyads in the more discrepant group is parentchild acculturation discrepancy related to deterioration in adolescents perceptions of parental knowledge which in turn is linked to more adolescent delinquency studies have found that parental knowledge comes from different sources such as parents active surveillance and adolescents voluntary disclosures studies measuring perceived parental knowledge also support this notion it is possible that both processes surveillance and disclosure are compromised for the more discrepant parentchild dyad in comparison the less discrepant parent may assume more responsibility for actively tracking the childs activities because he or she relates to the child better for their part adolescents may be more willing to share their daily experiences with their less discrepant parent as they may feel that this parent understands them an interesting finding in the current study is that adolescent delinquency in early adolescence is consistently related to contact with deviant peers in middle adolescence but not as consistently to delinquency in middle adolescence in fact contact with deviant peers during middle adolescence seems to bridge delinquency in early and middle adolescence this result suggests that it may be ideal to time an intervention for reducing delinquency before early adolescence when it may be most effective at reducing the longterm consequences of problem behaviors early onset of delinquent behaviors is a sign of a lifecoursepersistent pattern whereas adolescencelimited delinquent behaviors are more likely to exist only in middle adolescence as the lifecoursepersistent pattern of delinquency clearly poses more of a developmental risk it is important to develop early intervention programs aimed at preventing this persistent pattern from developing implications the current study demonstrates that acculturation discrepancy in parentchild dyads is implicated in child maladjustment moreover it suggests that the parent who is more discrepant poses the greater risk to child outcomes intervention programs usually target mothers or whichever parent in a family signs up for the program however this may not be a good strategy if the participating parent happens to be the less discrepant parent in the family rather it may be more fruitful for future interventions to use a baseline measure to identify and target the parent whose acculturation level is more discrepant from that of the child the current study also identifies parental knowledge as a proximal mediator of the relationship between parentchild discrepancy in american orientation and adolescent delinquency a lack of shared values beliefs and activities may create misunderstanding and precipitate disagreements among family members intervention programs need to facilitate effective communication by providing approaches such as active monitoring and encouraging adolescents disclosure limitations there are some limitations of the current study first families in which only one parent participated including all singleparent families in the project were not included in the sample thus our findings may not be applicable to those families in a similar vein given the low participation rate future studies with different samples are needed to examine whether the current findings can be replicated second there are few significant crosslagged relationships between study variables this lack of significance may be attributed to the gap of 4 years that occurred between data collection waves third although the direction of parentchild acculturation discrepancy was included as a covariate the current study could not compare model parameters between families with different discrepancy directions future studies with larger sample sizes are needed to examine whether the direction of the parentchild acculturation discrepancy has an effect on how it impacts child adjustment finally the current study assumes that a high level of parental knowledge and a low level of adolescent delinquency are adaptive it is possible however that an extremely high level of parental knowledge indicates an overly controlling parenting style and an extremely low level of adolescent delinquency indicates poor peer relationships both of which are indicators of adolescent maladjustment future studies are needed to examine how various levels of parental knowledge and adolescent delinquency are related to adolescents longterm developmental outcomes conclusion the current study explored the possible mediating mechanism of the relationship between parentchild acculturation discrepancy and adolescent delinquency and compared the mediating pathways between more and less discrepant parentadolescent dyads in chinese immigrant families for parentadolescent dyads more discrepant in american orientation acculturation discrepancy in early adolescence is an ongoing risk factor for adolescents engagement in delinquent behaviors in both early and middle adolescence these results suggest that future intervention programs need to include the parent whose acculturation level is more discrepant from that of the child facilitating better communication between parents and children thereby increasing parental knowledge during early adolescence may be the most promising strategy for interventions aiming to reduce adolescents affiliation with deviant peers and subsequent engagement in delinquent behaviors influence adolescent development within a crosscultural context her current research is on parenting practices and adolescent adjustment in chinese immigrant families in the us conceptual longitudinal model linking parentchild acculturation discrepancy parental knowledge deviant peers and adolescent delinquency in chinese immigrant families a paths concurrent relationships between model constructs within wave 1 or wave 2 b paths autoregressive relationships between the same constructs across wave 1 and wave 2 c paths crosslagged relationships between distinct constructs from wave 1 to wave 2 d paths alternative crosslagged relationships between distinct constructs from wave 1 to wave 2 descriptive statistics for raw scores of study variables descriptive statistics and correlations among study variables in chinese orientation models descriptive statistics and correlations among study variables in american orientation models su

parentchild acculturation discrepancy has been considered a risk factor for child maladjustment the current study examined parentchild acculturation discrepancy as an ongoing risk factor for delinquency through the mediating pathway of parental knowledge of the childs daily experiences relating to contact with deviant peers participants were drawn from a longitudinal project with 4 years between data collection waves 201 chinese immigrant families participated at wave 1 123 girls and 78 boys and 183 families 110 girls and 73 boys participated at wave 2 based on the absolute difference in acculturation levels tested separately for chinese and american orientations between adolescents and parents one parent in each family was assigned to the more discrepant group of parentchild dyads and the other parent was assigned to the less discrepant group of parentchild dyads to explore possible withinfamily variations the mediating pathways were tested separately among the more and less discrepant groups structural equation modeling showed that the proposed mediating pathways were significant only among the more discrepant parentadolescent dyads in american orientation among these dyads a high level of parentchild acculturation discrepancy is related to adolescent perceptions of less parental knowledge which is related to adolescents having more contact with deviant peers which in turn leads to more adolescent delinquency this mediating pathway is significant concurrently within early and middle adolescence and longitudinally from early to middle adolescence these findings illuminate some of the dynamics in the more culturally discrepant parentchild dyad in a family and highlight the importance of examining parentchild acculturation discrepancy within family systems

introduction hiv preexposure prophylaxis has transformed the landscape of hiv prevention it forms part of a series of behavioural and biomedical interventions of varying levels of efficacy that have disrupted the normative power of condoms in hiv prevention discourse from the 1990s onward other interventions in this series have included negotiated safety 1 postexposure prophylaxis 2 strategic positioning 3 serosorting 4 and treatmentasprevention 5 prep is highly effective at preventing hiv 6 and has the advantages of not being coitally dependant and providing receptive sexual partners with an intervention they can use without requiring the insertive partners cooperation 7 despite these advantages the use of prep in populations of gay bisexual and other men who have sex with men was initially problematised by some prominent figures in the united states gay community when first approved in the us michael weinstein president of the aids healthcare foundation dismissed prep as a party drug larry kramer founding member of both the gay mens health crisis and activist organisation actup described taking a pill to prevent hiv rather than using a condom as cowardly freelancer david duran wrote disapprovingly that prep gave gay men who prefer to engage in unsafe practices a way to bareback without having to worry about hiv in a piece memorably titled truvada whores referencing the brand name of the medication used for prep 8 the stark community divisions between those advocating for prep and those warning that it could do more harm than good signal the cultural significance of condomprotected sex as normative in hiv prevention discourses for gbmsm despite the raft of other interventions listed above that had to some extent already displaced condoms 1 2 3 4 safe sex sex was a concept generated from the very earliest days of the hiv epidemic the development of safe sex culturewhich included but was not confined to condom usefocused on articulating and promulgating menus of sex practices that enabled rich expression and enjoyment of sex while precluding hiv transmission between partners there are examples of safe sex materials developed even prior to there being certainty that a sexually transmissible virus was the cause of aids 9 taking collective responsibility for sexual health and the avoidance of hiv transmission among gay men was described by weeks as a concrete exercise in sexual citizenship and he suggested that men who failed to do this risked moral pariah status 10 for many years in australia the term safe sex was synonymous with condom use even though other forms of safe sex were articulated and practiced 1 maintaining high prevalence of condom use was deemed critical to controlling hiv incidence by communitybased organisations and public health experts alike 11 12 13 by 2010 however there was emerging evidence of the effectiveness of new antiretroviral strategies to reduce or prevent hiv transmission to sexual partners either by suppressing the viral loads of people living with hiv or through the use of antiretroviral drugs as prophylaxis by hiv negative peopleprep 14 one of the normative challenges that prep brought to hiv prevention discourse was that it required individuals to acknowledge a risk that gay men had been told to avoid for three decades outside of relationship sex 15 although the efficacy of treatmentasprevention also allowed for consideration of bareback sex it was premised upon the use of antiretroviral drugs in people living with hiv suppression of the infective agent is a timehonoured strategy in infectious disease control and is less contentious in that context though in practice some hiv negative men remain nervous despite the strong evidence of effectiveness 16 with prep the focus shifted to the routine use of antiretroviral drugs in hiv negative people potentially for protracted periods of time an approach analogous to malaria prevention in travellers but on a far greater scale this shift was described by thomann as the pharmaceuticalisation of the responsible sexual subject and is connected to end of aids discourses that posit hiv prevention as a medical and technological problem 15 recent research has also shown both that taking prep is associated with lowered anxiety in gay and bisexual men who would otherwise be at risk of hiv 17 18 19 and that clinicians will prescribe prep to gay men where there is no clear clinical risk of hiv acquisition speculating that there might be undisclosed risk factors 20 to date there has been considerable qualitative research on the willingness of gbmsm to use prep its acceptability 21 22 23 24 25 26 and community perceptions of its value in hiv prevention 27 research in canada and the us has also explored the impact of prep with respect to sexual health communication and behaviour and social and community issues among gay and bisexual men 1928 however there has been little australian research that explores the meaning of prep and how men in gay male sex cultures see it shaping evolving norms of safe sex this study investigated perceptions of prep and conceptualisations of safe sex during the period of incrementally increasing access in australia drawing predominantly upon perspectives of gbmsm and also on stakeholders comprising hiv community staff and healthcare providers at the beginning of the study prep was only available through very limited trials and through personal importation access changed dramatically in march 2016 when largescale implementation studies commenced with more than 10000 gbmsm enrolled in new south wales 29 in april 2018 subsidised access under australias pharmaceutical benefits scheme made prep available nationwide at a standard subsidised price 30 thus this study spanned a period of rapid change in prep access and uptake with data collection beginning in october 2015 continuing until december 2018 the study aimed to explore how prep was impacting on sex cultureshow gbmsm saw prep as affecting their sex practices as well as perspectives on how prep affected existing cultural norms for hiv prevention methods the sydney indepth prep study was a qualitative study that explored evolving norms of safe sex during the introduction of prep in australia sinprep drew on participatory action research methods with respect to data collection analysis and communication of results 31 prior to data collection a reference group was established to guide the research this comprised representatives from the local lgbtiq hiv positive and transgender community organisations and two researchers with extensive experience in research on gay male sexuality this group met regularly in the early period of data collection to discuss initial findings and developments in prep access as data collection progressed the first author met periodically with representatives of the local community organisation acon to discuss how findings could inform health promotion campaigns under development and participated in information sessions with the community organisation to discuss implications study findings were reported to and discussed with community organisations prior to presentation or publication so that findings could inform development of health promotion campaigns recruitment data collection commenced in october 2015 and ceased in december 2018 study participants were drawn from three distinct populationssexually active gbmsm clinicians involved in prep prescribing staff working in hiv and lgbtiq community organisationseach with different recruitment strategies sexually active gbmsm community participants were recruited primarily through the social media channel of a local communitybased lgbtq organisation acon supplemented by fliers distributed at gay community organisations events venues and word of mouth this group included hiv negative men taking prep hiv negative men who chose not to take prep and men living with hiv both cis and trans identified gay men were eligible for the study and participants were recruited from sydney nsw in 2016 and 2017 there was further targeted recruitment through kirby institute research data bases purposively inviting transgender gay men and gay men on prep access studies who reported they had ceased taking prep only people who had given permission to be contacted for research participation opportunities were contacted using this method clinicians from public sexual health clinics and general practice with high caseloads of gbmsm were purposively selected communitybased staff were recruited through invitations to major lgbtiq organisations which passed the invitations onto key personnel who then decided whether to participate data collection data were collected in the form of indepth semistructured interviews for clinicians and gay community participants and a focus group of communitybased professionals interviews were audio recorded and transcribed verbatim by a professional transcriber interviews lasted approximately 60 minutes while the focus group ran for 90 minutes interviews were usually held facetoface although three gay community participants were interviewed by phone participants in the gay community group chose their own pseudonyms health care providers were assigned numbers as were focus group participants gay community participants were interviewed individually as they were discussing very personal issues data were collected from communitybased professionals in a focus group as this allowed the for a rich discussion where participants built on each others views and compared experiences without privacy risks as they were not discussion their own private behaviour all data were collected by the first author who is a queeridentified woman with extensive networks in the lgbtiq and hiv communities domains of interviews and focus groups gay community participants were asked questions about how and why they saw prep as relevant to their sexual lives whether or how it was changing their sexual lives and how they rated the importance of sex in their lives hiv negative men were also asked about the importance of remaining hiv negative in addition to other questions about access to prep and adherence for those taking prep health care providers and communitybased professionals were asked about emerging issues in the provision of prep their views on optimal implementation and the challenges of health communication communitybased professionals in focus groups were asked about the impacts of prep of safe sex health promotion complexities of access and observed changes in community norms research ethics this study was approved by the university of new south wales human research ethics committee and the acon research ethics review committee all participants who participated in facetoface interviews or focus groups provided written informed consent participants interviewed by telephone provided formal verbal informed consent participants were not remunerated for their participation analysis transcripts from interviews and the focus group were reviewed and then coded using nvivo software coding was initially inductive and comprised descriptive and conceptual codes codes were reviewed and mapped in relation to each other and developed into key themes by the first author in discussion with reference group members study investigators and stakeholders and at formal presentations of preliminary findings descriptive themes were further compared and analysed leading to higher order concepts drawing on braun and clarkes six step process of reflexive thematic analysis 3233 results a total of 24 hiv negative gay men currently or recently on prep seven gay men who had never taken prep and six healthcare providers took part in semistructured indepth interviews one focus group was conducted with four community hiv sector staff two of the hiv negative men currently or recently taking prep were transgender and 22 were cisgender gay community participants were aged between 1853 years all gay community participants described themselves as sexually active many had primary relationship partners or husbands but also had other regular andor casual partners among those with primary relationship partners relationship agreements included complete openness dont ask dont tell agreements monogamy with exceptions playing together and monogamy this article draws predominantly on the interview data with gay community participants three major cross cutting themes were identified changing norms and clashing symbols encompassed the decreasing centrality of condoms in risk reduction and participants responses to that and has a subtheme on negotiation where the emergent norms are discussed in the specific context of sexual negotiation stigma encompassed both stigma related to hiv and stigma related to not taking prep responsibility and care comprised participants accounts of their views of activities as seemingly disparate as regular sti testing promotion of prep andor other risk reduction in their social circles and contribution to research which were nevertheless linked conceptually in participants discourse to giving back to or promoting the wellbeing of their communities changing norms and clashing symbols participants across all three groups strongly endorsed the idea that established norms of safe sex had changed and that condom use was no longer central although most of the men in the gay community participant group had been having at least some condomless sex before prep nearly all these men whether on prep or not reported that their own sexual practice had been affected directly or indirectly by increasing prep access this impact was in the form of reduced condom use in casual sex among the sexually active men not on prep there was a minority view that prep could not and arguably should not replace condom use as they deemed condom use to be central to sti control many of the men on prep or those living with hiv however deemed curable stis a minor annoyance only as can be seen in the following quote stis are not as of concern for me you know for the sake of the argument you go in and get a jab you go and take a couple of pills you know and and were fine hivs the big one that we dont have a cure for teddie 32 on prep for many participants a shift away from a condombased norm while remaining protected from hiv brought a new sense of freedom regardless of the lack of protection from other stis i feel like shackles have been loosened a little chukki 43 on prep this freedom was connected to the physical pleasures of condomless sex as indicated by mannie a 35 year old gay community participant who expressed this as i dont like being fucked by a plastic bag some men however perceived that there were socially valuable aspects of condom culture which they feared were being lost for these men condom use had a symbolic value as a marker of caring either specifically for a sex partner or more broadly for community by adopting tangible sexual practices that prevented the transmission of hiv for men who perceived that condom use could indicate care there was some concern that prep could symbolically erode this if someone only wants to fuck you without a condom then are they actually thinking about the bigger consequences of the act steve 53 on prep other men however used advocacy for prep in their virtual and reallife social circles as a way of protecting and promoting community values i made like some facebook post about it my words were its a way for hiv negative people to be active in fighting hiv mark 24 on prep with regard to how prep impacted on the concept of an inclusive community again there were clashing perspectives hiv positive participants suggested that prep was diminishing what they perceived as a sexual division between hiv negative and positive men theres quite a big split between condoms people that use condoms consistently and people that use prep whats sort of happening i think is that people that are on prep are a lot more open to sleeping with people that are positive mike 38 hiv there were two facets identified in thisfirstly that taking antiretroviral drugs opened hiv negative men up to understanding social issues related to taking a medication associated with hiv and secondly that negative men taking prep were less likely to serosort 4 one of the hiv positive participants however who only had condomless sex said that he still serosorted i will not choose someone thats that is hiv negative okay yeah yeah id only i only have sex with people that are hiv positive ron 40 gay community participant hiv notably not all hiv negative participants whether on prep or not were accepting of having known hiv positive men as sexual partners and in particular were troubled by the idea of condomless sex with a known positive partner despite other riskreduction interventions such as prep or the potential partner having an undetectable viral load i understand that someone who has an undetectable viral load is you know safe but nevertheless it just kind of plays on your mind josh 45 takes prep periodically such as when travelling one hiv negative participant not on prep was adamant that he would only have condomless sex with an hiv positive partner if he could see their viral load test results like theres guys ive met online who one of thems positive and he wants to do it without the condom and i said i wanna see your viral load blood test results nick 57 not on prep while almost all participants were very clear that they understood that an undetectable viral load meant safe sex from the perspective of hiv risk several said they would expect a positive person with an undetectable viral load to use a condom others admitted that they avoided known hiv positive men as sex partners though recognising that they probably had had unacknowledged hiv positive sex partners negotiation how risk reduction was negotiated for casual sexual encounters was a major issue of debate regarding changing norms in sexual negotiation the massive changes caused by the increasingly pervasive role of online sex applications was as much an issue as the changes in hiv risk reduction occasioned by prep and treatmentasprevention particularly for older men who were veterans of gay bars and sexonpremisesvenues preptaking participants were divided as to whether they would list on prep on their profiles as this set up the presumption of condomless sexon the one hand this was seen as increasing the attractiveness of a profile but on the other it would shut down the potential for negotiation i figure that the only people who need to know that are the people who are naked next to me if you wanna have sex with me i actually want to have some connection with you as a human being steve 53 on prep hook up apps were also a medium for discussion of prepboth for providing information about it to curious others and also for heated and sometimes polarised debate about the social and community value of prep having prep listed on a hookup app was widely seen as something that forestalled negotiation about hiv risk reduction if you do have it on they take that as like oh hes going to like be into like bareback like no condoms calvin18 on prep another participant who was taking prep but had to stop due to unmanageable side effects noted the difference in both volume and quality of responses he got on hook up apps from when he had on prep in his profile and when he subsequently removed it the minute you put prep out there on your profile people would get straight to the point with what they wanted to do with you and like oh okay this is kind of cool and then youll get a lot more of onprep guys message you as well im like whoa okay no no can i have a conversation with you first see your face first thatd be nice you just dont get that when its not on the profile sussman 30 former prep user for some men particularly those who expressed some difficulty with negotiating with sex partners prep was a way of protecting themselves without any need for communication about hiv risk basically i really didnt know how to navigate conversations a lot or i just forgot about conversations in the moment so this was something i like to think im pretty organised so for me being able to do something daily is a lot easier than one thing like when youre with somebody lance 34 on prep several men in the study including negative men not taking prep talked about having condomless sex with a range of regular fuckbuddies with whom they had established trust relationships the people that i do have sex with without a condom who are on prep i know are tops i know that they test regularly and ive i had a long history with them before longish history max 39 not on prep several of the hiv negative menboth those on prep and those notreported some experience of vicarious prep 34 where one partner was on prep and the other relied on that for risk management by proxy while several participants thought that this was an adequate strategy with known and trusted fuckbuddies it was also strongly criticised by other participants thus while there was a consensus that the sex culture had changed particularly with respect to how sex is negotiated there were differing views about the meaning of that change in this theme and whether it was just about more freedom for condomless sex or whether there was social value in the change stigma participants spoke about stigma in a range of different ways and these accounts illustrated some of the many contradictions associated with the arrival of prep on the hiv prevention landscape some men described how the deliberate avoidance of men with hiv as sexual or relationship partners which has been well documented 35 still persists even among prep users many participants also described how they either excludedor were excluded byother men because they were not using prep despite some consensus that prep should have contributed to reducing the serodivide between hiv positive and hiv negative men the stigma associated with an hiv diagnosis was frequently spoken about as a primary reason for wanting to stay hiv negative and sometimes for avoiding sex with known hiv positive partners even when on prep i do know that theres like medication and its like manageable but the stigma scares me i think thats part of the reason i havent been with an openly positive partner because im like even on prep i wouldnt wanna take that risk calvin 18 on prep many participants perceived that with increased uptake of prep many within gay male sex cultures had become less accepting of hiv negative men who opted not to take it i understand for some people theres a lifestyle decision around using prep but its not for everyone and the stigma is that if youre against prep or you dont think you need to take it up that youre somehow an idiot so thats the new stigma in the community that if youre on prep youre a responsible socially considerate golden gay and if youre not on it youre somebody who can be poohooed and dismissed and attacked justin 40 not on prep this idea that not using prep and wanting condomprotected sex diminished sexual capital was echoed across the different groups of participants some participants openly acknowledged that they would reject a potential sex partner if he wanted to use a condom if im at a sex party if i turn around and somebodys put a condom on i will roll my eyes and get up and walk away jack 39 on prep jacks reported actions convey not just a no thank you to prospective partner but a pointed act of rejection other participants reported filtering out prospective partners who wanted to use condoms by positively selecting partners on the basis of prep use whats your name are you on prep marc 32 gay community participant on prep other gay community participants confirmed that expressing an interest in using condoms was likely to result in rejection to be honest with you if its in sydney or melbourne you could almost guarantee that a condoms gonna be a dealbreaker for the other person david 40 on prep this perception that wanting to continue to use condoms could adversely affect a mans sexual capital was also predicted by one of the health providers the sexual social milieu is going to change and if you want to have sex youre going to have to adapt to the new flavour unless youre the cutest boy on earth negotiating condom use is going to become harder healthcare provider 3 hiv community professionals working in a communitybased hiv testing site also noted that some men who had previously been condoms users were turning to prep due to peer pressure these days im seeing more and more people come with have been using condoms until today but they find that they when meeting people who are on prep and they dont want to use condoms they find that conversation a bit of an issue so eventually they feel like they are missing out because the guy on prep ends up not necessarily having sex with them because they dont want to use a condom so some people have decided to go on prep because they find that their casual partners dont want to have sex with them cause they wont use a condom hiv community professional 4 in this thematic area there was little evidence of prep use or prep users being shamed or stigmatised rather it was men who chose not to use prep who reported feeling that their social and sexual capital was diminished regarding hiv stigma many participants accepted that it was a given while some reflected on how their prep use could potentially reduce hiv stigma one of the key reasons that hiv negative participants gave for wanting to remain hiv negative was to avoid the perceived social burden and loss of sexual capital attached to an hiv positive diagnosis responsibility and care from a range of domains including condom use sexually transmissible infections testing and participating in research we identified the crosscutting theme of responsibility and care that is participants framed their responses on these issues in terms of either interpersonal responsibility or responsibility at a broader social level several participants framed frequent sti testing and subsequent communication of positive results to partners as a considered strategy of stopping the spread of them as much as i can this strategy included testing more regularly than the recommended three months and testing after significant risk events for some participants this sense of responsibility also extended to wanting to ensure that their sex partners had the skills to reduce their hiv risk for one participant on prep this meant resisting partners who wanted to rely on vicarious prep i think you have a moral responsibility to ensure that the person youre actually having sex with isif you actually have some knowledge and some ability to prevent that person from catching hiv then then you need to reinforce it in some sort of way and thats either condoms or prep and if you cant have the discussion and know that persons gonna be on prep in the near future then you need to reinforce with the condoms gordon 53 on prep two other participants talked at length about how they promoted regular sti and hiv testing in their social circles particularly to younger friends i spend a lot of time just checking in on my friends hi how are you hey have you had your tests recently mannie 35 on prep several participants talked about the importance of prep being available for men in serodiscordant relationships even if the hiv positive partner had an undetectable viral load and the couple was monogamous meaning that there was no hiv transmission risk the rationale for this was so that the hiv negative partner was taking responsibility for his own safety not relying on his partners adherence to medication to manage hiv risk it may be doublingup but then it gives the person capacity to to be responsible for their own safety josh 45 taking prep periodically in addition to wanting to take responsibility for their own sexual health there was also an element of distrust of a partners undetectable viral load as being a reliable form of safe sex as noted earlier some participants voiced nervousness of condomfree sex with known positive partners many men also talked about responsibility in terms of their participation in research to generate data for the good of the community one of the reasons im happy to do this interview however long this takes out of the day is i just think its a very good thing prep has been very good for me and if i can do things that encourage it to be more readily available and more accessible im happy to do that ian 53 on prep the concept of being a responsible sexual subject was important to the gay community participants in this study regardless of whether they were hiv negative or positive and whether or not they took prep while for some condoms remained important both practically and symbolically others were actively reframing practices such as sti testing as ways of taking responsibility this concept of research participation as a way of enacting a responsible attitude to community was also raised repeatedly by participantsthis was not related to a question asked by the interviewer but volunteered spontaneously by several participants discussion this study explored the impact of prep on evolving gay male sex cultures focusing on the perceptions of gay men in sydney australia and included perspectives from health service providers and communitybased stakeholders the findings reflect that the meaning of prep in the lives of these men needs to be understood in the context of sex cultures deeply inflected with norms that arose in response to the risk of hiv taking prep can provide access to the pleasure of condomless sex without hiv risk but it also disrupts decades of community norms where practices of risk reductioncondom use serosorting 4 negotiated safety 1 strategic positioning 3 all required negotiation and had to some degree become associated with a demonstration of care for self and other sometimes described as sexual citizenship 10 the displacement of older safe sex norms did not however indicate that participants were less invested in community many of the preptaking men in this study talked about how other practices related to prep such as frequent sti testing and proactive partner notification of diagnoses advocating for and educating others on prep and participating in research could also be construed as acts of care for partners and community 36 or a new form of citizenship in considering the impacts of prep uptake on the sexual culture we explored how discourses about prep contributed to shaping a normative goal of a new safe sex culture that embraces a much broader menu of options 37 we contend that the aspirational social norms articulated by the participants and discussed herein comprise a sex culture in which risks are minimised participants have a fair chance of finding sexual satisfaction regardless of hiv serostatus or choice of hiv risk reduction intervention free from stigma and discrimination with community practices that sustain and promulgate these norms in each of these three areasminimising risk having discriminationfree satisfying sex and developing and sustaining community practices that support these normsthere were areas of contention nearly all the gay community participants reported that their own sexual practice had changed with increasing community uptake of prep in that they were less likely to use condoms in casual sex this echoes findings of newman et al and pantalone et al 1928 but contrasts with a 2017 us study that found that participants reported that while prep brought a feeling of relief or reprieve from hiv stress it did not directly impact their practice 38 the difference with the 2017 study may reflect increasing community confidence with the effectiveness of prep confidence in prep did not however necessarily mean that participants were comfortable having sex with known hiv positive partners while some participantsparticularly those in serodiscordant relationshipswere very clear that such sex would be safe others expressed avoidance of sex with known positive partners despite taking prep these participants themselves recognised this avoidance as irrational given that the point of prep is to prevent hiv acquisition and that they had likely had sex with undisclosed hiv positive partners thus while some of the hiv positive men saw prep use as dissolving some of the barriers to sex between people of different serostatusbridging the serodivide 39 some hiv negative men continued to have discriminatory attitudes towards known hiv positive partners this contrasts with results from two separate us based studies 1828 which both found that prep uptake helped to diminish feelings of stigma toward men with hiv again this difference may be due to increased confidence with prep efficacy as the us studies recruited later than our cohort within our cohort there was also evidence of a significant bias against men who opted to use condoms as their primary risk reduction method echoing findings of both newman et al and pantalone et al who noted increased pressures for condomless sex and increased challenges in negotiating condom use 1928 this finding in three separate studies leads to a disquieting conclusion that opting to use condoms as primary risk reduction andor a making a disclosure of hiv positive status could diminish an individuals sexual capital and limit opportunities for satisfying sex with regard to supportive community practices that respect diversities and different choices some men saw the combination of prep and hookup apps as decentring communication around sexual practice and eroding the community building that some associated with sexual negotiation around condom use nevertheless they reported enjoying the sexual freedoms afforded by prep the finding that nonuse of prep could be stigmatised was also seen in a canadian study 40 orne and gall used a model of prep citizenship to explain how widespread prep uptake produced a culture of conformity to prepcentred regimens this model included taking up prep advocating it to others adherence repeat testing and posited nonusers as potentially infectious and stigmatised and irresponsible people as distinct from the good citizens taking prep this model has parallels with thomanns neoliberal sexual subject who acknowledges hiv risk 41 takes preemptive pharmaceutical action against it and becomes biomedically responsibilised both thomanns and orne and galls analyses foregrounded how prep advocacy or demand creationas distinct from advocacy for a choice of hiv prevention interventions available to allcan marginalise those who make different choices such as the choice to use condoms evidence from this study supports that contention in that some participants took up both prep use and prep advocacy as the response to hiv prevention which alienated men who did not want to take antiretrovirals preventatively of note however some prep takers in this study resisted discourses of conformity to universal prep use and continued a champion a range of options depending on circumstances in particular some participants discussed prep use in the context of travel as distinct from during everyday life given that for some travel was an opportunity for nonrelationship sex including within the context of a relationship agreement this phenomenon further breaks down the binary of prep user and nonuser 19 and documents a new form of riskreduction adaptation the qualitative approach of this study enabled a rich and nuanced analysis of the evolution of safe sex norms concomitant with the advent of prep while the specific impacts of prep on hiv risk reduction practice was one focus our other focus on normativity within these sex cultures illuminated how care can be demonstrated between casual sex partners when the problem of hiv risk has been largely dealt with by a daily pill and how differences in values could or should be accommodated in a sex culture that aspires to not discriminate on the basis of serostatus or choice of hiv risk reduction method prep access in australia was at least four years behind the us approval in 2012 as the first large scale implementation study in australia began in 2016 29 and subsidised national access began in 2018 30 this time lag between australia and the usand the fact that australian communitybased hiv organisations had to work hard to achieve subsidised access 42 may in part explain why there was a less severe antiprep backlash once the intervention was available the australian hiv community sector health care providers and sexually active gay men had seen the truvada whore controversy 8 which stereotyped prep users as promiscuous and irresponsibleplay out in the us before prep was widely available the context of having no nationally accessible funded mechanisms for prep access in australia some four years after the fda approval arguably contributed to heightening proprep sentiment 41 because the global connectedness of gay male communities allowed men in australia to witness the sexual freedom that prep facilitated in the us and recognise the advantages it could bring this study has some limitations gay community participants had to contact the researchers to take part in the study so those with strong views on the impacts of prep may have been more likely to volunteer the majority of participants were white but we did not collect data systematically on ethnicity accordingly the study may overrepresent the views of white gay men data were also collected over a period of three years during a period of rapid change so are not a snapshot of a point in time but a collection of perspectives that were in the process of evolution most of the study participants were taking prep and a significantly smaller number of hiv negative men not on prep and hiv positive men were included so while the sample includes perspectives from a range of different actors they are not equally sampled finally as this paper is about the impacts of prep on a sex culture the voices of the gay community participants have been privileged over those of the healthcare providers and hiv communitybased professionals conclusion the impacts of prep are complex and need to be considered in the context of evolving gay male sex cultures in which prep is only one element prep was not the catalyst for condomless sex for most of the men in this group but the introduction and scaleup of prep access arguably enabled men to talk about condomless sex more openly and to consider what matters in gay male sex cultures where condom use is decentred this study has important implications for health promotion it reveals how new community conversations about hiv prevention can promote prep use as the single best option constructing it as a rigid new standard to which men should adhere instead of promoting and promulgating choice and genuine acceptance that different values can mean that different options may work better for some individuals the identification of a potentially damaging emerging norm in these data that of prep use as being positioned prescriptively as the best form of hiv prevention for hiv negative men and stigma attaching to nonuse informed the development of acons 2017 campaign how do you do it in which the importance of individual choice from a range of effective options was emphasised with respect to hiv prevention 43 while recognising the great importance of prep for many men this study suggests that rather than promoting prep as the new safe sex orthodoxy there is a need to ensure that there is a range of hiv prevention options that have both high efficacy and high acceptability accordingly health promotion should focus on building community attitudes that respect diversity and challenge the primacy of any one prevention tool data cannot be shared publicly because it contains sensitive information that the study participants did not consent to have shared data access queries may be directed to the unsw human research ethics coordinator

while hiv preexposure prophylaxis prep is highly effective it has arguably disrupted norms of safe sex that for many years were synonymous with condom use this qualitative study explored the culture of prep adoption and evolving concepts of safe sex in sydney australia during a period of rapidly escalating access from 20152018 drawing on interviews with sexually active gay men n 31 and interviews and focus groups with key stakeholders n 10 data were analysed thematically our results explored the decreasing centrality of condoms in risk reduction and new patterns of sexual negotiation with regards to stigma we found that there was arguably more stigma related to not taking prep than to taking prep in this sample we also found that participants remained highly engaged with promoting the wellbeing of their communities through activities as seemingly disparate as regular sti testing promotion of prep in their social circles and contribution to research this study has important implications for health promotion it demonstrates how constructing prep as a rigid new standard to which gay men should adhere can alienate some men and potentially create community divisions instead we recommend promoting choice from a range of hiv prevention options that have both high efficacy and high acceptability

background the low appeal of general practice and primary care as a career option is a recurrent problem for healthcare systems throughout europe usa and other countries in the organization for economic cooperation and development 12 a highperforming primary healthcare workforce is necessary for an effective health system however the shortage of health personnel the inefficient deployment of those available and an inadequate working environment contribute to shortages of consistent and efficient human resources for health in european countries the european commission projects the shortage of health personnel in the european union to be 2 million including 230000 physicians and 600000 nurses by the year 2020 if nothing is done to adjust measures for recruitment and retention of the workforce 3 research has shown a strong workforce in general practice is needed to achieve an efficiency balance between the use of economic resources and efficient care for patients 4 most of the research focused on the gp workforce concentrated on negative factors the reasons students did not choose this as a career or gps were leaving the profession were widely explored burnout was one of the most frequently highlighted factors 5 in many oecd countries apart from the united kingdom the income gap between gps and specialists had expanded during the last decade promoting the appeal of other specialties for future physicians 6 health policy makers aware of the problem of a decreasing general practice workforce tried to change national policies in most european countries to strengthen general practice health professionals respond to incentives but financial incentives alone are not enough to improve retention and recruitment policy responses need to be multifaceted 7 dissatisfaction was associated with heavy workload highlevels of mental strain managing complex care expectations of patients administrative tasks and workhome conflicts focusing on these issues created a negative atmosphere 5 8 9 10 in the above mentioned report of the european commission on recruitment and retention of workforce in europe the authors used a model of huicho et al as a conceptual framework to analyze the situation 11 attractiveness and retention are two outputs used in the model retention is determined by job satisfaction and duration in the profession the concept of job satisfaction is complex as it changes over time according to social context job satisfaction is a pleasant or positive emotional state resulting from an individuals assessment of his or her work or work experience 12 there is a weak relationship between enjoyment and satisfaction suggesting that other factors contribute to job satisfaction 1314 furthermore general practice is a specific field and theories on job satisfaction in this field are not fully explained by theories on human motivation in general according to the research group hypothesis it was important to investigate the positive angle separately in order to understand which factors give gps job satisfaction that was the focus chosen by the research team the literature highlighted the poor quality of the research about job satisfaction within european general practice most studies were carried out by questionnaire 15 focusing on issues of health organization or business and did not reach the core of gp daily practice some studies had confusion bias caused by authors prerequisites on the attractiveness of general practice 16 surprisingly few qualitative studies explored the topic of satisfaction 1718 literature did not show an overall view of gps perception of their profession it was not certain that these positive factors were similar across different cultures or in different healthcare contexts consequently research into positive factors which could retain gps in practice would help to provide a deeper insight into these phenomena the aim was to explore the positive factors supporting the satisfaction of general practitioners in primary care throughout europe method this research is descriptive qualitative study on positive factors for attractiveness and retention of general practitioners in europe research network a stepbystep methodology was adopted the first step was to create a group for collaborative research 1920 the egprn created a research group involving researchers from any country wishing to participate belgium france germany and israel poland bulgaria finland and slovenia undertaking such a study in several different countries with different cultures and different healthcare systems presented a challenge this has been made possible by the support of the egprn in the various meetings held throughout europe figure 1 gives an overview of the position of the general practitioner in each country according to the different healthcare systems the authors scored the importance of some specificities of practice in their own country from 0 to 5 the research team decided to conduct a descriptive qualitative research study from gps perspective in each participating country 2122 the first interviews were completed in the faculty of brest in france the aim was to pilot the first indepth topic guide study procedure and data collection the research team discussed every step of the study in two annual workshops during egprn conferences within the duration of the study as there were few examples in the literature and as the existing models of job satisfaction were more oriented towards employees working in a company the international research team developed an interview guide based on their previous literature review 16 the guide was piloted in france and was adapted and translated to ensure a detailed contribution from the gps interviewed and subsequently a rich collection of qualitative data in each country local researchers conducted the interviews in their native language in accordance with the research question interviewers were looking for positive views overall interviewers were gps working in clinical practice and in a university of college except in belgium where the interviewer was a female psychologist working in the department of gp the gps were first asked to give a brief account of a positive experience in their practice 21 the interview guide was used to encourage participants to tell their personal stories not to generate general ideas but to focus on positive aspects to ensure a maximal variation in collection techniques in order to collect both individual and group points of views interviews and focus groups had to take place saturation had to be reached in each country 21 data analysis a thematic qualitative analysis was performed following the process described by braun and clarke 25 in each country at least two researchers inductively and independently analyzed the transcripts in their native language using descriptive and interpretative codes they issued a verbatim transcript of one particular part of or sentence from the interview to illustrate every code in the codebook each code was extracted in the native language and translated into english the contextual factors were explored in each setting by the local team of researchers and these factors were taken into account during the analysis then the whole team discussed the codes several times in facetoface meetings during seven egprn workshop meetings the research team merged the national codes into one unique european codebook during a twoday meeting the research team performed an indepth exploration of interpretative codes and a final list of major themes was generated credibility was verified by researcher triangulation especially during data collection and analysis during the egprn workshops peer debriefings on the analysis and the emerging results were held interviewers and researchers from such diverse backgrounds as psychology sociology medicine and anthropology reflected on the data from their own researchers perspective results table 2 gives an overview of the characteristics of the participants the mean age was high which is an indication of a long duration in the profession six main themes were found during analysis the results are summarized in the fig 2 international codebook on gp satisfaction gp as a person the analysis of the data showed that the gp was a person with intrinsic characteristics including interest in peoples lives with a strong ability to cope with different situations and patients gps loved to practice and the passion for their job was more important than the financial implications i also work with a very heterogeneous population ultrareligious and secular from various countries of origin really pleasant to work with patients its not only the financial aspect i work for pleasure i dont do it for the money if i dont like it anymore ill stop doing it gps said they wanted to stay ordinary people with a strong need to take care of their personal wellbeing this the significance of the gps residential environment topic 6 coping strategies to overcome difficulties was more than just having time for hobbies and leisure gps were looking for other intellectual challenges and personally enriching activities in their free time general practice is a beautiful profession but you are on your own too much even in a group practice you see the community from a limited perspective its important to keep in touch with the community the fact remains that you are probably a father or mother or a partner as well as being a physician its interesting to have a different perspective it broadens your way of thinking reading books is the same its essential to read good books and to empathize with the characters this is enriching for you as a human being but also for your practice gps said they wanted to be there for their patients to find common ground with them but they also wanted to control the level of involvement with their patients they described the ability to balance empathy with professional distance in their interaction with patients and being able to deal with uncertainty in the profession the gp as a person theme was important as all the above conditions were required in order to be a satisfied gp who wishes to remain in clinical work gp skills and competencies needed in practice gps reported satisfaction about making correct diagnoses in challenging situations with low technical support and being rewarded with patients gratitude the intellectual aspect of medical decisionmaking led to effective medical management and was a positive factor for gps general practice is the first point of care for the patient and gps felt themselves to be the coordinators and managers of care and the advocates for the patient to be the key person in primary care requires strong interprofessional collaborative skills and effective support from other medical specialties and from paramedics gps believed that it was highly important to be an efficient communicator to perform all these tasks gps were patientcentered and wanted to provide care using a comprehensive and a holistic approach a patient centered approach is a wonca core competency of general practice while efficient communication with the patient is a generic skill for all health workers they wanted to bring together a broad medical knowledge with a high level of empathy balancing the patients concerns with official guidelines guiding the patients education was an important role for the gp who was also a coach for life style changes this theme was linked to the holistic model for general practice which is also a woncas core competency to be both competent and do a bit of everything this is intellectually extremely stimulating and challenging work happy and satisfied when making the correct diagnoses the patient arrives and thanks me for the good diagnoses you dont just see common colds during the day you get interesting cases and you have time to explore them this makes general practice interesting its a 360°job variation is important its our task to empower young muslims to encourage them to study well to become nurses or physicians belgian gp doctorpatient relationships patients are free to choose their gp and this is important because of the particular aspects of the doctorpatient relationship in primary care there was a strong relationship between the gp as a person and the gp who enjoyed a rewarding interpersonal relationship with patients gps had enriching human experiences with patients which was important to the physicians selffulfillment as a human being mutual trust and respect in their relationships were important dimensions being a patientcentered physician was a rewarding challenge gps felt they were a part of the patients environment but with the need to set their professional limits gps learned about life through their patients gps said they were ageing with their patients and had a longterm relationship with some of them they were real family doctors and often cared for several generations they saw babies grow up and become parents themselves these unique doctorpatient relationships enhanced gp satisfaction i am the doctor for this whole family and in general practice that is something important some i got to know when they were small kids and they still come to see me at the age of 18 or older we know much more about them than other doctors because our patients have chosen us we accompany patients throughout pregnancy cancer and death and from the moment before birth until the age of 99 years and over patients asked for a home visit and insisted i join them at their meal and sometimes i did that but only when they were more like friends… ive had a lot of invitations to weddings… gps also liked to negotiate with patients to help them to make decisions but also to motivate them to make lifestyle changes autonomy in the workplace freedom in practice was closely related to work organization which was important in all countries gps stayed in clinical work if they had chosen their own practice location the living environment needed to be attractive for the family gps wanted to apply personal touches to their consulting rooms to make choices in the technical equipment they used which suited their personal requirements fig 2 international codebook on gp satisfaction even more important was the possibility of choosing work colleagues who shared the same vision of general practice satisfied gps contributed to the organization of the practice and were influential in decisions about work and payment methods where there was a salaried system gps wanted to earn a reasonable salary to have a satisfying worklife balance flexibility at work was not to be interpreted as a demand from the management to be flexible in working hours but to have the flexibility to make ones own choices most gps preferred additional career opportunities such as teaching working in a nursing home and conducting research to fulfil all these conditions gps wanted to work in a wellorganized practice with a competent support team with a secretarial service practice assistants and the necessary technical equipment another condition was an organized outofhours service gps did not want to be disturbed outside practice hours without prior arrangement this is the most important in our practice that i decide when and how to work if someone says that a practice room must be completely impersonal it has to be interchangeable i understand this its respectful towards the others but a personal touch is important for communicating something about yourself to the patient that is important it is important to have ones own organizational systems and equipment i didnt have to do night shifts teaching general practice gps reported that they wanted to acquire new medical knowledge and learn new techniques they liked to transmit the skills of their job they were proud of their profession and they wanted to teach and to have an effective relationship with trainees teaching contributed to feelings of satisfaction with the profession gps mentioned the importance of training in attracting junior colleagues and the positive aspect of the mutual benefit to gps and trainees teaching gave gps more incentives for their own continued professional development and enabled them to complete their competencies gps feel gratified where general medicine is recognized as a specialty at the university and by the public authorities guiding younger colleagues is the most rewarding part of my job i like to transmit what i have learned i was a tutor for a seminar group teaching i like to do that those people had to learn that was very pleasant i am teaching general practice to students and i have found i have a flair for it it is really fun i feel good accompanying young trainees through the process of making their choices all that you do in teaching transmitting your knowledge to another improves your accumulated experience you see yourself through the eyes of others supportive factors for worklife balance factors that supported an efficient worklife balance were the possibility of having a full family life with a social support network and the opportunity to benefit the whole family by enjoying holidays money and free time money was not the most important issue but income needed to be sufficient for a comfortable family life meaning sufficient resources for a satisfying education for the children and the possibility of having regular holidays gps found they have job security which enables them to feel secure and free from unemployment worries gps explained that they wanted to choose how to separate professional and private life they said they wanted to have social contacts in the community which would give them a broader perspective in terms of their patients having relationships with patients outside the practice was important gps said they needed to be part of the social community if they were to stay in general practice gps wanted to have a full family life and to keep free time for this family medicine is an opportunity to be with the family my family supports me i try to keep work and leisure time away from each other it is important in terms of coping in my leisure time i have a different role from that of a doctor country specific themes besides those international themes there were some country specific results in poland and in slovenia even when they were prompted in the interviews gps did not mention the importance of teaching belgian gps said how important discussing the vision and mission involved in starting a group practice was to them they took time for this process and wanted junior colleagues in practice who would share their vision and their mission statements needed to be updated regularly to meet the needs of a changing society and the challenges in health care group practices used external coaching to overcome problems vision and mission are important we started from ten values as respect diversity the aim to train young gps… you have to renew the vision and mission regularly and to adapt at the changing community belgian male gp french gps were very attentive to the need for organized continuity of care the gps wanted to be there for their patients but they also wanted to protect their personal lives the word vocation had a religious connotation that displeased some gps finish gps appreciated the stimulating working community and multidisciplinary teamwork in addition they valued the set working hours and professional development work available in the workplace israeli gps were proud of their respected position they preferred a private practice in their own style and stressed the importance of teamwork the clinics were i felt good were clinics that the staff was amazing and enlisted the nurses were good and the secretaries did the work and there was a feeling that we were working for better medicine there were weekly meetings where we really thought how to do better a feeling of teamwork for polish gps there were some positive developments in financing medicine which were providing better opportunities for an effective worklife balance in poland there was a theme which favoured having a strong union that can influence policy it gave the gps an identity as a group the fact that i work here as i work my income is not too high but still is make it possible that my kids can attend private schools and dont have to go to normal state schools polish female gp discussion main results throughout europe common positive factors were found for satisfaction of gps in clinical practice one of the main characteristics of gps was the need for specific competencies for managing care and communicating with patients they needed to cope with problems during their career and professional collaboration gps were stimulated by intellectual challenges not only within the profession but they also wanted enough time for personal development outside the workplace to counterbalance the stress of daily practice positive gps are persons with intrinsic specific characteristics participants described themselves as feeling comfortable in their job when they were trained in specific clinical and technical skill areas and had efficient communication skills the longterm doctorpatient relationship is perceived positively by the gps they love teaching all these specific skills to younger gps and appreciate the feedback and mutual benefit to be found in teaching activities finally gps need policy support for wellmanaged practices and outofhours services to maintain their optimal worklife balance strengths and limitations of this study to our knowledge this multinational data analysis from 183 gps is the first european multicentre qualitative study on this topic 1626 this study collected complete and complex data from eight countries one of the strengths was to study a diverse population of gps with different cultures and health systems despite these differences the main satisfaction factors to become a gp and to stay in clinical practice are found in all contexts for instance money is important but its relative because the idea to have enough to lead a comfortable family life with enough free time is for every gp crucial although income might vary over europe credibility and transferability credibility was verified by researcher triangulation especially during data collection and analysis during the workshops peer debriefings on the analysis and the emerging results were held interviewers and researchers from such diverse backgrounds as psychology sociology medicine and anthropology reflected on the data from their own researchers perspective as the results in several countries with different healthcare systems were very similar the transferability of data seems possible the main weakness was a possible interpretation bias the 183 gps provided very rich data in several languages it was the strength of this research but also a difficulty the analysis and interpretation of the verbatim analysis was a linguistic and cultural problem a different classification of themes could be achieved but this was limited by the group meetings and the massive number of emails phone discussions and skype® discussions required during the research process the number of gps interviewed varied in the different countries potentially leading to differences in the informational detail and in the depth of the analysis of the interviewsfocus groups however data saturation was reached in all settings limiting this possible bias discussion of the findings the theme gp as a person was highlighted in this study and in the literature review 16 the studies found this special identity for gps was linked to their intrinsic characteristics the theme of gp as a person was important in each of the european countries a gp is of necessity someone with a specific personality which is suited to general practice gps like to take care of people 27 feeling of caring » 28 i can have a big impact on peoples lives 27 this is a strong personality characteristic in a gp which policymakers might take into consideration when formulating policies which concern the medical workforce the gp skills and competencies were found in literature 1629 but in a more restricted form they focused on an effective medical management of the patient and the subsequent feeling of being competent in a scottish qualitative study gps highlighted the satisfaction derived from the perception of the consultation outcome although clinical competence was an integral part of the doctors satisfaction they alluded to personal attributes that contributed to their individual identity as a doctor 30 take care of them and do the best you can 27 in our study we identified all wonca core competencies and this is important 4 validation of woncas characteristics and competencies in hundreds of interviews across eight european countries shows the strength of the wonca theorem and common characteristics between gps wherever they work the analysis of the data demonstrated a strong link between competence and satisfaction it is necessary to give general practitioners the opportunity to acquire and improve these skills the importance of the doctorpatient relationship was described as an effective factor in job satisfaction for the general practice workforce 3132 nevertheless previous studies concentrated less on the rewarding nature of the relationship its long duration and the mutual interaction freedom to manage the workplace organization has been described and is confirmed here it does not prevent long working hours but focuses on the organization of the practice 33 34 35 there was consistent evidence that gps needed freedom for work satisfaction 36 gps wanted autonomy in their work 17 the teaching and learning activities have been described and this study confirmed their importance academic responsibilities provide positive stimulation and new perspectives for gps 173637 they wanted to be recognized by the academic world clerkships in general practice were seen as important for attracting students to a career in general practice 38 the influence on students was important for their career choice 39 the practice of clinical teaching in initial medical education with positive role modelling was also important 4041 there was a strong link between the gp hisher family and the community they are living in this was especially true for those practising in rural areas 39 42 the gps family was sensitive to the fact that general practice is a respected profession outside their professional role other forms of satisfaction were important such as having strong social support from schools leisure activities and a satisfying quality of life in the residential environment 43 and of course the importance of an income in balance with their heavy workload finally the results highlighted a particular theory to describe gp satisfaction which focuses on human relationships specific competencies patients and the social community implications for medical education and practice learning the core competencies of general practice in initial and continuous medical education is very important and should lead to extended educational programs in europe mobilizing stakeholders is a necessary condition of success however it is not sufficient 7 to improve the attractiveness of general practice universities should organise a specific selection process for gps not just for specialists this might engender greater respect for the profession roos et al performed a study by questionnaire on the motivation for career choice and job satisfaction of gp trainees and newly qualified gps across europe 15 the most frequently cited reasons for choosing general practice were compatibility with family life challenging medically broad discipline individual approach to people holistic approach and autonomy and independence the current study has focused on working gps and not on trainees but some of the results overlap roos research it remains essential to teach undergraduate medical students the biomedical aspects of general practice but it is also necessary to teach the management of primary care interprofessional collaboration and communication skills trainees need to think about their own wellbeing and to learn to cope with problems in daily practice the intellectual aspect of general practice is important decisionmakers should use all the means at their disposal to promote the profession by providing continual development gps want to be involved in the management of their practice stakeholders should be aware and very cautious about this topic which is described as extraordinarily sensitive systems that try to administrate gp practices without involving the gps should be aware that they will experience difficulties implications for research further studies would be useful with the objective of studying which satisfaction factors have the greatest impact on recruitment and retention in general practice this description of satisfied gps will be disseminated throughout europe to implement new policies for a stronger gp workforce this may assist the international research team in the design of further studies to investigate the links between these positive factors and the growth of the gp workforce at this stage the research team will test the usefulness of each positive factor in helping each country to design efficient policies to increase its workforce conclusion throughout europe gps experience the same positive factors which support them in their careers in clinical practice the central idea is the gp as a person who needs continuous support and professional development of special skills which are derived from the woncas core competencies in addition gps want to have freedom to choose their working environment and organize their own practice and work in collaboration with other health workers and patients national policy arrangements on working conditions income training and official recognition of general practitioners are important in facilitating the choice of a career in general practice stakeholders should be aware of these factors when considering how to increase the gp workforce availability of data and materials some data in this study are confidential the data generated and analyzed during the current study are not publicly available but the datasets generated analysed during the current study are available from the corresponding author on reasonable request abbreviations egprn european general practice research network gp general practitioner gps general practitioners na not applicable ubo université de bretagne occidentale france wonca world organization of national colleges academies and academic associations of general practitioners family physicians authors contributions b lf designed the study collected data drafted and revised the paper h b designed the study collected data and revised the paper jy lr designed the study collected data drafted and revised the paper h l collected data and revised the paper s c collected data and revised the paper a s collected data and revised the paper r h collected data and revised the paper p n revised the paper r a collected data and revised the paper t k collected data and revised the paper z kk collected data and revised the paper t m revised the paper l p designed the study collected data and revised the paper all authors read and approved the final manuscript competing interests zalika klemencketis and radost assenova are members of the editorial board of bmc family practice the other authors hereby declare that they have no competing interests in this research author details 1 ea 7479 spurbo department of general practice université de bretagne occidentale brest france 2 department of primary and interdisciplinary care faculty of medicine and health sciences university antwerp antwerp belgium 3 centre for public health and healthcare hannover medical school hannover germany 4 department of family medicine tel aviv university tel aviv israel 5 clinical psychology department nicolaus copernicus university torun poland 6 department of urology and general medicine department of general medicine faculty of medicine medical university of plovdiv plovdiv bulgaria 7 university of tampere faculty of medicine and life sciences tampere finland 8 department of family medicine faculty of medicine university of ljubljana ljubljana slovenia 9 department of family medicine faculty of medicine university of maribor maribor slovenia

background general practice gp seems to be perceived as less attractive throughout europe most of the policies on the subject focused on negative factors an egprn research team from eight participating countries was created in order to clarify the positive factors involved in appeals and retention in gp throughout europe the objective was to explore the positive factors supporting the satisfaction of general practitioners gps in clinical practice throughout europe method qualitative study employing facetoface interviews and focus groups using a phenomenological approach the setting was primary care in eight european countries france

introduction australian aboriginal and torres strait islander people possess a rich and vibrant culture and have lived on and cared for the country for over 60000 years 1 the sudden disruption to lives and culture brought by british colonization in 1770 has created deep inequities and a high burden of poor health for aboriginal and torres strait islander people which has been sustained until this day 2 this inequity was sustained over the subsequent 200 or more years by a series of racist australian policy eras resulting in marginalization disadvantage and extreme poverty 1 one of the outcomes for aboriginal and torres strait islander people has been a decline in physical activity levels 3 contributing to poor health including the development of chronic diseases such as type 2 diabetes 4 chronic diseases represent 70 of the gap in disease burden between aboriginal and torres strait islander people and nonaboriginal australians 5 over onethird of the total disease burden aboriginal and torres strait islander people experience could be prevented by modifying behavioral risk factors such as physical inactivity 6 here we use the terminology aboriginal to refer to the indigenous peoples of australia as this terminology is preferred by the communities participating in this study whilst nationally aboriginal children participate in more physical activity than their nonaboriginal counterparts this difference has been shown to decrease as children transition to adolescence 7 two studies conducted in new south wales reflect this activity decline 89 gwynn et al reported that compared with their nonaboriginal counterparts rural aboriginal children aged 1012 years were engaged in more physical activity 8 however by adolescence physical activity participation rates were lower in a cohort aged 1317 years 9 a gender difference was also identified with aboriginal boys more likely to participate in physical activity than girls 9 aboriginal communities differ around australia not only by virtue of geographical location but also due to differences in factors such as language and culture 1 it is therefore important to describe the experiences of aboriginal children from different communities across the nation to gain insight into the breadth of experiences around participation in sport and physical activity and better inform relevant strategies and policies five studies have reported aboriginal young peoples perceptions about physical activity 10 11 12 13 14 of these three explored childrens views of their physical activity in relation to type amount and the role this plays in their community 111314 only two explored physical activity barriers neither in nsw 1012 the barriers identified in the latter studies included poor community facilities lack of transport costs associated with participating in physical activity and experiences of racism 1012 aboriginal adolescent girls were reported as feeling shame and shyness wearing swimming costumes in pools and wearing sports clothes to exercise 1012 an established relationship between schools and the community was identified as a key facilitator to physical activity participation as was the involvement and support of family and friends 10 11 12 13 14 a recent study conducted with torres strait islander communities found that community role models had a positive effect on some barriers to physical activity participation 16 none of these studies were conducted in nsw and given the cultural diversity between aboriginal communities it is yet to be established how applicable these findings are to young people in that state 17 a recent systematic review of barriers and facilitators of sport and physical activity among aboriginal and torres strait islander children and adolescents found limited research with a number of australian states not represented 18 the only study from nsw was not peerreviewed and reported adult community members perceptions of the barriers and facilitators for children this study was conducted as a substudy of the many rivers diabetes prevention project in response to that studys findings regarding the physical activity of aboriginal children 919 the mrdpp aimed to improve the nutrition and physical activity of children living in the north coast of rural nsw 19 and found physical activity among aboriginal children declined over time with differences in patterns of decline existing between aboriginal and nonaboriginal children 9 despite tending to be more active in primary school 8 aboriginal children from these communities recorded significant declines in nonorganized organized and school activity over time when compared with their nonaboriginal counterparts 9 to gain insights into this finding and to inform future physical activity health promotion programs the study team proposed exploring the aboriginal childrens perceptions of barriers in their communities to sport and physical activity participation 19 this study aimed to explore rural nsw aboriginal childrens perceptions of the barriers and facilitators to their sport and physical activity participation the first author of this paper is a nonaboriginal woman who completed an undergraduate degree at the university of sydney jg is a researcher and nonaboriginal woman who coled the mrdpp with nt and has worked with the participating communities of this study for 17 years nt is an aboriginal woman from one of the participating communities who was the manager health promotion and senior project officer of the mrdpp js is an aboriginal woman who is also from one of the participating communities and was an aboriginal project officer of the mrdpp rp ej and naj are researchers and nonaboriginal coauthors who contributed their expertise in physical activity to this research methods study design this study utilized a qualitative photovoice methodology derived from the principles of participatory action research the photovoice method requires participants to take photos which to them represent the topic or issue to be explored participants are then interviewed and asked to talk about the photos typically discussing why these were taken and their meaning the photos and interviews are the data used in the qualitative analysis this method crosses cultural and linguistic barriers and enables participants to identify their communitys strengths and concerns 20 photovoice has been shown to be suitable and culturally appropriate for research with aboriginal communities exploring issues as varied as food insecurity 21 and the experiences of aboriginal health workers 22 in this study the photovoice method allowed children to explore the environmental and contextual factors that they perceived to influence their sport and physical activity participation 20 aboriginal governance structure and ethics the aboriginal community governance structure and procedures that guided the mrdpp and this substudy are described elsewhere 23 aboriginal project officers employed in the mrdpp and from the participating communities led the design and implementation of this research ensuring cultural safety 23 the apos also liaised with other organizations contributed to the thematic analysis and coauthored this publication in writing this paper authors applied the consolidated criteria for reporting qualitative research checklist this was to ensure transparency with the research methods and the important aspects of the process of this study were reported 24 ethical approval was received from the hunter new england local health district human research ethics committee and the aboriginal health and medical research council of nsw participants and recruitment aboriginal boys and girls aged 1014 years residing in two communities on the midnorth coast of nsw were invited to participate recruitment was undertaken using a snowball approach 25 with apos contacting parents through the aboriginal corporation medical services in both communities parents were asked to inform their children of this study and the children who were interested consented to participate consenting children then invited their peers to participate snowball sampling continued until no further potential participants could be identified 25 informed consent was obtained from all participants involved in the study a total of 26 aboriginal children consented to take part in this study of these 18 children attended the introductory session and were given cameras a total of 17 children returned their cameras and each participated in an individual yarn about their photos the number of photos taken per child varied between 8 and 11 thirteen yarns were audiorecorded and hand notes were taken for the remaining four due to the community location of the yarn in aboriginal and torres strait islander culture a yarn is a relaxed and informal style of conversation that takes its own time often flowing around a topic as information and stories are shared and then within the topic until the natural completion of the yarn 26 varied between 8 and 11 thirteen yarns were audiorecorded and hand notes were taken for the remaining four due to the community location of the yarn in aboriginal and torres strait islander culture a yarn is a relaxed and informal style of conversation that takes its own time often flowing around a topic as information and stories are shared and then within the topic until the natural completion of the yarn 26 procedure parents of potential participants were handed recruitment packages with child and parent information statements and consent forms children who signed the consent forms were contacted by apos via their parents and invited to attend an introductory group yarn in which the study aims consent process and study procedures were explained each child was provided with a digital camera and informed of its functions participants were given a week to take photos of the perceived barriers and facilitators to their physical activity participation in their community the children also took photos of the physical activities that they enjoyed or wished to engage in at the end of the week yarning sessions were undertaken with each child in either a community location or the acms according to participant convenience and preference these were conducted by apos or the lead investigator audio recorded or handwritten where the location was not conducive to audio recording and audio recordings later transcribed for analysis children were invited to yarn about each of the photos they had taken and these were uploaded to a secure location on the researchers computer prompts were codesigned with the apos from the participating communities 27 once all individual yarns were completed participants were then invited to a followup group yarn to select photos for community posters nine children and two parents took part in the first group yarn in community a and five children and one parent took part in the second yarn to finalize their choices aunty in aboriginal culture is a term used to describe a respected female elder in the community who may not necessarily be a family member 28 in community b apos reached consensus about which photos best reflected the themes arising from the individual yarns with children two children and two parents then met for a followup group yarn procedure parents of potential participants were handed recruitment packages with child and parent information statements and consent forms children who signed the consent forms were contacted by apos via their parents and invited to attend an introductory group yarn in which the study aims consent process and study procedures were explained each child was provided with a digital camera and informed of its functions participants were given a week to take photos of the perceived barriers and facilitators to their physical activity participation in their community the children also took photos of the physical activities that they enjoyed or wished to engage in at the end of the week yarning sessions were undertaken with each child in either a community location or the acms according to participant convenience and preference these were conducted by apos or the lead investigator audio recorded or handwritten where the location was not conducive to audio recording and audio recordings later transcribed for analysis children were invited to yarn about each of the photos they had taken and these were uploaded to a secure location on the researchers computer prompts were codesigned with the apos from the participating communities 27 once all individual yarns were completed participants were then invited to a followup group yarn to select photos for community posters nine children and two parents took part in the first group yarn in community a and five children and one parent took part in the second yarn to finalize their choices aunty in aboriginal culture is a term used to describe a respected female elder in the community who may not necessarily be a family member 28 in community b apos reached consensus about which photos best reflected the themes arising from the individual yarns with children two children and two parents then met for a followup group yarn a repeated reflexive approach was taken throughout the process of finalizing photos deemed suitable for inclusion on posters in community a photos were printed out by the research team and brought to the first followup group yarn children considered their photos and selected those that best represented their views of barriers and facilitators of physical activity a parent or caregiver of each participant was present for this process in community b due to local community factors at the time children did not meet as a focus group to identify their selection here the apos considered the transcripts and handwritten notes discussed each childs photos and reached consensus regarding those that best reflected the issues raised by the majority of participants in their interviews participants taking part in the group yarn concurred with the apos reasoning and choice a repeated reflexive approach was taken throughout the process of finalizing photos deemed suitable for inclusion on posters in community a photos were printed out by the research team and brought to the first followup group yarn children considered their photos and selected those that best represented their views of barriers and facilitators of physical activity a parent or caregiver of each participant was present for this process in community b due to local community factors at the time children did not meet as a focus group to identify their selection here the apos considered the transcripts and handwritten notes discussed each childs photos and reached consensus regarding those that best reflected the issues raised by the majority of participants in their interviews participants taking part in the group yarn concurred with the apos reasoning and choice the final selection of photos was then considered for inclusion in several draft posters of differing designs by the research team these posters were intended to be facilitators for community discussion of results apos invited all participants and their parents to take part in a poster design focus group in each community handwritten notes of the discussion were taken from these focus groups which largely included parental feedback to add richness to the findings notes were crosschecked against key themes by the first author and information relating to these themes was included data analysis yarning transcripts and photographs were entered into a qualitative research software package nvivo version 11 29 for thematic analysis thematic analysis was informed by braun and clarkes six stages which involved data familiarization initial coding and searching and reviewing and defining themes 30 to enhance the rigor of thematic analysis sl and jg independently coded the first three yarns before discussing their similarities and differences this aimed to reduce subjectivity that can occur when coding is completed by one researcher 31 the remainder of yarns were coded by the first author codes were grouped together by looking at the relationships and connections between them to create categories and subsequently subthemes and overarching themes 30 preliminary themes along with the original transcripts and photos were sent to the apos for their review and feedback this feedback informed the final themes posters containing participants photos and final themes were cocreated with the apos the final selection of photos was then considered for inclusion in several draft posters of differing designs by the research team these posters were intended to be facilitators for community discussion of results apos invited all participants and their parents to take part in a poster design focus group in each community handwritten notes of the discussion were taken from these focus groups which largely included parental feedback to add richness to the findings notes were crosschecked against key themes by the first author and information relating to these themes was included data analysis yarning transcripts and photographs were entered into a qualitative research software package nvivo version 11 29 for thematic analysis thematic analysis was informed by braun and clarkes six stages which involved data familiarization initial coding and searching and reviewing and defining themes 30 to enhance the rigor of thematic analysis sl and jg independently coded the first three yarns before discussing their similarities and differences this aimed to reduce subjectivity that can occur when coding is completed by one researcher 31 the remainder of yarns were coded by the first author codes were grouped together by looking at the relationships and connections between them to create categories and subsequently subthemes and overarching themes 30 preliminary themes along with the original transcripts and photos were sent to the apos for their review and feedback this feedback informed the final themes posters containing participants photos and final themes were cocreated with the apos feedback of study outcomes to communities results in the form of the posters and a verbal presentation with or without powerpoint slides were discussed at meetings with local city council representatives key aboriginal community members involved in the mrdpp and members of the mrdpp steering committee stakeholders were provided with a copy of the final mrdpp report to contextualize the conduct of this study 19 results were also presented for discussion at meetings of the aboriginal educational consultative groups in both communities minor changes to wording in one poster were suggested and incorporated socioecological framework physical activity participation is a complex behavior and is determined not only by the individual or their local environment but by broader socioeconomic political and cultural contexts 32 a socioecological framework was applied to the barriers and facilitators identified by children to assist in understanding the scope of these complex factors and the levels at which these exist in the participants environment we applied the framework used in a recent mixedmethods systematic review of the barriers and facilitators to aboriginal and torres strait islander childrens participation in sport and physical activity 18 and coded the findings according to the levels they described individual interpersonal community and policyinstitutional in doing so we aimed to align our findings and contribute to building evidence for practice results thematic analysis revealed seven key themes interviews and photos depicted a wide range of sports and physical activities enjoyed by the participants including different types of football bikeriding basketball soccer running and swimming photos largely reflected the barriers that participants experienced when accessing physical activity opportunities barriers the physical environment was a key barrier to physical activity particularly for community as participants participants cited the littered and vandalized community facilities as a deterrent poorly maintained and rundown sporting venues were also reported with tennis and basketball courts overgrown with grass and no usable equipment the poor state of these facilities prevented children from playing there despite their desire to an this is a photo of the basketball court people used to drink there a lot and they used to like throw beer bottles and now its all wrecked because of them an the basketball nets are like poles are like falling tilting like its about to fall participants discussed their experience of a lack of safety when engaging in physical activity due to hazards in the surrounding physical environment the presence of litter such as glass in local playgrounds was identified by children as dangerous during the followup yarns most children described continuing to play in playgrounds and parks despite it being unsafe and you cant really see if theres any glass or anything so you never know when walking around in there so its not very safe the lack of designated space for children to engage in sports was identified by participants who also described playing nonorganized sports in spaces such as near main roads this supports childrens safety concerns around their physical environment and the lack of accessible and safe places to undertake physical activity children identified consumption of unhealthy foods including processed foods and sugary drinks as a barrier to engaging in an active lifestyle they discussed this factor as related to the development of obesity and diabetes which in turn they perceived as having a negative impact on being active photos captured unhealthy foods on participants laps and signs of fastfood stores soft drink …it can stop us from playing games outside and it could give you diabetes and you cant really like have what you want to eat sometimes well like junk food like would like stop you from a lot of sports like putting on the weight and like things stuff like that the followup yarns expressed the view that the proximity and exposure of unhealthy food and drinks was a contributor to the consumption of these discretionary items children would pass the corner shop on the way to school and high schools would sell sugarsweetened beverages to students participants acknowledged that engagement in excessive screenbased activities was sedentary behavior in interviews children acknowledged that screenbased activities displaced physical activity participation and recognized the impacts of this photos depicted different types of technology use including ipads and computers … sitting down …playing the play station or the phone instead of going out and being active… the cost to participate and access physical activity opportunities was noted by participants the high price of transport sports registrations equipment and its maintenance were prohibitive for some parents the cost barrier for parents hindered children from children identified consumption of unhealthy foods including processed foods and sugary drinks as a barrier to engaging in an active lifestyle they discussed this factor as related to the development of obesity and diabetes which in turn they perceived as having a negative impact on being active photos captured unhealthy foods on participants laps and signs of fastfood stores soft drink …it can stop us from playing games outside and it could give you diabetes and you cant really like have what you want to eat sometimes well like junk food like would like stop you from a lot of sports like putting on the weight and like things stuff like that the followup yarns expressed the view that the proximity and exposure of unhealthy food and drinks was a contributor to the consumption of these discretionary items children would pass the corner shop on the way to school and high schools would sell sugarsweetened beverages to students participants acknowledged that engagement in excessive screenbased activities was sedentary behavior in interviews children acknowledged that screenbased activities displaced physical activity participation and recognized the impacts of this photos depicted different types of technology use including ipads and computers … sitting down …playing the play station or the phone instead of going out and being active… the cost to participate and access physical activity opportunities was noted by participants the high price of transport sports registrations equipment and its maintenance were prohibitive for some parents the cost barrier for parents hindered children from children identified consumption of unhealthy foods including processed foods and sugary drinks as a barrier to engaging in an active lifestyle they discussed this factor as related to the development of obesity and diabetes which in turn they perceived as having a negative impact on being active photos captured unhealthy foods on participants laps and signs of fastfood stores the followup yarns expressed the view that the proximity and exposure of unhealthy food and drinks was a contributor to the consumption of these discretionary items children would pass the corner shop on the way to school and high schools would sell sugarsweetened beverages to students participants acknowledged that engagement in excessive screenbased activities was sedentary behavior in interviews children acknowledged that screenbased activities displaced physical activity participation and recognized the impacts of this photos depicted different types of technology use including ipads and computers sitting down playing the play station or the phone instead of going out and being active the cost to participate and access physical activity opportunities was noted by participants the high price of transport sports registrations equipment and its maintenance were prohibitive for some parents the cost barrier for parents hindered children from participating in their desired sport in one photo a participant held up a sign in front of a petrol station stating participating in their desired sport in one photo a participant held up a sign in front of a petrol station stating mum only has 5 left from her pay i play at a large regional city thats not going to get me there and back handwritten notes from the second group yarns reported that parents were not aware of the funding and support that may be available to enable their children to participate in organized sport lack of access to transport both public and private was associated with limited parental finances and availability of public transport particularly when children lived out of town participants were reliant on parents or extended family members for transport to regular sporting competitions or community facilities the availability of transport depended on family routine and dynamics the issues with availability and affordability of transport were emphasized during the followup group yarns children discussed walking due to limited access to transport and this being the leastexpensive option five communitylevel three interpersonallevel and two individuallevel barriers were identified when the socioecological model was applied children perceived barriers to participating in physical activity around the physical environment particularly the availability of safe and accessible community facilities lack of parental finances to support sports participation consumption of an unhealthy diet and participation in sedentary activities facilitators family members participation in sports andor their sporting achievements were identified in both community a and b as key factors facilitating physical activity providing children with important role models for being active …we started paddling out and i asked dad if i could have a go …my brother is surfin an we all love surfin… family activities such as fishing were enjoyed on a regular basis participants in community a reported that school facilitated their engagement in regular physical activity school events such as the athletics carnival encouraged children to engage in a variety of sports and to train for them in their own time the provision of facilities such as the school oval gave children opportunities to engage in physical activity during lunch times mum only has 5 left from her pay i play at a large regional city thats not going to get me there and back i dont do any sports after school but um every lunch time im normally playing touch footy or im doing basketball basketball with my friends handwritten notes from the second group yarns reported that parents were not aware of the funding and support that may be available to enable their children to participate in organized sport lack of access to transport both public and private was associated with limited parental finances and availability of public transport particularly when children lived out of town participants were reliant on parents or extended family members for transport to regular sporting competitions or community facilities the availability of transport depended on family routine and dynamics the issues with availability and affordability of transport were emphasized during the followup group yarns children discussed walking due to limited access to transport and this being the leastexpensive option five communitylevel three interpersonallevel and two individuallevel barriers were identified when the socioecological model was applied children perceived barriers to participating in physical activity around the physical environment particularly the availability of safe and accessible community facilities lack of parental finances to support sports participation consumption of an unhealthy diet and participation in sedentary activities facilitators family members participation in sports andor their sporting achievements were identified in both community a and b as key factors facilitating physical activity providing children with important role models for being active we started paddling out and i asked dad if i could have a go my brother is surfin an we all love surfin family activities such as fishing were enjoyed on a regular basis participants in community a reported that school facilitated their engagement in regular physical activity school events such as the athletics carnival encouraged children to engage in a variety of sports and to train for them in their own time the provision of facilities such as the school oval gave children opportunities to engage in physical activity during lunch times i dont do any sports after school but um every lunch time im normally playing touch footy or im doing basketball basketball with my friends group yarns reiterated these findings and discussed school as an important factor in helping children form an active lifestyle the school was an environment that offered a wide range of opportunities to be active and an opportunity for children to engage in sport with their peers schools also enabled participation in physical activity through the provision of financial support and transport both of which addressed factors described as barriers participants enjoyed regular physical activity when they had access to adequate equipment and opportunities in the final group yarns participants were enthusiastic about outdoor playnonorganized physical activity as it was enjoyable there was free choice of activities and anyone could participate despite experiencing the complex barriers that made it difficult for children to be active including gender role perceptions for one child participants still desired to engage in physical activity i took that picture like that cos its just saying that some kids actually wanna go in there and use it and stuff too old to play football because i am a girl i still want to play football though participants proposed several suggestions to improve opportunities for physical activity in their community this included better facilities and improved use of space by building community facilities the council should put ah real basketball court out the ridge cos we have a lot of space there three interpersonal and two each of individual community and institutional facilitators were identified when the socioecological model was applied facilitators were largely apparent at the individual and interpersonal level with friends and family key facilitators at the institutional level schools were central to many childrens ability to take part in sports and physical activity childrens vision for improvements to their opportunities for physical activity was directed at the community level they imagined facilities that better suited their community along with better use of space for community facilities discussion this study appears to be the first to explore rural nsw aboriginal childrens perceptions of the barriers to and facilitators of their sports and physical activity participation we found that the key facilitators of aboriginal childrens physical activity exist at the interpersonal and institutional levels of the socioecological approach 18 and are physical activity engagement with friends the strength of the family unit and schools presenting opportunities for children to be active the key barrier to physical activity participation identified by children was at the community level regarding poorly maintained community facilities and related safety issues other barriers perceived by participants included intake of unhealthy foods excessive screen time inability to afford physical activity opportunities experienced as costly and reliance on parents for transport the strength of the family unit as a key facilitator for physical activity aligns with the perceptions of aboriginal children elsewhere 10 11 12 13 14 children discussed their family members who participated in sport and their sporting achievements as supporting and encouraging their physical activity this factor is also a prominent facilitator for aboriginal and torres strait islander adults physical activity participation 3 aboriginal people view physical activity as a collective occupation providing connections with others and the wider community 33 aboriginal families play a crucial role in supporting children and young peoples physical activity engagement through encouragement rolemodeling an active lifestyle and facilitating activities involving exercise 1213 the lack of family involvement has been described as hindering childrens physical activity engagement in the torres strait and surrounding country 10 friends enable physical activity participation through the inherent enjoyment and fun experienced by children being active together in play general activity and sport 12 participants enjoyment and desire to participate in physical activity led them to hold aspirations for their community including how space can be utilized to build community facilities such as a new basketball court enjoyment of sport and a desire to remain physically active have also been identified as facilitators to physical activity participation by aboriginal adults 334 as such strategies to increase physical activity should explore options where children can also socialize with their peers or within an environment that encourages social connection school is experienced by aboriginal children in this study as an environment that not only has better access to facilities and equipment but fosters socialization with friends this aligns with findings elsewhere that have identified that an established relationship between schools and the community positively influences young aboriginal peoples engagement in physical activity 12 and that aboriginal children report school facilities and community events provide them with opportunities to be active 91112 deteriorating community facilities and the resulting lack of safety reported by these nsw rural children expands on reports from studies in other australian jurisdictions regarding rural aboriginal childrens perceptions 12 these factors present a significant deterrent to physical activity 35 nsw state government policies and legislations control the availability and quality of community facilities and accessibility of neighborhoods often through the actions of local councils that it funds 32 infrastructure in these communities is primarily funded by rates collected from residents 36 as rates are calculated on property value 36 and the value of the property is less in the participating communities fewer funds are available for infrastructure management we suggest that the potential benefits of supplementing rates with additional funds be considered by local councils to ensure that infrastructure relevant for childrens health and wellbeing is adequately maintained in disadvantaged areas participants in this study largely appeared to understand physical activity as engagement in organized sports such as football along with related nonorganized sportpractice the availability of relevant accessible community facilities is therefore important we note however that children did not consider the incidental exercise that takes place from day to day such as walking to and from community facilities or walking as transport as physical activity we call for local councils communities and schools to consider campaigns to promote alternatives to team sports such as bike ridingand walking to support childrens understanding that participating in such activities is also beneficial for their health such campaigns must be led by and codesigned with aboriginal communities 2737 children in this study identified the consumption of unhealthy foods and exposure to excessive screentime as barriers to physical activity children described the association of these factors with low levels of physical activity and poor physical health citing chronic diseases such as diabetes and obesity both prevalent in their communities 2 these have not been identified as barriers by young people in previous studies exploring aboriginal and torres strait islander childrens views on their physical activity 1012 and should be harnessed in the design of future strategies to improve physical activity participation sedentary behavior due to time spent on screenbased activities is an issue for all children however a national report has found that aboriginal children spend 25 min more on technology per day than their nonaboriginal counterparts 7 this is therefore a barrier that also warrants inclusion in programs that address childrens physical activity participation participants described parental circumstances around vehicle availability and sufficient finance to afford carassociated costs as barriers to accessing sporting competitions or community facilities this has also been identified by other young aboriginal people as a barrier to accessing physical activity opportunities 12 transport disadvantage is common for aboriginal people due to lack of access to and affordability of private and public transport options 38 particularly for those living in rural and remote parts of australia lack of transport has been identified as a key barrier to physical activity and sports participation by aboriginal and torres strait islander adults 3 the costs of public bus services in rural nsw have been found to be substantially higher than metropolitan areas and are more than residents are able to afford 39 a lack of affordable and accessible transport places aboriginal children at a further disadvantage when accessing physical activity opportunities we suggest that local councils consider offering a community bus service to support weekend sport participation for children the inability to afford to participate in physical activity including organized sports due to low income has been noted by young rural aboriginal people 12 aboriginal adults have also stated that the high cost of sports participation relative to their income is a very significant barrier to accessing physical activity opportunities 334 while costs are also cited as a top barrier for other australian children 40 additional financial barriers exist for aboriginal people who experience socioeconomic disadvantage more than other australians and possess a lower weekly household income compared to other households 5 associations between low physical activity levels and socioeconomic disadvantage have previously been identified 41 and the high costs associated with sport may contribute to low rates of physical activity for aboriginal children and youth in our study parents indicated that they were not aware of local schemes through sports organizations or local councils to support the costs of childrens participation in sports it has been suggested elsewhere that better promotion of sporting opportunities through local agencies and clubs to young aboriginal people may influence physical activity participation 12 the enduring impact of colonization on aboriginal communities is an overarching driver of the barriers to physical activity participation identified in this study and was identified as such by the apos on this study when discussing the results the socioeconomic disadvantage and lower weekly income evident in many aboriginal communities 5 have been acknowledged as enduring impacts of colonial government policies which also included regulating income of aboriginal people forced disconnection from traditional land forced removal of children and marginalization of communities 42 marginalization included being required to live in settlements or missions out of town and being either barred from entering a town or segregated if permitted to use facilities 1 poor community cohesion and racism were identified by aboriginal parents from the participating communities as an ongoing barrier to their children being active 19 and also have their origins in colonialgovernment policies that disrupted and fractured communities 33 adopting the principles of codesign 2736 when developing physical activity programs for aboriginal children and ensuring that these programs are led and delivered by local aboriginal community members 43 is recognized as imperative to improving the accessibility and cultural relevance of such strategies 2333 however these approaches are still yet to be widely implemented what has been missing from these commitments is the genuine enactment of the knowledges that are held by indigenous australians relating to their cultural ways of being knowing and doing privileging indigenous knowledges cultures and voices must be front and centre in developing designing and implementing policies and programs the sharing of power provision of resources culturally informed reflective policy making and program design are critical elements 44 strengths of this study include the use of a novel method of investigating aboriginal childrens perceptions of physical activity participation allowing their voices to be heard the participatory action research approach used in this research enabled a flexible response to participant and community needs and supported their engagement at all stages of the study a reflexive approach to the final selection of photos allowed careful consideration of those that best represented participants views the strong aboriginal community governance structure enabled guidance on all aspects of the research process 23 community consultations allowed findings to be discussed with various aboriginal community members who have been involved in the mrdpp and with local council representatives who wished for additional information the posters distributed to community stakeholders allowed for further dissemination of results at a local level a limitation to this study was that a number of communitylevel events and challenges unrelated to the study emerged in community b over the time that the yarns took place these impacted recruitment numbers and childrens participation in followup yarns however the participation of apos from the communities to some degree mitigated this issue and feedback received from the community when results were presented was positive conclusions this photovoice study enabled australian aboriginal children from rural nsw to describe their experiences of sport and physical activity participation in their communities for the first time results extend the limited representation of aboriginal childrens voices on this topic nationally the identification of key facilitators at the interpersonal and institutional level and of barriers at the community level offer guidance for future strategies to address improvements in enabling aboriginal children to participate more fully in the sports and physical activities that they aspire to prioritizing the maintenance of community facilities is important in enabling access to physical activity opportunities and children held strong aspirations for improved and accessible facilities transport accessibility along with the costs of sports participation continue to be barriers to aboriginal childrens engagement in sport and physical activity and require a wholegovernment response the strengths of families and friendships should be harnessed to facilitate participation in sport and physical activity barriers and facilitators identified by aboriginal children are a result of the enduring impact of colonization on families and communities aboriginal community codesign and leadership of all matters of relevance to their communities including in public health and health promotion are essential and widely recognized as central to improvements in health and wellbeing 45 however the development of policies and programs that embody these approaches is only emerging and implementation is yet to be fully understood and accepted only once this occurs will australian aboriginal children be enabled to wholly engage with and benefit from the sports and physical activity that they desire author contributions conceptualization jg js and nt methodology jg and sl software sl and jg validation sl jg js and nt formal analysis sl jg js and nt investigation sl jg js and nt resources jg data curation sl and jg writingoriginal draft preparation sl jg js and nt writingreview and editing sl jg js nt rp elj and naj visualization sl jg js nt rp elj and naj supervision jg project administration jg js and nt funding acquisition jg rp elj and naj all authors have read and agreed to the published version of the manuscript data availability statement restrictions apply to the availability of these data data was obtained from the participating aboriginal communities and are available from the authors with the permission of the representatives of these communities informed consent statement informed consent was obtained from all subjects involved in the study

participating in physical activity is beneficial for health whilst aboriginal children possess high levels of physical activity this declines rapidly by early adolescence low physical activity participation is a behavioral risk factor for chronic disease which is present at much higher rates in australian aboriginal communities compared to nonaboriginal communities through photos and yarning the australian aboriginal cultural form of conversation this photovoice study explored the barriers and facilitators of sport and physical activity participation perceived by aboriginal children n 17 in new south wales rural communities in australia for the first time and extended the limited research undertaken nationally seven key themes emerged from thematic analysis four themes described physical activity barriers which largely exist at the community and interpersonal level of childrens social and cultural context the physical environment high costs related to sport and transport and reliance on parents along with individual risk factors such as unhealthy eating three themes identified physical activity facilitators that exist at the personal interpersonal and institutional level enjoyment from being active supportive social and family connections and schools findings highlight the need for ongoing maintenance of community facilities to enable physical activity opportunities and ensure safety children held strong aspirations for improved and accessible facilities the strength of friendships and the family unit should be utilized in codesigned and aboriginal communityled campaigns

introduction adolescence more than in any other developmental stage is characterized by heightened susceptibility to peer influence 1 which makes adolescents vulnerable to initiating or maintaining risky habits such as heavy drinking 2 people are likely to engage in behaviors that match their perceptions of what is normative especially characteristics of those who represent idealized identities such as highstatus peers many deviant and risky behaviors are associated with high peer status and it is suggested that some adolescents strive to imitate their high status peers through a process of social comparison 3 which means that adolescents contrast their own sense of values interests beliefs and behaviors with their perceptions of others and in consequence of this construct a sense of identity various risk factors for problem drinking among youth have been identified by researchers the emphasis across studies has been on risk and protective factors 45 there is increasing evidence that social environmental factors influence alcohol consumption and harms among youth social capital is one contextual factor that has been related to binge drinkingdefined as consuming 5 or more drinks on one occasion 6 among adolescents social capital is defined as the resourcessuch as social support trust and information channelsaccessed by individuals through their social networks 7 social trust and social participation have each been protectively associated with alcohol use among high school students 8 binge drinking has a strong social component 910 adolescents are more likely to drink in social settings allowing for their drinking habits to be visible to peers the combination of risk taking and the visibility of alcohol use in peer settings may allow adolescents to maintain their social network status and gain popularity 11 in addition some studies have shown that binge drinking varies by gender and socioeconomic status although these associations are not always consistent because both alcohol use and peer influence increase during adolescence it is critical to consider longitudinal influences of peer groups on the developmental trajectory of adolescent alcohol use 12 furthermore studies that investigated the association between binge drinking and social capital have not attempted to identify differences among the subdimensions of the social capital construct 413 the aim of the present longitudinal study was therefore to investigate the association of social capital with longitudinal changes in the frequency of binge drinking among adolescents at public and private high schools in the city of diamantina brazil materials and methods study design and sample to investigate an incidence of binge drinking a survey was carried out involving all adolescents enrolled in the public and private schools of the city of diamantinamg brazil with a full 12 years during the data collection months of the study data related to school addresses and number of students enrolled in each class was obtained from the state and municipal education departments subsequently 633 adolescents from all 13 public and private schools in diamantina mg were invited to participate in the study being previously notified by telephone to schedule the researchers visit at that time the objectives of the research were clarified and what activities would be carried out at the school also presented were an approval of the ethics committee and as authorizations of the state and municipal secretariats of education after the consent of the management and the teaching staff classes with schoolchildren enrolled in public and private schools in the urban area of the city of diamantina and who were 12 full years on the day of the exam authorized by the parents guardians and agreed to participate in the research were contacted by the researcher during class time with the teachers presence for awareness raising adolescents not authorized by parents or guardians or who did not agree to participate in the study were excluded from the study the researcher explained the purpose of the research and asked the students to answer the questionnaires ensuring the confidentiality of the answers as well as the evaluation of student participation in the baseline survey the sample consisted of 588 students the reasons for dropouts were nonauthorization from parentsguardians or adolescents and failure to complete the questionnaires in 2014 a new data collection procedure was carried out with these adolescents when they were aged 13 years again all 13 public and private schools in diamantina mg were invited to participate in the study and were previously notified by telephone to schedule the researchers visit they only included adolescents authorized by their parents or guardians and who agreed to participate in the study thus the followup study involved a sample of 588 adolescents to achieved a 100 percent followup rate the researchers responsible for the data collection made calls to the homes of students who were not present on the day previously scheduled which led the researchers to return to some schools more than once furthermore access was relatively easy because researchers live in the region and had close contact with directors of the schools measures the alcohol use disorder identification test validated for use in brazil 14 was employed for the evaluation of alcohol intake the audit instrument can identify whether an individual exhibits hazardous drinking harmful drinking or alcohol dependence 15 audit c was used as this version can be employed as a standalone screening measure to detect hazardous drinkers among adolescents 1617 a how often did you have a drink containing alcohol in the past year b how many drinks containing alcohol did you have on a typical day when you were drinking c how often do you have five or more drinks on one occasion the latter item was used to identify binge drinking 18 the response options are never less than monthly monthly weekly and daily or nearly daily responses of never were coded as 0 in the analysis less than monthly and monthly were coded as 1 weekly and daily or nearly daily were coded as 2 although the audit c was used to measure alcohol involvement the dependent variable was change in alcohol consumption calculated from the difference in consumption observed between 2013 and 2014 categorized into reduced or unaltered frequency intake and increased frequency intake was based only on audit binge item our predictor variables included sociodemographic and economic characteristics and social capital for evaluation of social capital we used the social capital questionnaire for adolescent students which was developed and validated by our research team 19 the study population included in the development and validation of the instrument was a convenience sample made up of 101 students aged 12 years enrolled in the public and private school systems in city of diamantinamg brazil this questionnaire is composed of items selected from the national and international literature and has been submitted to face validation content analysis and analyses of internal consistency reliability and reproducibility 19 the factor analysis grouped the 12 items into four subscales social cohesion at school network of friends at school social cohesion in the community neighborhood and trust at school and in the communityneighborhood social capital scores range from 12 to 36 points with a higher score denoting higher social capital as a questionnaire designed for children and adolescents the decision was made to use a threepoint likert scale with response options of i agree i do not agree or disagree and i disagree this procedure was based on the target age group and was chosen to avoid confusion during the filling out of the questionnaire the findings confirm indications in the literature that networks of friends and neighborhood cohesion reflect experiences one shares with ones peers and underscore the importance of the present questionnaire as an assessment tool for measuring social capital based on the distribution to analyze the social capital by the adolescent the social capital variable was dichotomized by median as high and low the difference of the social capital at the followup in relation to the social capital at the baseline of each adolescent was calculated to obtain the difference between the measures of social capital in the two evaluations thus total score of social capital at followup minus total score of social capital at the baseline presented three response options increase in social capital reduction and unaltered we treated sex type of school maternal education and family income as time invariant statistical analysis data analysis was performed using the statistical package for the social sciences and included frequency distribution and association tests the chisquare test was used to determine the statistical significance of associations between binge drinking and the independent variables given the high prevalence of the outcome we used logbinomial model to calculate prevalence ratios and 95 confidence intervals 20 in this study log binomial models were used to calculate both univariate and multivariable models 20 the twotailed p value was set at 005 ethical considerations this study received approval from the human research ethics committee of the federal university of minas gerais all parentsguardians signed a statement of results the sample comprised 588 students boys accounted for 486 of the sample among these participants the vast majority attended public schools a total of 752 of adolescents were from families that earned up to three times the brazilian monthly minimum wage and 6160 of the mothers had less than eight years of schooling the prevalence of binge drinking in 2013 was 231 and in 2014 the prevalence had risen to 301 ie there was a 7 increase in the prevalence of binge consumption in the period of the 452 teens who reported never consuming five or more alcoholic drinks at one time in 2013 41 started to do so with some frequency in 2014 according with the changes in the score of social capital total between baseline and followup 340 adolescents unaltered their social capital total in followup 184 students showed an increase in social capital total in followup and 58 showed a reduction in followup six students did not adequately answer the questionnaire table 4 shows the percentage of the sample related to the in subscales of social capital between baseline and followup and its association with the difference on binge drinking between baseline and followup 166 students increased their social capital in the social cohesion at school subscale and 457 reduced or unaltered their score of social capital total between baseline and followup in the network of friends at school subscale twentysix adolescents who reported an increase in the social cohesion in the community subscale also showed an increase in binge drinking at the followup and 188 reported a reduction in the trust subscale and in the binge drinking at the same time logbinomial model shows the incidence of binge drinking according to the background characteristics of the respondents gender and socioeconomic status were not associated with the increase in the frequency of binge drinking however social capital was significantly associated with an increase in binge drinking by students table 6 shows the prevalence ratios of changes in the frequency of binge drinking according to social capital subscales adolescents who reported that they had an increase in social cohesion in the communityneighborhood subscale were 33 times more likely to binge drink themselves in addition adolescents who reported that they had a decrease in trust subscale were less likely to binge drink themselves however social cohesion at school and network of friends at school subscales were not associated with the outcome discussion the present study examined the frequency of binge drinking among adolescents at public and private schools in the city of diamantina the increase in the frequency of binge drinking in the followup period was 7 and this increase was fivefold greater among adolescents who exhibited an increase in social capital our social capital questionnaire was designed so that we can distinguish the influence of social capital in different contexts that the adolescent is exposed to ie the school environment versus the neighborhood environment we therefore analyzed the subscales separately our findings suggest that adolescents drinking behavior is more responsive to changes in the neighborhood context and trust rather than the school context and friendship network at school the literature suggests that the concept of social capital can be broken down into structural and cognitive social capital 21 structural aspects of social capital refer to roles rules precedents behaviours networks and institutions these may bond individuals in groups to each other bridge divides between societal groups or vertically integrate groups with different levels of power and influence in a society leading to social inclusion by contrast cognitive social capital taps perceptions and attitudes such as trust toward others that produce cooperative behaviour 22 in contrast to the results of the present study previous reports found that students from u s colleges with higher levels of social capital were at lower risk for binge drinking 523 the discrepancy may be due to differences in the aspects of social capital examined in the different settings specifically the study based on binge drinking in us colleges focused on the structural aspect of social capitalas measured by the participation of students in voluntary activities 23 however students in our brazilian sample were at greater risk of binge drinking if they reported higher social capital in the cognitive dimension ie feelings of more cohesion in their communities and neighborhoods and they are less likely to binge drinking if they have a decrease in the trust subscale the difference between these studies including the age of the subjects underscore the observation that social capital can have both positive and negative health implications depending on the form it takes 24 in samples with older adolescents who binge drinking more often we may find a richer and possibly more intuitive pattern of results individuals who have higher levels of social support and community cohesion generally are thought to be healthier because they have better links to basic health information better access to health services and greater financial support with medical costs 7 however it is important to consider the impact of complex community factors on individual behaviors some factors as social stratification and social selection may affect health risk behaviors including alcohol use 7 in addition previous research highlighted the importance of having trust in the peers with whom adolescents drank alcohol 25 young usually drink more with peers whom they trust probably because of a tacit acknowledgement that a friend understood unspoken rules and could be relied upon 25 past studies have found that binge drinking is usually performed in groups therefore peers play an important role in promoting binge drinking perhaps due to peer selection or peer influence 423 our results show that social cohesion in the community neighborhood subscale was significantly associated with increase in binge drinking and a decrease in trust subscale was related to the decrease in frequency of binge drinking among scholars although the literature is well established in relation to peer influence on binge drinking social cohesion at school and network of friends at school subscales were not associated with the outcome drinking is viewed by young people as a predominantly social activity which provides an opportunity for entertainment and bonding with friends 25 during lifetime friendships can direct development through support modeling and assistance but the significance of friendships is heightened during adolescence 26 previous study showed that adolescents baseline alcohol use status strongly predicted acquisition of friends exhibiting similar alcohol use patterns twelve months later 27 another study among young students 28 that analyzed individual and contextual risk factors for alcohol use assessed during childhood and adolescents revealed significant variability in the association between alcohol consumption and deviant friends and that deviant friends was a significant covariate of alcohol consumption furthermore this study revealed a significant interaction of disinhibition × parental alcohol use the childhood disinhibition interacted with parental alcohol use to moderate the covariation of drinking and deviant friends 28 the relationship between social environments and binge drinking is complicated in part because of reverse causality or simultaneity environmental factors may be spuriously linked to binge drinking because for example adolescents who live in neighborhoods where violent crime is high and access to illicit substances is easy may be less likely to be socially connected and more likely to consume alcohol 29 despite being a wellestablished determinant the influence of socioeconomic status on health is not well understood and little research has focused on the effects of this aspect on health during adolescence 30 in the present study the socioeconomic status was not associated with the increase in the frequency of binge drinking among adolescents some studies have demonstrated that adolescents from higher socioeconomic status backgrounds have a greater propensity to use alcoholic beverages and to engage in binge drinking 43132 this may be because of higher discretionary income or easier access to alcohol in their homes however other studies have found an association between lower socioeconomic status and greater alcohol consumption 1633 and still others have found no significant association between socioeconomic status and alcohol intake 3435 the literature highlighted that differences in results may be partially explained by the use of different indicators adopted such as family income social class level of schooling school type as well as the considerable variation in cutoff points as well as the specific culture and the age of the drinker in the present study we did not find statistically significant difference between incidence of an increase in binge drinking and gender this may be explained by changing gender norms over time which has made it more acceptable for girls to engage in risky behaviors 36 in accordance with our results a longitudinal study used a national data to describe gender differences in health behavior of adolescents and found that in the case of binge drinking girls behaviors have converged with the rates among boys 36 a limitation of our study is that as the data were derived from selfadministered questionnaires lack of attentiveness should be taken into consideration second despite emphasizing the importance of giving honest responses the findings may have been underestimated due to selfcensoring andor a suspicion that school authorities could gain access to the answers on the questionnaires third information on the influence of friends and characteristics of friendship networks such as density size quality of contacts proximity and centrality was not collected in the present study despite the fact that binge drinking has been associated with such factors 14 12 13 the aim of the questionnaire was to measure social capital that was easily understood and applicable to adolescent students that encompasses the different domains of social capital for this population even though this questionnaire did not measure characteristics of friendship networks such as density size quality of contacts proximity and centrality it is measures contexts that involve social relationships such as experiences at school and in the local community which can exert an influence on the behavior and decisions of adolescents thereby reflecting health determinants the social capital questionnaire for adolescent students demonstrate that this assessment tool is appropriate for epidemiological studies involving samples of adolescents in the investigation of the association between social capital and risk factors or health determinants finally we cannot generalize findings from this study to older adolescents within brazilian culture conclusion binge drinking involves groups of interconnected people who evince shared behaviors and is a public health and clinical problem targeting these behaviors should involve addressing groups of people and not just individuals 24 our results provide new evidence about the dark side of social cohesion in promoting binge drinking among adolescents social capital interventions must include school and community engagement parental involvement and peer participation components to address the complex array of factors that influence adolescent alcohol use all relevant data are within the paper and its supporting information files

adolescence is characterized by heightened susceptibility to peer influence which makes adolescents vulnerable to initiating or maintaining risky habits such as heavy drinking the aim of the study was to investigate the association of social capital with longitudinal changes in the frequency of binge drinking among adolescents at public and private high schools in the city of diamantina brazil this longitudinal study used two waves of data collected when the adolescents were 12 and 13 years old at the baseline assessment in 2013 a classroom survey was carried out with a representative sample of 588 students in 2014 a followup survey was carried out with the same adolescents when they were aged 13 years the alcohol use disorder identification testc audit c was employed for the evaluation of alcohol intake our predictor variables included sociodemographic and economic characteristics gender type of school mothers education family income and social capital for evaluation of social capital we used the social capital questionnaire for adolescent students scqas descriptive and bivariate analyzes were performed p 005 the logbinomial model was used to calculate prevalence ratios pr and 95 confidence intervals the twotailed p value was set at 005 the prevalence of binge drinking in 2013 was 231 and in 2014 the prevalence had risen to 301 gender pr 148 95 ci 087252 and socioeconomic status type of school and mothers education were not associated with the increase in the frequency of binge drinking however higher social capital was significantly associated with an increase in binge drinking by students adolescents who reported that they had an increase in social cohesion in the communityneighborhood subscale were 34 times more likely 95 ci 196610 to binge drink themselves our results provide new evidence about the dark side of social cohesion in promoting binge drinking among adolescents

introduction racism emerges whenever social and individual values norms and practices of a given group are considered superior to others racism occurs with the particular aim of creating maintaining or reinforcing power imbalances as well as the corresponding inequalities in opportunities and resources along racial lines 1 similar to most contemporary societies australia is characterized by coexisting expressions of cultural diversity on the one hand and negative impacts of racism on social cohesion on the other 1 in australia the mental health costs directly attributable to racism have been estimated at 235452 disabilityadjusted life years lost which is equivalent to an average 379 billion in productivity loss per annum or 3 of the australian annual gross domestic product over 20012011 2 such a strong relationship is an indication that racism may erode the very social fabric of the australian society by producing mental disorders and suffering which unevenly impacts upon racially marginalized groups social conceptions that shape intergroup relations form the common ground upon which intergroup attitudes and discriminatory behaviour take place 3 from an empirical viewpoint findings suggest that racist attitudes are associated with racist behaviours and racialethnic minorities experiences of discrimination 4 positive attitudes towards diversity however are negatively associated with discriminatory behaviour 5 in this study we propose to explore attitudes in relation to multiculturalism a construct of special relevance to the social economic and political fabric of contemporary australia 6 we focus on multiculturalism as an ideology of acknowledging and celebrating ethnic and cultural differences in which the need for preserving cultural identities is recognized 7 it reflects a sensibility and a disposition towards cultural differences among large sections of the population 8 data from the 2016 australian census revealed that one in three australians were born overseas and a similar proportion of individuals speak a language other than english at home nevertheless assimilationist attitudes expectations of conformation to the dominant cultureoften prevail as opposed to multiculturalist perspectives that accept and praise racial and ethniccultural diversity 9 understanding attitudes to multiculturalism can contribute to unveil the dynamics of racism and discrimination against minorities in the country fostering public debate and policy formulation aimed to promote positive intergroup relations 10 research on ethnicracial intergroup attitudes draws from theories on ideological attitudes that explain groupbased dominance and social cohesion 11 12 13 social dominance orientation for example reflects the degree to which respondents believe that hierarchybased dominance between social groups is natural 14 discrimination against minorities therefore can be explained by the degree of endorsement of the notion that groupbased hierarchies are natural and inevitable 14 endorsement of groupbased dominance and outgroup prejudice tends to increase among those who highly identify with the dominant group as they represent a mechanism of maintaining the ingroup status quo 12 research on ethnicracial intergroup relations in contemporary societies has also explored the rightwing authoritarianism concept 15 16 17 rwa is characterized by the endorsement of social conservative values morality collective security groupbased social cohesion and strict obedience to social authorities 1517 those who endorse rwa values can be more sensitive to threats to social stability being prone to conservative values as to increase their perception of control and collective security 18 perception of threat has been shown to mediate the association between group identification and attitudes towards multiculturalism 11 those that consider immigrants or ethnicracial minorities as a threat to the control of resources or maintenance of the dominant social values tend to endorse more conservativeassimilationist attitudes towards multiculturalism 1119 sustaining dominant group status quo can also be achieved by not acknowledging ethnicracial inequalities in the population the socalled colourblind racial ideology denies the existence of racism and justifies racial inequalities as a result of personal decisions meritocratic achievements and market forces 2021 by denying racist practices and racial inequalities it provides the discursive tools to downplay policy proposals aimed at promoting racial justice and therefore maintains the power imbalance between ethnicracial groups 20 following this perspective public denial of racism has been pointed as an obstacle to a deeper commitment to multiculturalism in australia 1322 although the existence of racism is acknowledged most australians fail to recognise the existence of angloprivilege a necessary step in reducing the imbalance in resource distribution and political representation among ethnicracial groups 13 taken together the results mentioned above point to the centrality of properly assessing the different facets of intergroup attitudes towards multiculturalism as to inform public debate and contribute to prevent and counteract discrimination it is important to note that the majority of the available scales used to assess racerelated attitudes have been developed and psychometrically examined among us populations 7 these tools may not be relevant or provide validreliable estimates of racerelated attitudes in nonus contexts though given the considerable contextual dependency of racism historiographic and sociological accounts of racial dynamics usually emphasize australian specificities in terms of colonization past and contemporary immigration policies and patterns of cultural diversity as key aspects australia is a settler society that started with a policy of angloceltic migration only this was later expanded to include migrants from other europeanbackgrounds having only in the 1980s opened its borders to migrants of asian and middleeastern descent these and other specificities cast serious doubts on the idea of simply adapting tools developed in a range of different countries to the australian context just like other multiculturalist societies including canada and new zealand multiculturalism was debated at a national level as a statepolicy in the 1970s backlashes from conservative sectors nonetheless contributed to prioritise an assimilationist perspective on the implementation of multiculturalism values in society australia has also historically dispossessed and oppressed the native aboriginal australians since british colonization with ongoing effects until present 23 our study does not focus on colonisation and racism faced by aboriginal australians as the unique features of these experiences can be diminished when considered under the umbrella of multiculturalism 24 to the best of our knowledge two measurement instruments that provide information on racial ethnic and cultural acceptance have been previously developed and assessed in australia 725 while the first has focused on intercultural understanding among teachers and students in schools 25 psychometric evaluation of the second was carried out in relatively young and convenience samples of primary and secondary school students and community members which limits their applicability at a national level and among older age groups therefore neither an integrated picture of attitudes towards multiculturalism across the country has yet been delineated nor a range of strategies to advance racial equity based on this knowledge have been proposed the present study proposes the racerelated attitudes and multiculturalism scale as a measure of attitudes towards multiculturalism the items were formulated to reflect social ideologies and collective beliefs that potentially influence ethnicracial intergroup attitudes the aim of this study was to verify its applicability to the australian context by assessing the extent to which the rrams provides a valid and reliable measurement of multiculturalist attitudes in a sample of australian adults across all states and territories in particular the internal validity of the rrams was assessed in terms of its configural structure metric propertiesthe magnitude of factor loadings as well as measurement invariance external validity of the rrams was then assessed in term of its construct validity methods study design and participants this was an australian populationbased study with data obtained from the 2013 national dental telephone interview survey which includes a telephonebased interview and a followup postal questionnaire the ndtis has been carried out periodically by the university of adelaide since 1994 and comprises a large national sample of australian residents aged 5 years and over the ndtis is a random sample survey that collects information on the dental health and use of dental services of australians in all states and territories the survey also collects data on social determinants of oral health and wellbeing which include detailed information on sociodemographic factors such as household income education country of birth remoteness of location and main language spoken at home for the 2013 survey an overlapping dual sampling frame design was adopted the first sampling frame was created from the electronic product australia on disc 2012 residential an annually updated electronic listing of peoplehouseholds listed in the white pages across australia both landline and mobile telephone numbers were provided on records where applicable a stratified twostage sampling design was used to select a sample of people from this sampling frame records listed on the frame were stratified by stateterritory and region where region was defined as capital cityrest of state a systematic sample of records was selected from each stratum using specified sampling fractions 26 to include households that were not listed in the white pages a second sampling frame comprising 20000 randomly generated mobile telephone numbers was used this sampling frame was supplied by sampleworx and the mobile telephone numbers were created by appending randomly generated suffix numbers to all known australian mobile prefix numbers as the mobile numbers did not contain address information the sampling frame could not be stratified by geographic region a random sample of mobile numbers was selected from the frame and contacted to establish the main user of the mobile phone this person was asked to participate in the telephone interview provided that they were aged 18 years or over all participant provided verbal consent to participate in the survey and datasets were deidentified to ensure anonymity 26 following the completion of the telephone interview survey participants were invited to respond to the postal questionnaire component those who agreed were sent a covering letter with the questionnaire and replypaid envelope enclosed a reminder postcard was sent two weeks later with if necessary two additional followup lettersquestionnaires sent subsequent to the postcard a total of 6340 australian adults aged 18 years took part in the 2013 ndtis with 2935 completing the followup postal questionnaire sample characteristics are displayed in table 1 two thirds of the sample were 45 to 98 years old and had technical and further education or went to university women corresponded to 603 of the sample the majority of participants were born in australia 128 were originally from europe and 105 from the other continents ethical approval ethical approval for the study was granted by the university of adelaides human research ethics committee statistical analysis statistical analyses were conducted with r software 27 and r packages lavaan 28 and semtools 29 phase 1 item development the rrams was developed by a group of researchers with expertise on the topics of racism multiculturalism and racerelated attitudes in australia to ensure content validity 30 the scale was based on large surveys carried out in the country that were codesigned by the abovementioned group of researchers these include the 201516 challenging racism project 31 and the 2013 survey of victorians attitudes to race and cultural diversity 32 the initial item development phase consisted in the design of items that reflect the different social ideologies that encompass multiculturalism and racerelated attitudes discussions among the panel of experts were held until reaching consensus that the items comprehended a varied number of theoretical perspectives underpinning the construct of interest a second group of expertsnot involved in the first development phasewas then consulted for feedback purposes in relation to comprehensiveness and clarity of the items the final rrams was proposed as comprised by two subscales the first subscale included six items reflecting theories and social ideologies in agreement with anglocentricassimilationist attitudes it included items reflecting alignment with rwa agreement with sdo endorsement of colourblind racial ideology zerosum racist thinking and endorsement of assimilationist ideology the second subscale comprised six items assessing agreement with inclusivepluralistic attitudes it included low compliance to rwa low sdo acknowledgment of racism acknowledgment of white privilege enjoy an advantaged position in our society and endorsement of multiculturalism besides their theoretical relevance these constructs have been found to be acceptable and appropriate for assessing population racerelated attitudes in previous national studies in australia 3132 response options for each item ranged from strongly disagree disagree neither agree nor disagree and agree to strongly agree phase 2 identification of a potential factorial structure since the rrams was conceptualized to measure agreement with both conformity to the dominant ethnoculture and agreement with promotion of ethnic diversity an exploratory factor analysis was initially run to empirically test this assumption the factorial solution suggested by the efa was then confirmed by means of a confirmatory factor analysis 33 in an independent sample to avoid capitalization on chance 3435 we randomly divided the ndtis sample into one group for the efa and another group for the cfa see table 1 for the distribution of each subsample according to sociodemographic characteristics considering that a sample size with at least 200 participants is sufficient for efa under normal conditions 36 and cfa has higher sample requirements 271 participants from the original survey were randomly selected for the efa factor retention relied on scree plot 37 criteria and parallel analysis 38 in the pa 1000 random and resampled datasets with the same number of rrams items and respondents were generated the rationale of the pa is that meaningful factors extracted in the current study should account for more variance than factors extracted from random data 36 factor extraction was conducted with maximum likelihood 39 and oblique rotation 40 items with nonsalient factor loadings were deleted additionally 100 bootstrapped samples were used to generate factor loadings 95 confidence intervals 41 phase 3 confirmation of the factorial structure in an independent sample after a factorial structure was derived from the efa the instrument was assessed using cfa in an independent sample the estimation method was weighted least squares 42 with a meanand varianceadjusted test statistic 43 missingness of individual item responses ranged from 09 to 22 and this was handled with multiple imputation of 20 datasets using the fully conditional specification method 44 we imputed information for individuals who responded to at least one item of the rramss rubins rules 45 were used to pool point estimates and standard errors to evaluate model fit the scaled χ 2 was used to test the hypothesis of exactfit additionally we used approximate fit indices such as the scaled comparative fit index and scaled root mean squared error of approximation values of cfi � 096 and rmsea � 05 indicate good model fit 46 while 05 rmsea � 10 indicates acceptable fit 35 since factorial structures derived from efa do not necessarily imply good fitting cfa models 47 in case the factorial structure had a poor fit model respecifications were informed by standardized residuals modification indices and the standardized expected parameter change 48 completely standardized solutions were reported throughout the paper phase 4 analysis of measurement invariance an initial multigroup cfa 49 was conducted to check if the same configural structure would hold for all sex age and educationbased groupsie this was done to check whether configural invariance could be confirmed with the data at hand the χ 2 cfi and rmsea and their previously described cutoff points were used to evaluate configural invariance the second level of measurement invariance metric invariance was assessed to ascertain whether factor loadings were similar across the same groups the final test scalar invariance was used to determine whether item thresholds were equal across sex age and education given that scalar models are nested within metric models and metric models are nested within configural models metric and scalar invariance were evaluated through a likelihood ratio test namely the δ χ 2 50 the δ χ 2 statistic was computed in each imputed dataset and pooled according to li meng 51 recommendations when the δ χ 2 was statistically significant the δcfi 52 was used to evaluate the magnitude of the difference models with δcfi � 002 indicated lack of invariance 53 whenever measurement invariance was not achieved tests of partial invariance were conducted 54 phase 5 reliability internal consistency was calculated with mcdonalds o h 55 and ordinal α 56 the mcdonalds o h has two advantages over the traditional and widely used cronbachs α it does not assume tauequivalence or a congeneric model without correlated errors 57 furthermore the ordinal α is reported given that cronbachs α underestimates reliability in ordinal likert scales adequate methods for calculating ordinal α confidence intervals are not available 58 phase 6 item reduction analysis in the item reduction analysis we evaluated interitem correlations corrected itemtotal correlations and item difficulties interitem correlations indicate the extent to which all items on a scale are examining the same construct without redundancy thus interitem correlations should be moderate and items with correlations lower than 20 were considered for deletion 59 the next step was the evaluation of citc one important aspect in instrument development is achieving a good balance between a small number of items and adequate reliability a recent study by zijlmans tijmstra 61 showed that the citc 62 performed better than other methods at identifying which items can be removed while maximizing reliability therefore items with the lowest citc should be the first to be considered for removal the corrected itemtotal correlation needs to be calculated within subscales since items can only be summed into a total score when they measure the same construct 63 for this reason citcs were calculated after the factorial structure was established given the ordinal nature of the data the interitem correlations and citcs were investigated with nonparametric kendalls τ 64 finally due to the limitations of classical difficulty indices such as the pvalue 65 we evaluated item difficulty with the li irf the location index based on the itemresponse function 66 the li irf is calculated based on the item locations which are a wellknown reparameterization of item thresholds of adjacent i and i 1 response categories 67 the li irf indicates the value of the latent trait in which respondents have an average score of half the maximum item score for example in a 5point rating scale the li irf indicates the level of inclusivepluralistic attitudes required for participants to score on average 2 in our study the li irf was chosen over item thresholds to convey item difficulty because of two advantages the interpretation of the li irf is easier since it is a single index compared to four thresholds per item and more substantive since it is based on the latent trait rather than on the latent response variables 68 nonetheless for the sake of completeness we also reported the item thresholds phase 7 construct validity to evaluate the rrams construct validity we investigated knowngroups validity according to sex education and age knowngroups validity compares the levels of the constructs in different groups and should be applied when it is known theoretically or due to previous empirical research that these groups differ on the variable of interest therefore knowngroups validity can inform whether the instrument is able to discriminate between two groups that are known to be different regarding the construct investigation of knowngroups validity is important in many instances such as when there is no goldstandard method of measurement to which the instrument can be compared 69 that is since there is no goldstandard or established instrument to measure racerelated attitudes and multiculturalism in australia it is not possible to define what would constitute a good measure for the rrams to display convergent validity with furthermore in our case there is previous evidence of groups that are known to differ according to multiculturalism and racerelated attitudes for example as multiculturalism can be perceived as identitythreatening by dominant group members 1119 we expected men to have more conservative attitudes towards multiculturalism when compared to women 2270 the same pattern was expected for older participants when compared to younger respondents 227071 participants with a university degree in turn were expected to be more supportive of multiculturalism than those with lower educational attainment this hypothesis is in accordance with previous findings showing that sense of economic security higher education and younger age were associated with more positive attitudes towards multiculturalism and lesser exclusionary attitudes 227071 therefore sex age and education were chosen as the exogenous variables for the evaluation of knowngroups validity to assess knowngroups validity latent mean differences were calculated by constraining the latent means in one of the groups to zero so this group would function as a reference group considering that latent variances were constrained to one in the completely standardized solution latent mean differences are interpreted as effect sizes analogous to cohens 72 d 73 finally we employed the empirical bayes model 74 to estimate factor scores which were plotted using kernel density 75 to inform not only the average but also the distribution of the latent trait according to groups results identification of a potential factorial structure investigation of the scree plot and pa indicated that 2 factors substantially explained more variance than factors extracted from randomly generated data it should be noted that although the third factor accounted for more variance than the third factor extracted from the random datasets the difference was trivial for this reason only two factors were retained the next step consisted of the evaluation of factor loadings results showed that item 2 item 3 and item 6 did not have substantial factor loadings and were therefore excluded item 5 had the smallest factor loadings after deletion of these four items and efa reanalysis the twofactor solution achieved simple structure this time however item 5 did not achieve a substantial factor loading that is the factors explained only 19 of the variance of item responses while 81 of the variance was explained by other sources such as measurement error for this reason item 5 was also excluded from the analysis confirmation of the factorial structure in an independent sample the 2factor model was then selected and its fit examined 341070 p 0001 cfi 0974 rmsea 0083 90 ci 0076 0091 since the null hypothesis of exactfit was rejected 341070 p 0001 we proceeded with indices of approximatefit the cfi indicated a good fit to the data while the rmsea was adequate residual correlations are displayed in s2 table considering the overall good fit of the model and that all items exhibited substantial factor loadings the twofactor model with 8 items was accepted anglocentricassimilationist attitudes was regarded as the first subscale whereas the second comprised six items assessing agreement with inclusivepluralistic attitudes analysis of measurement invariance next measurement invariance by sex education and age was evaluated regarding sex the lrt indicated that the metric model was not statistically different from the configural better when scalar invariance was evaluated the pooled δ χ2 was negative for both educationand agebased groups although a negative δ χ2 is not interpretable these negative values can occur when the difference between models are small 76 for this reason the threshold constraints were regarded as tenable 77 and provided indirect support for scalar invariance reliability the first subscale anglocentricassimilationist attitudes showed good reliability while the inclusivepluralistic attitudes subscale exhibited adequate reliability item reduction analysis interitem correlations ranged from 029 to 056 and no correlations were lower than 020 the citcs ranged from 039 to 058 within the anglocentricassimilationist attitudes subscale the easiest item was we need to stop people spreading dangerous ideas and stick to the way things have always been done in australia while the hardest item was racial or ethnic minority groups take away jobs from other australians that is with respect to item 10 respondents needed to have 072 standard deviations more anglocentricassimilationist attitudes than the average australian to produce an expected score of 2 out of 4 item 10 was the hardest item in the anglocentricassimilationist attitudes subscale since its endorsement required more anglocentricassimilationist attitudes than the other items within the inclusivepluralistic attitudes subscale the easiest item was we should do what we can to create equal conditions for different racial or ethnic groups while the hardest item was people from racial and ethnic minority groups experience discrimination in australia the hierarchy of item difficulties was identical when average item thresholds were inspected construct validity examination discussion the current study aimed to present the rrams as a measure of attitudes towards multiculturalism in australia and to examine some of its psychometric properties using data from a nationwide sample results showed that the two subscales of anglocentricassimilationist attitudes and inclusivepluralistic attitudes are initially valid and reliable for the australian population in the initial stage of psychometric assessment we identified poorly performing items and these were excluded one of these was item 2 an item originally designed to reflect rwa in relation to multiculturalism despite its original purpose item 2 might not reflect the cultural and racerelated topic in question this is one possible explanation why the responses to this item were not strongly influenced by respondents inclusivepluralistic attitudes towards multiculturalism for instance the wording challenging our government can be interpreted as referring to a general debate not necessarily reflecting ethnicracial differences on political representation and resources distribution future studies might test the item fit by emphasizing challenging our government as pressuring for a political agenda that prioritizes reducing social inequalities among ethnicracial groups and promotion of a pluralistic society items 3 and 6 also performed poorly and failed to capture assimilationist views item 3 was designed to reflect respondents sdo it was hypothesized that participants with high sdo and thus assimilationist views of multiculturalism would endorse the item contrarily to expected these respondents might have interpreted the phrasing some racial or ethnic groups as a reference to ethnicracial minorities conservatives might perceive affirmative action and social assistance policies as privileges and can endorse the notion that minorities have it easy conservative attitudes such as that of rwa and sdo have been linked to social and economic conservatism reflecting ideologies of competition and meritocracy 78 the ambiguity left by the item wording can thus explain its failure in discriminating assimilationist attitudes item 6 in turn might have not worked in its subscale because again contrarily to our hypothesis respondents with high assimilationist views might be willing to discuss racial and ethnic differences with the intent of promoting assimilationist and racist views 79 therefore the item performed poorly as respondents in the different strata of assimilationist attitudes could be prone do endorse the item for different reasons the last deleted item was item 5 one possible explanation for the items poor performance is that the recognition of privilege does not necessarily informs on inclusivepluralistic attitudes for example a previous study in the australian states of queensland and new south wales showed these as two independent dimensions 9 the poor loading on the inclusive attitudes subscale suggests that respondents might not link acknowledgment of white privilege to notions of a pluralistic society taken together these results potentially indicate that debates over multiculturalism in australia need to promote awareness of the connection between angloprivilege and racism scholars advocate that challenging racism and privilege is as a necessary step towards promoting the abandonment of assimilationist views in favour of more inclusive perspectives 913 the subscales anglocentricassimilationist attitudes and inclusivepluralistic attitudes achieved metric invariance and scalar invariance according to sex furthermore the two subscales achieved metric invariance according education and the results also supported scalar invariance that is anglocentricassimilationist attitudes and inclusive pluralistic attitudes influenced the item responses the same way in each group and the items were not more difficult for one group compared to another the rrams items can thus be used to compare menwomen participants withwithout tertiary education and youngolder participants and the scores will reflect true differences regarding anglocentricassimilationist attitudes and inclusivepluralistic attitudes rather than measurement bias 35 after ensuring measurement invariance between subgroups we compared the factor scores between men and women participants with and without tertiary education and participants up to and over 45 years of age the stronger predictor of assimilationist and inclusive attitudes was education while sex also influenced both constructs furthermore older individuals were more likely to have higher assimilationist attitudes the role of education in promoting inclusivepluralistic has been previously established 2270 and suggests education as an important target for future interventions aimed at promoting multiculturalism in australia the results also indicated that men and older individuals had stronger assimilationist attitudes in comparison with women and younger counterparts 71 in general the associations of the two subscales with sex education and age conformed to the theoretical expectations and provide further evidence of the rrams construct validity with regards to reliability the anglocentricassimilationist attitudes and inclusivepluralistic attitudes subscales showed adequate reliability 80 since values between 70 and 80 are considered appropriate for research purposes 81 in case the rrams is used in the future in highstakes scenarios 82 new items should be developed to increase reliability in the item reduction analysis all items displayed moderate interitem correlations and citc so no items needed to be removed the item with the smallest citc was item 7 followed by item 4 since reliability was only modest we considered that further shortening the scale would be more detrimental in terms of reliability and content validity than beneficial as a means of creating a briefer measure in addition with the exception of item 1 and item 12 items difficulties were spread across the latent trait once again although item 1 or item 2 could potentially be removed due to similar difficulties we believe removing additional items would be detrimental to content validity and the psychometric properties of the scale one limitation of the current study was that we were not able to evaluate convergent and discriminant validity the rrams was originally applied at the 2013 ndtis a study that focused on collecting information on the use of dental services in australia and did not include other psychosocial measures for this reason we considered knowngroups validity to be the best strategy to investigate the rrams construct validity while the results from knowngroups validity were in accordance with theoretical expectations future studies need also to investigate other forms of validity such as convergentdiscriminant and predictive validity for example future studies should evaluate whether the scores from the inclusivepluralistic attitudes subscale are positively correlated with scores from other instruments evaluating multiculturalist and inclusive attitudes our analyses did not account for sampling weights meaning that our sample is not representative of the australian population it is important to highlight however that our study included australians from all age groups and socioeconomic backgrounds across all states and territories of the country furthermore to the best of our knowledge this is the largest sample in which a measure of attitudes towards multiculturalism has been employed in australia lack of representativeness and its implications to the validity of scientific findings are central to longstanding discussions in the literature 83 because the purpose of the current analysis was to assess the psychometric properties of the rrams as opposed to purely describe prevalence estimates we do not believe that the lack of representativeness of our sample limits the validity of inferences made here the fact that a study sample is representative of some larger population does not mean that the associations between variables in the sample will apply to every subgroup of the population the overall association is simply an average value that has been balanced according to the distribution of people in these subgroups if a sample that is representative of the sex distribution in the target population the results will not necessarily be apply to both males and females but only to a hypothetical participant that is weighted on sex subgroups analyses are necessary if one wishes to investigate relationships between variables by subgroups which we have performed during the criterion validity assessment stage in conclusion we successfully developed a comprehensive racerelated attitudes and multiculturalism scale to the australian context we used robust cutting edge psychometric techniques and data from a large nationwide survey the small number of items means the instrument will likely be readily used by policy makers and in ensuing research future studies should assess the scaling properties of the instrument by using parametric and nonparametric item response theory techniques the instrument may nevertheless be useful to inform on multiculturalism attitudes across the country and hopefully contribute to a public debate aimed to promote multiculturalist inclusive attitudes with the potential to increase social cohesion in australia the authors do not have permission from the ethics committee to publicly release the datasets of the 2013 ndtis in either identifiable or deidentifiedform however data is available to bona fide researchers provided that all privacy

the present study aims to develop the racerelated attitudes and multiculturalism scale rrams as well as to perform an initial psychometric assessment of this instrument in a national sample of australian adultsthe sample comprised 2714 australian adults who took part in the 2013 national dental telephone interview survey ndtis which includes a telephonebased interview and a followup postal questionnaire we used exploratory factor analysis efa to evaluate the rrams factorial structure n 271 and then proceeded with confirmatory factor analysis cfa to confirm the proposed structure in an independent sample n 2443 measurement invariance was evaluated according to sex age and educational attainment construct validity was assessed through knowngroups comparisons internal consistency was assessed with mcdonalds ω h and ordinal α multiple imputation by chained equations was adopted to handle missing dataefa indicated that after excluding 4 out of the 12 items a twofactor structure provided a good fit to the data this configural structure was then confirmed in an independent sample by means of cfa χ 2 19 341070 p 0001 cfi 0974 rmsea 0083 90 ci 0076 0091 measurement invariance analyses suggested that the rrams items can be used to compare menwomen respondents withwithout tertiary education and youngolder participants the anglocentricassimilationist attitudes ω h 083 α ordinal 085 and inclusivepluralistic attitudes subscales ω h 077 α ordinal 079 showed adequate

why are middle childhood and early adolescence so important while there may be many reasons why middle childhood is an important developmental period with respect to the relation between social status and psychological wellbeing two likely reasons for its importance are advances in cognitive development during this period that render ones social status more personally relevant to ones sense of self and increases in the size and instability of the peer network advances in cognitive development research has shown that the relationship between social status and psychological wellbeing is an indirect one and is in part mediated by the messages one receives regarding ones social status importantly the extent to which those messages are internalized is directly related to their influence on psychological wellbeing what is often overlooked is that the following three cognitive abilities must be acquired before the messages regarding ones social statuses can be internalized an awareness of the categories one belongs to the ability to perceive messages from others and society regarding the categories one belongs to and the ability to internalize membership in those categories as personally meaningful harters extensive research on the self suggests that it is not until middle childhood that youth have acquired the last of these three abilities during middle childhood and early adolescence childrens cognitive ability to use more objective criteria and interindividual comparisons for selfevaluation increases the self also becomes more objective and outward focused this newfound cognitive capacity enables youth to more fully link their attributes including the social categories to which they belong to how they actually feel about themselves increases in the size and instability of the peer network the size and instability of peer networks peak during middle childhood cairns xie leung contend that the increases in the size and instability of peer networks may be at least in part driven by changes associated with the transition to middle school which may result in greater opportunities for interaction with a wider range of peers as a consequence just when youth are beginning to base their sense of personal value on interindividual comparisons and using peers as a social mirror they are also interacting with more peers and are more likely to be interacting with those peers for the first time the combination of changes in cognition as well as changes in social context may underlie the emergence of disparities in psychological wellbeing across the levels of social status during middle childhood and early adolescence sexualminority status in terms of the emergence of disparities in psychological wellbeing it is not clear whether middle childhood is an important time period for sm as it is for race gender overweight status and ses an important question regarding sm status is as follows when does ones awareness of his or her sm status emerge is it early on in development like ones awareness of race and sex or is it later on in development like ones awareness of being a college student or a parent retrospective reports indicate that sm individuals recall being treated differently by others often as early as age 8 before they develop or are even aware of their attractions to the same sex they recall feeling different from their peers and often this sense of feeling different has a negative valence and is centered around atypical genderrelated traits retrospective reports also indicate that around the age of 10 or 11 many sm individuals recall their first awareness of attraction to the same sex thus there is some evidence to suggest that awareness of ones sm status may emerge during the middle childhood years as such just as was the case for race sex overweight status and ses the years between middle childhood and early adolescence may prove quite formative with respect to the relation between sm status and psychological wellbeing though one may acquire a vague sense of sm status during middle childhood coming to grips with ones own sexuality does not end there a subset of youth go on to realize during early adolescence that this attraction to the same sex is what society deems as homosexual and then an even smaller subset go on to actually identify themselves as homosexual or bisexual awareness of sexualminority status is a prerequisite for others messages regarding sexual minorities to be internalized as personally meaningful and the period when ones awareness of his or her sm status appears to form extends into late adolescence or even early adulthood thus the relation between sm status and psychological wellbeing may itself be in flux through late adolescenceearly adulthood complicating things further is the possibility that growing awareness of ones sm status during adolescence will be accompanied by social isolation as well as victimization and stigmatization in both the school and the home many sm adolescents report feeling invisible and have a difficult time finding other sm adults to confide in or other sm peers with whom to socialize beyond feeling a level of invisibility sm adolescents also face a disproportionate amount of peer harassment bullying and aggression from their nonminority peers thus at a time when sm adolescents are coming to grips with their status they are typically doing so alone perhaps in the face of heightened harassment and aggression as a consequence the influence of sm status on psychological wellbeing may prove stronger between midto lateadolescence than between middle childhood and early adolescence moderators of sexualminority status and psychological wellbeing available crosssectional research has identified three factors that moderate the relation between sm status and psychological wellbeing sexual identification or orientation age of first awarenessdisclosure and gender status importantly to date the extent to which if at all these factors moderate the relation between sm status and growth in psychological wellbeing is unknown sexual identification while all those that exhibit samesex sexuality share the status of sm they vary dramatically as to whether or not they hold a sm identity as well as the nature of that identity if any among those exhibiting samesex sexuality some identify as heterosexual some as homosexual and others as bisexual this heterogeneity in identification among those who exhibit samesex sexuality could have implications for the relation between sm status and psychological wellbeing for example researchers who conceptualize sexualidentity formation as a progression through a set of stages have found among sm that those in the later stages report higher psychological wellbeing than do those in the earlier stages researchers have also found among those who identify as bisexual or homosexual acceptance of ones sexual identity is positively related to mental health finally there is some evidence to suggest that relative to those who identify as homosexual those who identify as bisexual may be at higher risk for deficits in psychological wellbeing age of first awarenessdisclosure the research above indicates that coming to terms with ones sexual orientation and integrating it within ones sense of self is associated with higher psychological wellbeing however the extent to which this is the case may vary with age there are risks associated with disclosing your sexual orientation to others such as increased victimization the disruption of close personal relationships and heightened disapproval from others for some these risks can outweigh the benefits of coming to terms with ones sexual orientation emerging research suggests that one factor related to whether or not the risks outweigh the benefits is age of first awareness or disclosure for example relative to those who progress through these milestones at a later age those who are aware of their samesex attractions or disclose their sexual orientation at younger ages report experiencing more gayrelated discrimination bullying and disrupted relationships during adolescence and they generally have fewer resources both interpersonal and intrapersonal to cope with these threats the increase in threats coupled with the decrease in sources of support is thought to translate into lower psychological wellbeing among those who progress through these milestones at an earlier age in fact friedman et al found that relative to those who were first aware of samesex attractions at an older age those who were first aware at an earlier age reported lower psychological wellbeing and physical health during adulthood gender the relation between gender and psychological wellbeing appears to be muted among the sexualminority population that is relative to the general population where females tend to report lower levels of psychological wellbeing than males the gender differences within the sm population are diminished or absent hypotheses and key questions though this study was partly exploratory in nature the following hypotheses guided our examination 1a by early adolescence we expected sm youth to report lower levels of psychological wellbeing than those of sexualmajority status 1b disparities in psychological wellbeing among sm and sexualmajority individuals were predicted to increase during adolescence by comparing the size of disparities at early adolescence to the extent if any that those disparities increase over adolescence we evaluated the relative influence of middle childhood and adolescence on the relation between sm status and psychological wellbeing 2 among those of sm status we expected those of bisexual status to report lower psychological wellbeing at the onset of adolescence as well as lower growth in wellbeing across adolescence 3a in terms of initial status differences and growth differences we expected earlier awareness of samesex attractions to be associated with lower psychological wellbeing and 3b we expected that the disparities in psychological wellbeing between sm and nonsm would be larger among those sm reporting earlier awareness of samesex attractions in terms of both intercept differences and growth differences we expected psychological wellbeing disparities between sm and nonsm to be more pronounced among males methods sample the data for this study came from the national longitudinal study of adolescent health a multiwave nationally representative sample of american adolescents using a clustered sampling design 80 high schools were recruited for participation the sample of schools was stratified by region urbanicity school type ethnic mix and size at the point of initial assessment the total sample was 20745 7 th 12 th graders two additional waves of data are available each taking place approximately one and six years later the sample and retention rates for each wave are 14988 and 15170 respectively for the present study only those respondents who completed a sexual orientation measure at wave 3 completed samesex attraction measures at waves 1 2 and 3 had data for age and were assigned a sample weight were included in the study with respect to psychological wellbeing respondents included in the study reported slightly lower levels of depression at wave 1 t 244 p 05 and wave 3 t 396 p 001 than those not included in the study those included in the study also reported slightly higher levels of selfesteem at wave 1 t 299 p 01 and wave 2 t 310 p 01 in every case where differences in psychological wellbeing were found effect sizes were small finally males 7528 p 001 and those in the older cohort 1808 p 001 were underrepresented among those included in the study among those included in the study the amount of missing data on the psychological wellbeing indices was low in order to maximize the data and include all possible cases we used full information maximum likelihood estimation a missing data algorithm available within mplus procedure the first wave of data was collected during 1994 and 1995 via inhome questionnaires the questionnaires covered a range of topics health status nutrition peer networks family composition and dynamics romantic partnerships sexual partnerships and risk behavior approximately a year later respondents completed a second inhome questionnaire that was similar in content approximately six to seven years after initial assessment respondents completed a third inhome questionnaire one that was similar in content to the first but also covered such topics as romantic relationships childbearing and educational histories measures psychological wellbeingwe focused on two indices of psychological wellbeing depressive affect and selfesteem depressive affect was based on a 9item truncated version of the cesd an example item is during the past week have you been bothered by things that usually do not bother you the possible range was from 0 to 3 with higher responses indicating higher levels of depressive affect cronbach alphas were 79 79 and 80 for waves 1 2 and 3 respectively selfesteem was based on a 4item scale used previously by regnerus elder an example item is you like yourself just the way you are the possible range was from 1 to 5 with higher responses indicating higher levels of selfesteem cronbach alphas were 83 81 and 79 for waves 1 2 and 3 respectively sexual orientation and sexualminority statusbased on the distinction between sm status and sexual orientation we classified individuals into one of four groups classification was based on a single question that was asked at wave 3 only please choose the description that best fits how you think about yourself the possible responses were 100 heterosexual mostly heterosexual but attracted to people of your own sex bisexual that is attracted to men and women equally mostly homosexual but somewhat attracted to people of the opposite sex 100 homosexual and not sexually attracted to either males or females all those who indicated no sexual attraction were dropped from analyses as were those who refused to answer the question all who identified themselves as 100 heterosexual were classified as heterosexualidentifiednonsm all who indicated some level of samesex sexuality qualified as a sm of these individuals those who identified as gay were classified as homosexualidentifiedsm those who identified as bisexual were classified as bisexualidentifiedsm and those who identified as straight but indicated an attraction to the same sex were classified as heterosexualidentifiedsm instability of reported samesex attractionsat wave 1 respondents were asked two yesno questions have you ever had a romantic attraction to a female and have you ever had a romantic attraction to a male for waves ii and iii respondents were asked the same questions but were asked to indicate if they experienced these attractions since the last time they were interviewed using the reported samesex attraction associated with ones wave 3 sexual orientation as the reference point we created three dummy variables to assess instability in samesex attraction one for each wave among those who indicated a sexual orientation at wave 3 that included samesex attractions a report at any given wave of no samesex attractions was coded as 1 and a report of samesex attractions was coded as 0 the opposite pattern was true for heterosexualidentifiednonsm for this group a report of samesex attractions at any given wave was coded as 1 while a report of no samesex attraction was coded as 0 in concrete terms relative to the reported samesex attraction associated with ones wave 3 sexual orientation these dummy variables were an indication of inconsistency in reported samesex attraction with 1 indicating inconsistency and 0 indicating consistency the wave 3 instability dummy variable likely reflected confusion or measurement error either in the wave 3 sexual orientation measure or the wave 3 questions pertaining to attraction to each sex in contrast the wave 1 and 2 instability dummies may have reflected developmental changes or instability in awareness of andor willingness to report samesex attractions for example among those reporting a sexual orientation at wave 3 that includes samesex attractions those who also reported samesex attractions at waves 1 andor 2 may have become aware of their samesex attractions at an earlier age than those who did not report samesex attractions at waves 1 and 2 consistent with previous research preliminary analyses revealed that the independent influence of instability in reported samesex attractions at waves 1 and 2 on psychological wellbeing was modest and nonsystematic however additional preliminary analyses indicated that instability in samesex attractions at both waves 1 and 2 was strongly predictive of psychological wellbeing the influence of instability at waves 1 or 2 was modest and the influence of instability at wave 3 was often nonsignificant based on these preliminary findings we chose the three following dummy variables instability at waves 1 and 2 versus all others instability at waves 1 or 2 versus all others and instability at wave 3 versus all others when each of these dummy variables were included as controls the reference group became those who reported samesex attractions over time that were consistent with their wave 3 sexual orientation and the samesex attractions that they reported along with that sexual orientation cohortalthough age at wave 1 ranged between 12 and 20 years of age over 95 of the sample ranged between 13 and 18 we dichotomized the sample so that we could more closely examine how the relation between sm status and psychological wellbeing varied across adolescence a dichotomous cohort variable was created those between the ages of 12 and 15 were classified as young whereas those between the ages of 16 and 20 were classified as old gender status was based on selfreport respondents indicated whether they were male or female nihpa author manuscript nihpa author manuscript nihpa author manuscript results basic descriptive statistics the means standard deviations sample size and relative percentage for each of the four sexual orientation groups are listed in table 1 the percentages and frequencies for unstable and stable reports of samesex attractions are listed in table 2 patterns of samesex attraction across waves 1 and 2 are listed in the first three columns in the sample as a whole 831 reported samesex attractions at both waves 1 and 2 that were consistent with the samesex attractions associated with the sexual orientation that they reported at wave 3 the remaining 169 of respondents reported wave 1 and wave 2 samesex attractions that were inconsistent with the sexual orientation they reported at wave 3 87 were inconsistent at both waves and 82 were inconsistent at only a single wave generally instability in these factors was higher among those of sm status wave 3 patterns of samesex attractions are listed in the last two columns of table 2 in the sample as a whole 943 reported samesex attractions at wave 3 that were consistent with the sexual orientation that they reported at wave 3 the remaining respondents reported samesex attractions that were inconsistent generally instability in these factors was higher among the heterosexualidentifiedsm group the last column of table 2 lists those who reported samesex attractions across all three waves that were consistent with the sexual orientation that they reported at wave 3 sexual orientation at wave 3 and adolescent trajectories of psychological wellbeing in order to examine adolescent trajectories of psychological wellbeing we used the growth curve model presented in figure 1 the factor coefficients for the linear slope were set at 0 1 and 65 because the average time between waves 1 and 2 was 1 year and the average time between waves 1 and 3 was 65 years the intercept factor measured initial levels of psychological wellbeing whereas the slope factor measured linear change in psychological wellbeing across waves 1 2 and 3 we used multiplegroup analyses to examine model differences across the four sexual orientation subgroups all analyses were conducted within mplus version 52 in order to account for add healths sampling design we included a stratification variable and used a maximum likelihood estimator that is robust to the estimate of standard errors as suggested by the administrators of add health when using mplus all multigroup comparisons were based on χ 2 differences tests when we conducted multigroup comparisons only the model parameter of focus was constrained to be equal across the groups unless otherwise specified all other model parameters were free to vary across groups because ordinary χ 2 difference tests cannot be computed when using a robust maximum likelihood estimator differences in model fit were tested via the equations provided by satorra and bentler due to space constraints fit indices are not presented for each growth model though in every case the fit was excellent depressive affectpertinent results are listed in the first two columns of table 3 among the entire sample intercept levels of depressive affect were low and growth in depressive affect was negative intercept levels of depressive affect were equivalent across the three sm groups δχ 2 342 p 84 however collectively the three sm groups reported higher intercept levels of depressive affect than heterosexualidentifiednonsm δχ 2 27717 p 001 among the three sm groups growth of depressive affect was more negative among the bisexualidentifiedsm and homosexualidentifiedsm groups than it was among the heterosexualidentifiedsm group δχ 2 427 p 05 also only the heterosexualidentifiedsm group differed from the heterosexualidentifiednonsm group δχ 2 5052 p 05 in sum at intercept the three sm groups did not differ from one another but they collectively reported higher levels than heterosexualidentifiednonsm for heterosexualidentifiedsm these initial differences increased over time but for homosexualidentifiedsm and bisexualidentifiedsm these differences remained stable over time selfesteemin the sample as a whole intercept levels of selfesteem were high and growth in selfesteem was positive but moderate intercept levels of selfesteem were equivalent across the three sm groups δχ 2 790 p 67 however collectively the three sm groups reported lower intercept levels of selfesteem than did heterosexualidentifiednonsm δχ 2 9405 p 001 with respect to growth in selfesteem none of the four sexuality groups differed from one another the influence of instability in reported samesex attractionsthe above analyses suggested that reported sexual orientation during early adulthood was associated with psychological wellbeing during adolescence next we examined whether instability in reported samesex attractions was related to adolescent patterns of psychological wellbeing and whether that instability influenced the relation between declared sexual orientation at wave 3 and psychological wellbeing during adolescence we did so by repeating the analyses above but including the following instability dummy variables as exogenous predictors of each growth factor unstable at waves 1 and 2 unstable at wave 1 or 2 but not both and unstable at wave 3 by including these dummy variables in the growth model the reference group among the sm groups became those who reported stable samesex attractions across all three waves and the reference group among the heterosexualidentifiednonsm group became those who consistently reported no samesex attractions the influence of the three instability dummy variables on each psychological wellbeing growth factor is presented in table 4 based on multigroup analyses the relation between the instability dummy variables and depressive affect did not differ across the three sm groups however the relation did differ between the sm groups and heterosexualidentified nonsm the same was true for selfesteem consequently in table 4 the results are listed for heterosexualidentified nonsm and for the three sm groups combined but they are not listed separately for each of the three sm groups focusing first on sm in reference to those who persistently reported samesex attractions at all three waves those who reported no samesex attractions at waves 1 and 2 reported higher psychological wellbeing at intercept however they reported smaller increases in psychological wellbeing over time among heterosexualidentifiednonsm the relation between instability in reported samesex attractions was much more muted with those reporting samesex attractions at both waves 1 and 2 reporting lower depressive affect at intercept controlling for instability in reported samesex attractions did alter the relation between reported sexual orientation at wave 3 and adolescent psychological wellbeing pertinent results are in the third and fourth columns of table 3 concerning depressive affect intercept levels among the heterosexualidentifiedsm group and the bisexualidentified sm group were equivalent δχ 2 265 p 11 collectively however they were higher than levels of depressive affect among both the homosexualidentifiedsm group δχ 2 406 p 05 and the heterosexualidentifiednonsm group δχ 2 35896 p 001 in addition the homosexualidentifiedsm group reported higher intercept levels than the heterosexualidentifiednonsm group δχ 2 16341 taken together at intercept the heterosexualidentifiednonsm group reported the lowest depressive affect followed by the homosexualidentifiedsm group followed by the heterosexualidentifiedsm and bisexualidentifiedsm groups who reported equivalent levels to one another as well as the highest levels overall growth in depressive affect was equivalent across the three sm groups δχ 2 1141 p 56 however declines in depressive affect over time were more evident among the sm groups than among the heterosexualidentifiednonsm group δχ 2 3879 p 001 there were fewer group differences in selfesteem at intercept the three sm groups reported equivalent levels of selfesteem δχ 2 291 p 23 but collectively they reported lower levels of selfesteem than the heterosexualidentifiednonsm group δχ 2 6784 p 001 there were no group differences in the growth of selfesteem summarywave 3 sexual orientation was associated with psychological wellbeing it appeared to have a stronger relation with intercept levels than with growth with sm reporting lower psychological wellbeing at intercept among the sm groups early and stable reporting of samesex attractions was associated with lower initial levels of psychological wellbeing but greater increases in psychological wellbeing over time within the heterosexualidentifiednonsm group early and stable reporting of no samesex attractions was associated with lower initial levels of depressive affect relative to cases of unstable samesex attractions the relation between wave 3 sexual orientation and adolescent depressive affect was different among those who reported stable samesex attractions specifically after controlling for instability in reported samesex attractions the discrepancy between sm and heterosexualidentifiednonsm was larger at the intercept however sm also reported greater increases in psychological wellbeing over time relative to heterosexualidentifiednonsm thus relative to those reporting unstable sexual attractions over time among those reporting stable sexual attractions over time the initial gap in psychological wellbeing between sm and heterosexualidentifiednonsm was larger however that gap also closed at a faster rate over time sexualminority status and psychological wellbeing cohort and gender differences building on earlier analyses we next examined whether the relation between samesex sexuality and psychological wellbeing varied across cohort and gender preliminary analyses indicated that cohort differences and gender differences in psychological wellbeing were equivalent across the three sm groups consequently for this portion of the analyses we did not distinguish between the individual sm groups but instead compared all sm to the heterosexualidentifiednonsm group cohortin order to examine differences across cohort we used a cohortbysmstatus grouping variable that broke respondents into four groups young heterosexualidentifiednonsm old heterosexualidentifiednonsm young sm and old sm when using this grouping variable we used the model constraint command within mplus which allows for the creation of new model parameters based on mathematical operations involving already existing model parameters using the model constraint command we created four new model parameters a young intercept difference score minus an old intercept difference score minus a young growth difference score minus and an old growth difference score minus note that these difference scores represented the model factor for sm relative to the model factor for heterosexualidentifiednonsm thus a negative value indicated that the sm factor was lower whereas a positive value indicated that the sm factor was higher through a series of focused model comparisons we examined whether these difference scores varied across the young and old cohorts specifically based on χ 2 difference tests we compared the fit of a model where the young intercept difference score and the old intercept difference score were constrained to be equal to the fit of a model where they were not constrained to be equal we conducted a similar model comparison for the young growth difference score and the old growth difference score we used this approach because it allowed for the examination of a twoway interaction while allowing the relation between instability in reported samesex attractions and psychological wellbeing to vary across groups we conducted analyses with and without controlling for instability in reported samesex attractions we examined differences in depressive affect and selfesteem in separate models results are listed in table 5 where significant differences are indicated by a superscripted number when not controlling for instability in reported samesex attractions the young growth difference score was larger than the old growth difference score δχ 2 617 p 05 among the young cohort growth in depressive affect was more positive among sm than among heterosexualidentifiednonsm among the old cohort however growth in depressive affect was equivalent across the two groups preliminary analyses revealed that the relation between instability in reported samesex attractions and both depressive affect and selfesteem was equivalent across cohort for heterosexualidentifiednonsm for sm we found that the relation between instability in reported samesex attractions was equivalent across cohort for depressive affect but it varied across cohort for selfesteem the relation was more pronounced among the young cohort as shown in table 6 based on these preliminary findings we constrained the relation between instability in reported samesex attractions and psychological wellbeing to be equal across cohort as in earlier analyses we allowed the relation between instability in reported samesex attractions and psychological wellbeing to vary across heterosexualidentifiednonsm and sm when controlling for instability in reported samesex attractions the relation between sm status and depressive affect did not vary across cohort however for selfesteem the intercept difference score δχ 2 713 p 01 and the growth difference score δχ 2 514 p 05 were much larger among the young cohort and only among the young cohort were these difference scores significantly different from zero more specifically only among the young cohort did those of sm status have relative to heterosexualidentifiednonsm lower selfesteem at intercept but greater increases in selfesteem over time genderin order to examine genderbysm differences we used the same analytic strategy that we used to examine cohortbysm status differences except that we used a different grouping variable the genderbysm status grouping variable broke respondents into four groups male heterosexualidentifiednonsm female heterosexualidentifiednonsm male sm and female sm results are listed in table 5 again significant differences in difference scores are indicated by a superscripted number in table 5 when not controlling for instability in reported samesex attractions depressive affect growth difference scores were not equivalent among males and females δχ 2 436 p 05 more specifically among females growth in depressive affect was more positive among sm than among heterosexualidentifiednonsm among males however growth in depressive affect did not differ across heterosexualidentifiednonsm and sm the relation between sm status and selfesteem did not vary across gender preliminary analyses revealed that the relation between instability in reported samesex attractions and both depressive affect and selfesteem was equivalent across gender for heterosexualidentifiednonsm however the relation between instability in reported samesex attractions and both depressive affect and selfesteem varied across gender the relation was more pronounced among males as shown in table 6 the relation between instability in reported samesex attractions and psychological wellbeing was thus constrained to be equal across gender for heterosexualidentifiednonsm and was allowed to vary across gender for sm again we allowed the relation to vary across heterosexualidentifiednonsm and sm as well when controlling for instability in reported samesex attractions the relation between sm status and psychological wellbeing did not vary across gender summarythe relation between sm status and psychological wellbeing varied across both cohort and gender in the case of depressive affect patterns evident among the entire sample when instability controls were not included were more evident among those in the young cohort and females however in the case of selfesteem patterns found among the entire sample were more evident among the young cohort a pattern that was not evident among the entire sample emerged as well among the entire sample there was no instance when growth in selfesteem varied across any of the sexual orientation groups however among the young cohort growth in selfesteem was more positive among sm growth in selfesteem was equivalent across sm status among the old cohort this differential growth pattern across cohort only emerged when controls for instability in reported samesex attractions were included finally the relation between early and stable reports of samesex attractions and psychological wellbeing was more pronounced among males discussion overall four main conclusions can be drawn from this study psychological wellbeing disparities between sm and nonsm are in place by early adolescence and then for many the remainder of adolescence is a recovery period when the disparities narrow over time early and stable reporting of samesex attractions is associated with a greater initial deficit in psychological wellbeing but because it is also associated with a quicker recovery over time the effects are often not long lasting though the relation between sexual orientation during early adulthood and adolescent psychological wellbeing was quite similar across gender the negative relation between psychological wellbeing and early stable awareness of samesex attractions was more pronounced among males relative to bisexual and homosexualidentifiedsm the understudied yet relatively sizable group of heterosexualidentifiedsm appeared to be at equal risk for deficits in psychological wellbeing what does sexual orientation during early adulthood mean for adolescence before discussing the findings we will address some implications that the studys measure of sexualminority status might have for the conclusions that can be drawn the measure of sexual minority status was based on a measure of sexual orientation during early adulthood thus the measure of sexual orientation was a static measure that failed to account for the fluidity of sexual identification over time nonetheless the measure was linked with indicators of psychological wellbeing that predated it by over six years while ones declared sexual orientation during early adulthood may not be indicative of ones sexual orientation during adolescence it is likely indicative of whether one dealt with samesex sexuality during some point of adolescence it is also likely indicative of the importance or primacy of that samesex sexuality within ones overall sense of adolescent sexuality for example while both those who identified as homosexual and bisexual during early adulthood likely dealt with samesex attractions during adolescence for those who identified as homosexual during early adulthood those adolescent samesex attractions may have been a more important or central component of their adolescent sexuality importantly though a rough indication the measures of samesex attraction during adolescence help to narrow when during adolescence these individuals were first dealing with this samesex sexuality thus when paired together the adolescent measures of samesex sexuality and the early adulthood measure of sexual orientation provide among a large national longitudinal sample a meaningful account of sexuality as well as emerging awareness of that sexuality the emergence of the negative relation between sm status and psychological wellbeing the driving motivation for this study was to examine whether the negative relation between sm status and psychological wellbeing is similar to that of other social statuses where differences are primarily in place by early adolescence or continues to emerge through the adolescent years when sm are thought to encounter unique developmental challenges the findings suggest that the negative relation between sm status and psychological wellbeing is largely in place by early adolescence this is evidenced by the fact that among both the young and old cohorts and regardless of adolescent patterns of reported samesex attractions the discrepancies in psychological wellbeing were largest at the studys onset moreover middle childhood and early adolescence appear to be more of a struggle for those who report early and stable samesex attractions since by early adolescence these individuals report the greatest deficits in psychological wellbeing relative to heterosexualidentifiednonsm across adolescence the negative relation between sm status and psychological wellbeing either remained stable or decreased among those who reported early and stable samesex attractions the negative relation between sm status and psychological wellbeing decreased across time importantly among the young cohort this pattern held true for both depressive affect and selfesteem this finding suggests that for those who reported early stable samesex attractions the negative relation between sm status and psychological wellbeing decreased across time even among those who were early adolescents at the onset of the study when ignoring samesex attractions and focusing on early adulthood sexual orientation the relation between sm status and psychological wellbeing was stable across time except for two instances the first exception was among the whole sample where the negative relation between heterosexualidentifiednonsm and heterosexualidentifiedsm increased across time this pattern held only for depressive affect and it was likely due to the fact that heterosexualidentifiedsm were the group most likely to report unstable samesex attractions these types of attractions in turn were associated with less of an increase in psychological wellbeing across time the second exception was among the young cohort where the negative relation between sm status and psychological wellbeing increased across time again this pattern held only for depressive affect and only for those reporting unstable samesex attractions as noted above this pattern was reversed when controlling for instability in reported samesex attractions taken together the negative relation between sm status and psychological wellbeing generally did not become more pronounced across adolescence to the contrary it either remained stable or even decreased among those who reported early and stable samesex attractions why is the negative relation in place by early adolescence most of the challenges associated with being a sexual minority are confronted over the course of adolescence not prior to it the relation between declared sexual orientation during early adulthood and psychological wellbeing seems to manifest by early adolescence and does not increase thereafter which speaks to the deleterious effects of feeling different from others during middle childhood and early adolescence though individuals must deal throughout the lifespan with being members of devalued groups and the sense of difference that accompanies those memberships middle childhood is the first time individuals are confronted with this sense of difference after all it is not until middle childhood that youth are cognitively capable of internalizing this sense of difference as meaningful to their own personal sense of value consequently they likely have not yet acquired the tools for dealing with this sense of difference as a result those in middle childhood may be more likely to have their sense of wellbeing negatively influenced by that sense of difference potentially compounding the deleterious effects of this sense of difference during middle childhood is the fact that unlike individuals of other stigmatized groups sm often deal with this sense of difference in isolation since those around them are predominantly if not completely of the sexual majority contrast this to other youth of atrisk social status such as females or members of racial minorities who are likely to have role models in the home or at school as well as peers and friends who share their status and likely have parents or extended family members actively socializing them to deal with the challenges associated with their social status finally the initial deficits may be larger among those sm reporting early and stable samesex attractions because they are more likely to be dealing with this novel sense of difference at an even earlier age an age at which they are even more likely to be isolated from others in the sm community who recovers and why the negative relation between a declared sexual orientation during early adulthood that includes samesex attractions and adolescent psychological wellbeing did decrease across adolescence but only for a select group the recovery or narrowing of psychological wellbeing deficits between sm and heterosexualidentifiednonsm was limited to those who reported early and stable samesex attractions in the case of selfesteem the recovery was limited to the young cohort those who ranged between 12 and 15 at the onset and between 18 and 23 at the conclusion of the study why the recovery was limited to those who reported early stable samesex attractions requires further examination but we offer two possible explanations first sm who reported early stable samesex attractions had farther to recover that is relative to heterosexualidentified nonsm sm who reported early and stable samesex attractions reported far lower initial levels of psychological wellbeing than did sm who did not report early and stable samesex attractions second sm who reported early and stable samesex attractions may have benefited from having longer to adjust to their status and incorporate it into their sense of self regardless of the reason it seems that the earlier the awareness of samesex attractions the greater the initial deficit in psychological wellbeing but also the steeper the recovery this pattern of recovery among those reporting early stable samesex attraction is inconsistent with friedman et als findings that those progressing through gayrelated developmental milestones at earlier ages tended to report lower functioning during adulthood respondents included in the friedman et al study were teenagers in the early to mid 1980s whereas respondents in add health were teenagers in the mid to late 1990s perhaps historical increases in the acceptance of homosexuality have contributed to reductions in the longterm consequences of an early awareness of samesex sexuality in cases where there was a recovery such recovery was generally not complete sm still reported deficits in psychological wellbeing during early adulthood those deficits were simply smaller than they were during early adolescence with and without controls for instability in reported samesex attractions posthoc comparisons of wave 3 psychological wellbeing revealed that each of the three sm groups sill reported lower psychological wellbeing relative to the heterosexualidentifiednonsm group the only exception was among homosexualidentifiedsm who reported early and stable samesex attractions this group reported wave 3 levels of depressive affect that were equivalent to heterosexualidentifiednonsm overall lack of gender differences the relation between sexual orientation during early adulthood and adolescent psychological wellbeing was largely equivalent across gender there was however a gender difference in the negative relation between early and stable reports of samesex attractions and initial levels of psychological wellbeing with the negative relation proving more pronounced among males as noted in the introduction previous research has found that the negative relation between sm status and psychological wellbeing is more pronounced among males this studys findings suggest a more nuanced pattern instead of the relation between sexual orientation and psychological wellbeing being more pronounced among males it may be that an early awareness of ones samesex attractions has a more detrimental impact on males than females for the most part the relation between early awareness and growth of psychological wellbeing did not vary across gender suggesting that these effects persist into early adulthood early awareness may be more problematic for males because sexuality as well as gender roles are generally more rigid among males and because relative to females exhibiting samesex sexuality males exhibiting samesex sexuality are more likely to be victimized by members of their own gender limitations this study has several important limitations the first being the limitations of our measure of sexual orientation as discussed earlier a second limitation is that the sample sizes of the smsub groups were likely not sufficiently large to capture small to modest effects this may be why the present study found few psychological wellbeing differences among the three sm groups finally the earliest data available in add health are from early adolescence ideally the data would extend back into middle childhood unfortunately preadolescent data on the sm community are difficult to obtain in part because parents and guardians tend to be wary of researchers asking their preadolescent children questions pertaining to sexuality conclusions and next steps sexual minorities or those exhibiting samesex sexuality are a heterogeneous group who vary not only in sexual orientation but also in the developmental course they follow in terms of their awareness and acceptance of their sexual orientation among those exhibiting samesex sexuality there also is heterogeneity in terms of developmental patterns of psychological wellbeing across adolescence trajectories of psychological wellbeing converge such that by early adulthood those exhibiting samesex sexuality look more similar to both one another and those not exhibiting samesex sexuality in developmental science this phenomenon is termed equifinality multiple pathways to the same end point this pattern of findings highlights the important contributions that developmental theory and longitudinal data can make to our understanding of samesex sexuality sexual orientation and psychological wellbeing more specifically the pattern of results suggests that the negative relation between sm status and psychological wellbeing is in place by early adolescence and the exact pathway or trajectory that one follows across adolescence is more a function of the timing of awareness of same sex attractions than it is of actual sexual orientation these results raise the possibility that community resources and social support groups geared towards sm youth now available in many highschools may benefit students in grade school and middle school as well finally findings from this study are consistent with emerging research suggesting that relative to those who identify as a sm heterosexualidentifiedsm an understudied though sizable subgroup of the sm population who comprise about 8 of the overall population and about 80 of the sm population are at relatively equal risk for deficits in psychological wellbeing future research should incorporate this subgroup when possible growth model examining psychological wellbeing across 3 waves 617 p 05 2 δχ 2 713 p 01 3 δχ 2 517 p 05 4 δχ 2 436 p 05 table 6 among sm the relation between reported instability in samesex attractions and psychological wellbeing by cohort and gender

emerging research has shown that those of sexualminority sm status ie those exhibiting samesex sexuality report lower levels of psychological wellbeing this study aimed to assess whether this relation is largely in place by the onset of adolescence as it is for other social statuses or whether it continues to emerge over the adolescent years a period when sm youth face numerous challenges moreover the moderating influence of sexual orientation identification early versus later reports of samesex attractions and gender were also examined using data from add health multiplegroup latent growth curve analyses were conducted to examine growth patterns in depressive affect and selfesteem results suggested that psychological wellbeing disparities between sm and nonsm were generally in place by early adolescence for many the remainder of adolescence was a recovery period when disparities narrowed over time early and stable reporting of samesex attractions was associated with a greater initial deficit in psychological wellbeing especially among males but it was also associated with more rapid recovery independent of the timing and stability of reported samesex attractions over time actual sexual orientation largely failed to moderate the relation between sm status and psychological wellbeing importantly the sizable yet understudied subgroup that identified as heterosexual but reported samesex attractions appeared to be at substantial risk

introduction health is defined not only as the absence of disease and disability but also as a state of complete physical mental and social wellbeing 1 psychosocial economic and cultural factors and adequate utilization of health services are important in achieving and maintaining wellbeing 2 the number of refugees and asylum seekers in the world is increasing in 2022 1126 million people in the world were in the group defined as refugees or asylum seekers 3 more than 35 million syrian refugees live in turkey health problems are more common in migrants 4 in addition the psychosocial and economic conditions of migrants and the language barriers they face negatively affect their health status as their search for health services remains limited 2 migration experience and cultural factors affect migrants perception of drugs and antibiotics and unconscious drug use is common among migrants 56 antibiotic resistance is one of the most important global public health threats worldwide in particular unconscious and improper use of antibiotics accelerates the development of resistance which affects the success of treatment of infectious diseases and the duration of hospitalization leading to an increase in healthrelated costs and mortality rates 78 rational use of drugs especially antibiotics is an important factor that prevents morbidity and mortality related to diseases 9 inadequate health literacy selfmedication and overthecounter medication supply are important factors leading to widespread and uncontrolled use of drugs 10 interventions in turkey have shown that educational activities are effective in improving the prescription distribution and utilization of antibiotics 11 12 13 health literacy is defined as the knowledge and cognitive and social competence required for individuals to access understand evaluate and use healthrelated information to protect and improve their health make decisions about their health status and improve their quality of life 1415 health literacy is an important public health goal that also refers to the state and competence of individuals to meet complex health needs 16 17 18 challenging living conditions cultural factors language barriers the complex and multidimensional structure of the health system and social and economic disadvantages negatively affect migrants search for and utilization of health services and their health in general 15 the fact that information sources in health are diverse and information is dense has made the internet an important resource for accessing the right information for health the internet is a useful and effective tool for accessing accurate healthrelated information and developing various skills to protect and improve health 19 ehealth literacy refers to an individuals ability to search find understand and evaluate healthrelated information from digital sources and use it for any health condition andor problem 11819 various studies with migrants have shown that their health literacy levels are inadequate and problematic 2021 immigration is an important social determinant of health related to access to health services utilization of health services health perception and health literacy 2022 health literacy is of critical importance in eliminating health inequalities and increasing the health levels in society 21 the health literacy levels of individuals is an important and determining factor in rational drug use therefore efforts to increase the health literacy level of immigrants will contribute greatly to increasing their knowledge about rational drug use and developing positive attitudes in this study it was aimed to determine the rational drug use and health literacy levels of syrian adults living in a district of istanbul and to examine the related factors results the mean age and sd value of the research group was 3919 ± 1310 in this study 522 of the participants were female and 478 were male it was determined that 465 of the immigrants in the research group were in the age group of 40 and above 769 were married 530 had high school and higher education 804 had low income 640 had been living in turkey for 7 years or more 714 lived in the same house with 5 or more people 365 had chronic diseases 609 used regular medication and 871 applied to a physician in the first place when they got sick data on the sociodemographic characteristics and diseasehealth status of the research group are shown in table 1 in this study 970 of the immigrants in the research group stated that medication should only be used when prescribed by a doctor furthermore 937 stated that people should not keep antibiotics in their homes and then use them for other diseases in total 961 stated that physicians should prescribe antibiotics only when needed and 758 stated that using enough medication not too much leads to recovery data on immigrants attitudes and approaches to rational drug use are shown in table 2 the eheals mean and sd value of the immigrants was 2057 ± 726 it was determined that 803 of the immigrant group had limited health literacy and 197 had adequate health literacy data on the ehealth literacy scale scores are shown in table 3 in the study group the mean ranking of eheals was significantly higher in immigrants who were in the 3039 age group married had low income had been living in turkey for 7 years or more did not have chronic diseases did not use regular medication and had a monthly outofpocket health expenditure of less than 500 tl the comparison of sociodemographic and healthdisease status with eheals is shown in table 4 among the independent variables age group gender education level and regular medication use were found to contribute significantly to the model the regression analysis of health literacy level according to sociodemographic characteristics is shown in table 5 discussion socially and economically disadvantaged migrants are one of the groups that should be prioritized for public health interventions it is important to determine the knowledge and behaviors of migrants regarding rational drug use health literacy is an important tool to increase the health level of individuals and society the level of health literacy among migrants is a critically important determinant of rational drug use in this study we aimed to determine the rational drug use and ehealth literacy levels of syrian migrants and to evaluate the associated factors it was found that 769 of the migrants in the study group were married 530 had high school or higher education 804 had low income 609 used regular medication 871 consulted a physician first when they got sick and 803 had limited ehealth literacy approximately 35 million syrian immigrants live in turkey the average age of immigrants is 2232 years overall 7268 are women and children in total 3023 are under the age of 10 furthermore 223 live in temporary shelter centers and 977 live in cities and the ratio of syrian immigrants to turkeys population is 373 23 the fact that the individuals in the research group first consult a physician when they get sick shows that they care about their health and seek to protect their health in addition the 871 preference for consulting a physician when ill suggests that immigrants do not experience difficulties in accessing health services in turkey in a metaanalysis it was shown that migrationrelated factors as well as social and economic conditions may affect the health of immigrants 24 in this study 97 of the immigrants in the research group stated that medication should only be used when prescribed by a doctor furthermore 937 stated that people should not keep antibiotics in their homes and then use them for other illnesses moreover 961 stated that doctors should prescribe antibiotics only when needed in total 758 stated that using enough medication not too much leads to recovery in this study 510 stated that people can stop taking medication if they feel well during treatment in total 38 stated that people can stop taking medication if they feel well during treatment and 38 stated that people can stop taking medication if they feel well in this study 0 stated that there is no harm in recommending medication to their relatives with similar complaints of the sample 387 stated that herbs can be used instead of medication in this study 625 stated that using herbal medication as much as desired is not harmful to health furthermore 367 stated that the form and duration of medication use cannot be determined by the individual in this study 610 stated that medications cannot be used to the same extent in every age group in total 681 stated that the duration of use of medications is not the same and 674 stated that expensive medications are not more effective the fact that the majority of the immigrants in the study group have low income and about half of them have an education level below high school suggests that their knowledge and perceptions about antibiotics are not sufficient however the results of the study show that the general knowledge and perceptions of immigrants about antibiotic use are better than expected 25 in addition it is seen that medication compliance is low and it is common to recommend medication to relatives with similar symptoms on the other hand the presence of positive perceptions of herbal medicines and their use among syrian immigrants may be related to sociocultural factors and past experiences increasing antibiotic resistance is now considered a public health problem because it poses both a threat to human health and a serious economic cost 2627 in a study conducted with immigrants in the netherlands it was shown that immigrants had a more limited perception and knowledge of antibiotics compared to the native population 5 although physical and mental health problems are common in immigrants their low socioeconomic status is associated with poor health outcomes 28 there are studies showing that treatment compliance is low in immigrants 29 studies conducted in turkey have shown that age marital status education level income level family structure place of residence employment status and health education status are associated with rational drug use 30 31 32 in a different study it was shown that giving importance to health and seeking healthy life behaviors positively affected the attitude toward rational drug use 33 in another study conducted in turkey sociodemographic characteristics such as age gender employment status and education level were found to be associated with the level of rational drug use knowledge of syrian immigrants 34 in a metaanalysis it was shown that factors such as previous similar symptoms and antibiotic experiences perceived low severity of the disease intention to recover quickly difficulty in accessing a physician or health facility lack of trust low cost and ease of use affectincrease selfmedication 35 in another metaanalysis a positive relationship was found between health literacy and medication adherence 36 today the internet has become a frequently used source of health information because of its ease of access and use low cost and ubiquity people frequently use the internet for disease prevention healthy living behaviors and general disease conditions 37 however there may be some difficulties for users to access useful and quality health and medical information online 38 it is inevitable that individuals with low income and low levels of ehealth literacy such as immigrants will experience difficulties in this situation as a matter of fact the eheals median value of the migrants in our research group was found to be 21 the ehealth literacy level of 803 of the immigrant group was found to be limited and 197 was found to be sufficient in a recent study conducted in the same city it was also observed that immigrant health literacy levels were insufficient 39 immigrants in the study group with low income levels may have limited internet access and use in addition low education level and sociocultural factors in the study group may have affected immigrants access to accurate and reliable information about health on the internet and their ability to understand and use this information in addition immigrants health perceptions chronic disease status and healthinformationseeking behaviors or habits may affect their ehealth literacy levels the level of education and health literacy of society affects the health status of individuals and their attitudes and perceptions towards medicines 40 on the other hand in disadvantaged groups such as immigrants and the elderly technological applications can make a significant contribution to individuals access to reliable health information and making the right health decisions 41 it is important that the health services of immigranthosting countries are appropriate to the personal needs living conditions sociocultural characteristics and competence levels of immigrants improving health literacy plays a critical role at this point in turkey syrian immigrants can access health services free of charge 42 in addition health services are provided to these immigrants by syrian healthcare professionals through reinforced immigrant health centers in these centers where specialist physicians in various branches work preventive health services outpatient diagnostic and therapeutic health services are provided without language barriers this situation positively affects syrian immigrants access to and use of health services and contributes to the protection and improvement of their health it should not be overlooked that it also contributes positively to their health literacy status a metaanalysis has shown that the concept of health literacy is very important for protecting and improving the health of individuals and is an important determinant of the health level of society 43 basic health literacy facilitates individuals access to health services enables reducing health inequalities and contributes to the development of health services policies at the societal level 44 in the research group the mean ranks of ehealth literacy were significantly higher in the age group of 3039 married low income living in turkey for 7 years or more not having chronic diseases not using regular medication not doing anything for a while when they get sick and using medication according to their own experience and having a monthly outofpocket health expenditure of less than 500 tl the presence of social support within the family among married individuals in the research group may have contributed to the wellbeing and better health of individuals in a metaanalysis the positive effect of education income level and the presence of social support on individuals health literacy was shown 45 immigrants who live in turkey for longer periods of time overcome the language barrier to a large extent since they are in contact with the community their children or siblings go to school and their spouses or family members work there is always someone in the family who speaks turkish this makes it easier for syrian immigrants who live in turkey for longer periods of time to follow official procedures and access and use health services as a matter of fact syrian immigrants who are registered in the city where they reside in turkey can access public health services free of charge thanks to their temporary protection status and they can also get their medicines free of charge or by paying copayments this is supported by the fact that the vast majority of immigrants in the study had a small outofpocket health expenditure the high level of ehealth literacy of immigrants who do not have chronic diseases and do not use regular medication may be related to the fact that they use digital resources more intensively in accessing reliable and accurate information about protecting their health and adopting healthy life behaviors because they care more about their health systematic reviews have shown that education level is associated with ehealth literacy 46 it is inevitable for individuals with low health literacy to skip preventive health services treatment compliance chronic disease management and more generally have poor health outcomes 47 factors such as cultural beliefs about health and illness language problems and socioeconomic status affect immigrants communication with healthcare providers and their understanding and compliance with medical instructions 48 in the logistic regression analysis established to predict the level of ehealth literacy according to sociodemographic characteristics model fit was found to be good since it is thought that the effect of some independent variables would be more significant within the scope of the research these variables were included in the regression analysis in addition in order to obtain a stronger prediction model with fewer variables regression analysis was performed only with some independent variables among the independent variables age group gender education level and regular medication use were found to contribute significantly to the model female gender advanced age low education level and regular medication use decrease the level of health literacy in the traditional sociocultural structure of syrian immigrants it is mostly men who have more contact with the outside social environment attend school and have a job for this reason immigrant women are less likely to access the internet as they lack both language learning and economic independence this situation also contributes to the limited ability of immigrant women to search understand and use healthrelated information on the internet immigrants with older age and lower educational attainment have more problems accessing the internet and understanding and evaluating accurate and reliable healthrelated information on the internet in a study conducted with syrian immigrants in sweden it was shown that immigrants with low educational levels had limited health literacy 2 providing education to individuals with chronic diseases positively affectedincreased rational drug use and health literacy 49 prolonged length of stay positive perception of social status and educational level of immigrants in the country of migration affect the level of health literacy 20 immigrants are at high risk of having limited health literacy this plays an important role in achieving better health for themselves and their families 50 in another metaanalysis it was shown that providing accessible and reliable health information on the internet or in the media in simple and understandable language would contribute to improving individuals health literacy levels 51 strengths and limitations of the research given turkeys significant standing in global migration statistics research conducted on migrants within the country undeniably offers critical contributions to the literature the present study was meticulously executed in an area densely populated by migrants employing arabicspeaking interpreters this approach ensured a direct engagement with the migrants allowing for a more authentic representation of their voices and experiences specifically by focusing on this distinct and often hardtoreach migrant group our research aims to fill a palpable gap in the literature by centering on their subjective evaluations however it is imperative to underscore certain limitations of our study conducting the research in a singular region may impose constraints on the generalizability of the findings to the broader migrant population in turkey additionally the involvement of interpreters while invaluable could potentially raise concerns about the accuracy and impartiality of the translated responses from the migrants moreover as the study predominantly focuses on arabicspeaking migrants it does not encompass insights from migrants of other linguistic backgrounds materials and methods research type and research population a crosssectional study was conducted the population of the study consisted of syrian immigrants over the age of 18 who applied to sultanbeyli strengthened migrant health center sultanbeyli is the district with a total population of 358201 and has the lowest socioeconomic level in istanbul around 22000 syrian immigrants live in the district strengthened migrant health centers are organizations that provide primary health care services to syrian refugees who have settled in turkey these centers are staffed by specialist physicians general practitioners dentists allied health personnel psychologists and social workers the centers are mostly staffed by syrian healthcare professionals therefore there is no language barrierproblem 52 there are 8 of these centers in istanbul 1 of which is located in sultanbeyli district all immigrants over the age of 18 who volunteered to participate in the study were included in the study without sampling measurement tools for the study a questionnaire was prepared based on the literature and consisted of three sections the first part of the questionnaire consisted of statements evaluating sociodemographic characteristics and health status the second section includes statements on rational drug use prepared according to the guidelines and guidelines in the literature the third section includes the ehealth literacy scale arabic form the survey was conducted facetoface with immigrants through arabicspeaking interpreters rational drug and antibiotic use survey the rational drug use questionnaire was prepared based on the world health organizations public awareness survey on antibiotic resistance conducted in 6 different who regions in 2015 the rational drug use scale whose validity and reliability studies have been conducted in turkey and other sources in the literature this section consists of statements aiming to obtain information about the rational drug use status and attitudes of immigrants 73053 the statements in the section are in a 5point likert type and consist of a total of 13 items each item has a response scale ranging from strongly disagree to strongly agree the section also includes negative statements the relevant statements were compiled in order to learn the level of knowledge of the participants about the use of medicines and antibiotics and to evaluate their attitudes the items in the section provide a subjective assessment of the rational use of medicines and antibiotics by immigrants 730 ehealth literacy scale the eheals was developed by norman and skinner in 2006 and aims to measure literacy skills useful in assessing the effects of strategies for delivering online information and applications 118 the eheals consists of 8 items and participants are asked to rate each item on a 5point likert scale total scores range from 8 to 40 with higher scores indicating higher selfperceived ehealth 154 eheals scores are divided into thresholds of inadequate problematic and adequate the eheals arabic validity and reliability study was conducted by wangdahl et al 19 however since the use of 3 thresholds in the arabic eheals threatens the validity and reliability of the scale the scale was divided into two limited and sufficient in our study a 2point version of the scale was used to identify those with ehealth literacy problems 119 eheals psychometric tests show that it is a valid and reliable instrument and has also been translated adapted and validated in arabic 254 statistical analysis for statistical analysis the eheals was accepted as the dependent variable statistical package for the social sciences program version 260 was used for statistical analysis continuous variables were expressed as mean ± standard deviation and median categorical variables were expressed as numbers and percentages kolmogorovsmirnov and shapirowilk tests were performed for normality analysis of the data and skewness and kurtosis values of the scales with p 005 were analyzed it was accepted that the values with skewness and kurtosis values between ±15 were normally distributed and the values not between ±15 were not normally distributed since the data in the research group did not show normal distribution the mannwhitney u test and kruskalwallis test were used in data analysis chisquare and fishers exact tests were used to compare categorical variables between groups correlation analysis was used for the relationship between continuous variables logistic regression analysis was performed to predict the level of ehealth literacy according to the independent variables model fits were evaluated and the variables that contributed significantly to the model were examined in statistical analyses p 005 was considered significant ethics committee permission ethics committee permission was obtained from the istanbul medipol university noninterventional clinical research ethics committee on 24 november 2022 with decision number 991 the individuals included in the study were asked to participate in the study after being informed about the research and permissions a questionnaire was administered to individuals who agreed to participate in the study conclusions it was observed that syrian immigrants have very good knowledge and attitudes about antibiotic supply and use however it was observed that their knowledge and attitudes regarding drug use treatment compliance and herbal medicines were not sufficient the ehealth literacy level of 803 of the immigrants in the research group was found to be limited and 197 was found to be sufficient the eheals level of syrian immigrants was found to be associated with being married having a low income level living in turkey for a longer period of time chronic disease regular medication use and monthly outofpocket health expenditure in addition advanced age low education level female gender and regular medication use affected the low level of ehealth literacy interventions targeting disadvantaged groups such as immigrants are very important in preventing infectious diseases reducing treatment costs and monitoring chronic diseases at this stage health literacy interventions play a critical role in todays digital environment ehealth literacy interventions for immigrants will help them access reliable health information online and make the right decisions about their health in addition health promotion interventions such as ehealth literacy will enable immigrants to care about their health and improve their quality of life the success of health policies will be enhanced if countries with a high concentration of immigrants plan and implement health services by taking into account immigrants needs learning competencies language problems living conditions and sociocultural characteristics ehealth literacy interventions for immigrants will facilitate the provision of health services and contribute to the safe access of immigrants to health services data availability statement all datasets and analyses used throughout the study are available from the corresponding author upon reasonable request institutional review board statement prior to initiating the research ethical approval was secured from the ethics committee of istanbul medipol university on 24 november 2022 with decision number 991 all individuals involved in the study were comprehensively informed about the research aims and procedures and were subsequently invited to participate our research was conducted in full accordance with the declaration of helsinki and informed consent was obtained from every participant informed consent statement informed consent was obtained from all participants involved in the study

rational drug use is a pivotal concept linked with morbidity and mortality immigration plays a significant role as a determinant affecting individuals healthrelated attitudes behaviors and the pursuit of health services within this context the study was initiated to assess the factors influencing health literacy and rational drug use among syrian immigrants in istanbul a crosssectional study was undertaken on 542 syrian adults utilizing a threepart questionnaire encompassing sociodemographics rational drug use and the ehealth literacy scale eheals with an average age of 3919 ± 1310 years a majority of participants believed medications should solely be doctorprescribed 97 and opposed keeping antibiotics at home 937 yet 625 thought excessive herbal medicine use was harmless the mean eheals score stood at 2057 ± 726 and factors like age marital status income and duration of stay in turkey influenced ehealth literacy associations were seen between low ehealth literacy and being female being older having a lower education level and regular medication use syrian immigrants displayed proper knowledge concerning antibiotics yet exhibited gaps in their understanding of general drug usage treatment adherence and herbal medicines approximately 803 had limited health literacy pointing to the need for targeted interventions for enhanced health and societal assimilation

convinced of the need to raise full awareness of the risks and to take action this is no longer the case since the entry of an issue such as global warming in the public discourse at national and worldwide level where a lack of clarity dissenting opinions or biases generated by special interests are widespread also while more cost and benefit calculations are now being made publicly about a serious emissions cut what the public seems to be sensitive to is not just economic expediency but also the fate of the earth and future generations hence a more and more complex public discourse about global threats implies a role for philosophy as does the necessity to motivate views that used to be selfevident to narrow and specialized audiences having said something about the intention of this special issue i do not think comments or criticism of the chapters are what is required from the editorat least in this case i have also refrained from writing a conclusion because i deem it more fruitful for the reader to look at the plurality of positions vocabularies and research interests expressed by the authors rather than come to a somehow unifying conclusion everyone will pick out the stimuli emanating from this plurality that is most relevant to themselves what i will try to do in the following is rather to signal five foci in the articles that compose this issue what links are there between risk and responsibility what novelties are highlighted by the authors definitions and the history of risk why act responsibly how can we act thus not all of the authors problematize the linkage between risk and responsibility and those who do so give different versions of it pellizzoni sticks to the classical notion of responsibility as imputability and sees responsibility as structurally coupled with risk taking pulcini looks at the emergence of global risks such as nuclear war as the factor that redefines responsibility as an attitude towards others rather than the imputability of a certain type of behaviour to an actor in my contribution only risks that can be managed by humans are seen as capable of being a source of responsibility which is regarded as feeling responsible for something and towards somebody this is not the only limit i set to the scope and meaning of risk many authors converge in underlining that the magnitude of the new risks particularly in the environmental realm and more precisely the new magnitude of the eventual loss creates new settings for reflection on responsibility jamieson sees the difficulties of interpreting climate change as a problem of individual moral responsibility but concludes that particularly with an eye to this problem it is the very everyday understandings of moral responsibility that should be changed that the new situation requires a redefinition of our moral categories is a position largely shared by pulcini as we have just seen on other terrains other authors point out the effects of these new elements ferretti argues that in the case of risks of a possibly catastrophic dimension and affecting different generations the compensation model based on tort law can no longer apply pellizzoni points at the epistemological novelty of risks which due to their very radical nature cannot be assessed by the usual scientific procedure of trial and error most authors adhere to the classical definition of risk as what combines the possibility of harm or loss with the probability that it will actually happen many authors also cite the distinction between risk and uncertainty but only in my contribution is this distinction taken as narrowly as to exclude extreme events such as nuclear war or catastrophic climate change from the category of risk pellizzoni on the contrary regards uncertainty as a special case of risk with regard to climate change jamieson distinguishes between the risks represented by a large but still linear change and an even larger nonlinear change as uncertainties in forecasting future phenomena are sometimes taken as grounds for not taking action to contain them it is particularly important that dalla chiara makes evident how much uncertainty contemporary science contains as a fundamental and so to speak physiological category this is done by reference to quantum mechanics along with heisenbergs uncertainty principle and the emergence of fuzzy thinking in logics further controversy is met in the historical assessment of the risk category all those who tackle this issue converge in seeing risk as feature of modernity but ferretti and cerutti underline the progressive side of risk taking as a widening of choice and therefore of liberty while pellizzoni tends to view this stance as a manifestation of neoliberal ideology as for the reasons justifying the acceptance of responsibility for major risks or threats impending on humankind both jamieson and cerutti concur in maintaining the insufficiency of what jamieson calls prudential responsibility based on the selfinterest of the present generations while jamieson resorts to respect for nature as the ultimate reason for assuming responsibility for climate change in my contribution the argument is based on an obligation towards human generations of the distant future pulcinis reasons are teleological rather than normative acting out of responsibility for global risks as mentioned sub 1 is the only way out of the pathologies of the global age there are a wealth of proposals as to how to implement our responsibility towards the risks and threats that impend over human life some authors put at the centre the redressing of the unjust distribution of risk and harm whose geography howeverjamieson warnsis shaped by the social divide within rather than between countries perhaps surprisingly more participation is not seen as a significant factor in combating injustice ferretti claims the superiority of distributive justice itself while pellizzoni argues that the problem is the need to democratize society rather than science and knowledge outside the justice paradigm pulcini points at the importance of new sentiments capable of letting us feel the new severity of the human condition under global risks while i argue that the survival of humankind is the primary problem in the context of which considerations of fairness make sense the special issue closes with turnheim and tezcans analysis of a case in point that is the functioning of the un framework convention on climate change seen as an instance of complex governance defined by the relationship with science an inbuilt reflexivity and forms of governmentality obviously the papers in this issue contain more than i can possibly summarize in this introduction whose goal is to give a sense of the variety of positions and approaches as for the latter i wish to stress the attempt made here to give a joint voice to philosophical positions as different as the normative ethics relating to the theory of justice and the moral and political philosophy concerned with the fate of modernity this multiplicity is intended to provide a variety of stimuli to those who are open to them not to generate an unlikely synthesis

it is no novelty to couple together risk and responsibility as scientific themes for joint reflection 1 what we have attempted to do in this special issue is primarily to investigate these two issues as categories that is as philosophical concepts that require clearcut definitions as a starting point for examining their intertwinement and any ultimate shifts in their meanings under new circumstances such as the emergence of technological risks or global challenges this intent has motivated a shift in the main role among disciplines here political philosophy ethics and philosophy of science are given the leading role in debating risk whereas elsewhere this is given to decision theory sociology of risk and political science the latter represented in this issue by just one paper that of turnheim and tezcan this shift is however not just brought about by the disciplinary affiliation of this guest editor nor by a chance mix of authors its rationale lies rather in re ipsa in the growing request for philosophical elaboration on themes that used to be confined to social or even hard sciences there are two reasons for this first the amount of possible harm contained in technological development as a whole global warming or in its most lethal chapter nuclear weapons raises ultimate problems of life and death wellbeing and extreme misery for the whole of humankind that can typically only be grasped by philosophy ethics metaphysics or theology second comes a need currently emerging in public discourse about global risks or threats as long as the reasoning about them took place in epistemic communities for example of climatologists or public health specialists or ecological advocacy groups attitudes of scepticism or confusion rarely arose and nearly every partner to the conversation was f cerutti

background indigenous peoples around the world experience higher rates of poor health poverty poor diet inadequate housing and other social and health problems relative to nonindigenous people these disparities are found in nearly all countries with indigenous populations including some of the wealthiest nations in the organisation for economic cooperation and development 12 the narrowing of these gaps in health and socioeconomic outcomes has been a focus of successive governments in these nations since at least the 1970s understanding the complex historical political and socioeconomic factors that have led to the present situation has also been a key focus for medical and social sciences across the past four decades 12 highprofile reviews published by the united nations and others in recent years have documented the common factors underlying the continuation of health and social inequalities experienced by indigenous populations across the globe including systematic loss of culture and language dispossession from traditional territories and economic and social marginalization 2 3 4 indigenous inequality is a global health problem but it is perhaps most surprising to witness its continuation in some of the worlds most wealthy countries a commonly used barometer for the comparison of health and socioeconomic development across countries is the united nations human development index australia canada and new zealand regularly place among the top 10 countries in the world on this annual measure which combines education income and life expectancy 5 a previous study showed that these countries indigenous populations would rank far lower on the hdi league table than their total populations revealing the relative disadvantage of indigenous peoples 6 each of these countries has since demonstrated a commitment to improving outcomes for indigenous peoples by signing the united nations declaration on the rights of indigenous peoples 7 which specifically articulates indigenous peoples rights to improvement of their economic and social conditions the work of marmot and others has demonstrated the existence of marked social gradients in health among the populations of wealthy nations 8 in some cases the poorest groups in these societies have health and lifeexpectancy profiles similar to those living in developing nations much of this observed discrepancy in health outcomes has been attributed to socalled social determinants of health which we might define as those nonhealth indicators of life outcomes which influence an individuals health status across their life course these can be socioeconomic indicators such as education employment status income and wealth property rights justice system contacts and social connections and supports which impact a persons ability to obtain preventive health knowledge apply that knowledge to their own life and access appropriate health services when treatment is required for a given condition marmots observations around health outcomes for the poor in relation to the unequal distribution of resources in wealthy societies 8 have been placed into global indigenous perspective by the work of gracey king and smith 34 where marmot suggests that improving education employment and income among disadvantaged segments of society will have positive implications for health and general wellbeing 8 gracey king and smith 34 point out that the health of indigenous populations may also be affected by additional and unique factors such as cultural security connection to lands language and culturally defined notions of health and wellbeing 34 our focus is on australia canada and new zealand in 2006 the combined indigenous populations for these developed nations was 27 million persons from a total population of about 55 million people 9 10 11 these countries share a common pattern of mainly british colonization over their indigenous populations however important factors have uniquely shaped indigenoussettler relations in each these include geography the relative size of indigenous and settler populations and in canada the influence of other colonial powers 12 despite these differences persistent social economic and health disparities between indigenous and nonindigenous populations exist in all three countries drawing on these perspectives our study documents the relative progress made toward reaching equitable levels of socioeconomic development among indigenous citizens in australia canada and new zealand from 19812006 and looks at prospects for closing gaps in social determinants of health with nonindigenous citizens in the coming 25 years we focus on relative inequality in the human development domains of education employment and income specifically among those aged 25 to 29 years this is the age range by which most higher education has been completed allowing us to more clearly see changes in educational attainment patterns it is also the age by which a number of other important transitions have generally taken place such as leaving the parental home the transition from school to work and the commencement of family formation which have lifelong implications for wellbeing and intergenerational transfers of human capability indeed closing the gap likely requires particular attention to young people and to the quality of these transitions we believe this is the first time one study has brought together longterm data comparing these social determinants of health in the indigenous populations of these three nations methods study design this study reports results from an analysis of census data for australia canada and new zealand census data were used in preference to other data sources because of the long time series available consistency in measurement of questions and concepts over time the availability of data for the same time points for each country the absence of sample size issues and the coverage of both indigenous and nonindigenous populations any effects on indigenous wellbeing of the recent global slowdown in economic activity are not represented as 2006 is the most recent census year for which these data are available for comparison between all three countries we measured progress of indigenous persons aged 2529 years relative to nonindigenous persons aged 2529 years over a 25 year period and across three human development domains education employment and income information to support this investigation was obtained from the national statistics agencies of australia canada and new zealand for the census years 1981 1986 1991 1996 2001 and 2006 covering each domain of interest 13 14 15 indigenous populations australia canada and new zealand have all included questions in their population censuses to identify their indigenous populations in each of the years 19812006 this has allowed the data for each of the domains examined in the analyses to be disaggregated by indigenous status for the three countries the term indigenous persons is used interchangeably to refer to australian aboriginal and torres strait islander peoples canadian aboriginal peoples and new zealand māori data access and permissions census data for australia canada and new zealand were available to the authors via custom tabulations from their respective national statistical agencies no special permissions or ethics committee approvals were required for this study as all research was undertaken using publically available deidentified and confidentialised data ensuring the anonymity of all persons represented by the data measures education domain our measure was the proportion of indigenous and nonindigenous persons aged 2529 years who had achieved a highest qualification of bachelor degree or above in each of the census years 19812006 for each country bachelor degree or above includes bachelor degrees plus all postgraduate degrees graduate diplomas and graduate certificates that require a completed bachelor degree as a prerequisite for enrollment while there are some differences in the way overall education statistics have been classified on the census forms of the three countries there is very good comparability across all three countries for the classification bachelor degree or above used by our study australia the australian bureau of statistics provided us with a set of customized data tables from the census of population and housing showing highest level of qualification by indigenous status for persons aged 2529 years calculated for all census years 1981 to 2006 we report data from these tables on persons with a classification of bachelor degree or above highest level of qualification is derived from responses to census questions on the highest year of school completed and level of highest nonschool qualification the data excluded overseas visitors for all years 13 canada statistics canada provided us with a set of customized data tables from the census of population showing highest level of schooling by aboriginal designation for persons aged 2529 years calculated for all census years 19812001 and highest degree certificate or diploma for 2006 14 the data refer to the highest grade or year of elementary or secondary school attended or the highest year of university or other nonuniversity education completed university education is considered to be above other nonuniversity education also the attainment of a degree certificate or diploma is considered to be at a higher level than years completed or attended without an educational qualification from this data we were able to calculate the proportion of aboriginal and nonaboriginal persons aged 2529 years who had achieved a highest qualification of bachelor degree or above in each of the census years new zealand statistics new zealand provided us with a set of customized data tables from the census of population and dwellings showing highest qualification by māori ethnic group for persons aged 2529 years calculated for all census years 1981 to 2006 15 highest qualification is derived for people aged 15 years and over and combines responses to census questions on the highest secondary school qualification and postschool qualification to derive a single highest qualification the output categories prioritize post school qualifications over any qualification received at school from this data we were able to calculate the proportion of māori and nonmāori persons aged 2529 years who had achieved a highest qualification of bachelor degree or above in each of the census years labour force domain our measure was a census derived unemployment rate for each country the census labour force variables were consistent for all three countries with classifications of employed unemployed and not in the labour force provided via custom tables from the statistical agencies of each country 13 14 15 a person is said to be unemployed if they had no job in the past week but were actively looking for work a person is regarded as being in the labour force if they are currently employed or actively looking for work persons in neither category are regarded as being not in the labour force and are not included in unemployment calculations unemployment rates were produced for the indigenous and nonindigenous populations for each country using the following calculation unemployment rate ¼ unemployed persons persons in the labour force â 100 additionally there had been little change in the categories of labour force status at the broad level across the six censuses for any of the countries making this variable suitable for analysis across multiple time points income domain our measure was median indigenous personal income as a proportion of median nonindigenous personal income in each of the census years for each country the information on annual personal median incomes for persons aged 2529 years for each census year for australia canada and new zealand was sourced from the statistical agency of each country 13 14 15 results for the indicator the proportion of those with a bachelor degree or higher qualification the gaps in all countries were wide and in fact grew wider over the period for example in australia for those aged 25 to 29 years the gap rose from 8 to 25 percentage points between 1981 and 2006 australia clearly fared the worst of the three countries in terms of the increase in the gap for this indicator but even the best performer canada showed a gap of 176 percentage points by 2006 this is not to say that educational outcomes for indigenous people have worsened the data for all three countries clearly indicate absolute gains in the proportion of indigenous people with bachelor degree or higher qualifications however in relative terms indigenous people were increasingly behind the nonindigenous populations on this measure while indigenous people had consistently higher unemployment there was fluctuation in the unemployment rate gap over the period 1981 to 2006 for all three countries by 2006 both australia and canada showed a narrower gap than that observed in 1981 while the gap for new zealand had widened slightly however australia maintained the widest unemployment rate gap of the three countries over the entire period despite the gap reducing from 169 to 110 percentage points canada finished the period with the narrowest gap median indigenous income as a proportion of nonindigenous median income ranged from 772 to 452 in 1981 and improved slightly over the period to range from 809 to 544 in 2006 overall the gap remained steady for australia while for canada and new zealand there was some fluctuation over the period again australia fared the worst with indigenous median annual income barely reaching above half that of nonindigenous people across the reference period while canada and new zealand had made some improvements by 2006 discussion wealthy developed nations with a colonial past such as australia canada and new zealand have typically underresourced the human development of their indigenous populations for much of their postcolonial histories impact has been felt across most aspects of indigenous life including health education participation in the economy legal rights to traditional lands and resources cultural security and wider issues of social inclusion though government mandated reparations have been in place since at least the 1970s long standing inequality has left the indigenous peoples of these countries behind their nonindigenous counterparts on indicators of health wealth social justice and general wellbeing 2 this research comparing social determinants of health for australia canada and new zealand suggests that such inequalities have persistedin some cases barely improving across employment projects cdep and doing so has meant being recorded as employed on official labor force statistics reducing indigenous unemployment and potentially distorting the true gap 16 25 years with australia the worst performer overalldespite concerted efforts by governments to close gaps in outcomes for indigenous people in recent decades these countries are now challenged with finding new approaches to solving this social inequality issue if health and socioeconomic conditions for indigenous people are to even approach parity with nonindigenous persons within a generation the social determinants of health observed in this study covered educational attainment labour force activity and income we specifically examined the gaps between indigenous and nonindigenous people using the proportion with a bachelors degree or higher unemployment rates and median annual income there are other indicators of wellbeing upon which these populations could be compared however peoples connection to the labour force higher formal educational attainment and income are critical aspects of participation and inclusion in these societies and key social determinants of health in the terms of nobel laureate and hdi author amartya sen being engaged in work and having sufficient income represent functionings that help one to make meaningful life choices in order to realize capabilities 17 in the context of advanced economies these capabilities have direct implications for wellbeing while a persistent gap exists between indigenous and nonindigenous outcomes for these indicators we hypothesized that this gap should have narrowed over time our results show that in absolute terms there was some improvement on all three indicators for all three countries but no consistent narrowing of the relative gaps for any country as table 1 shows reductions in the indicator gaps for some time periods are due to fluctuation in the measures for nonindigenous people as opposed to improvements for indigenous people the increasing gap in educational attainment is largely due to rapid increases in the proportion of university qualified young people in the nonindigenous populations of all three countries this expansion in higher education is closely linked to compositional shifts in developed economies away from manufacturing and into knowledgebased service industries and each of these countries has experienced periods of macroeconomic restructuring towards a more knowledge based economy 18 as relatively fewer indigenous people complete university education they are largely excluded from this sector of the economy with education becoming an increasingly critical component to accessing the employment and income benefits of advanced modern economies the effects of these compositional changes may have offset any gains from social policy investments in closing socioeconomic gaps reducing these gaps means addressing a complex set of issues increasing educational attainment requires appropriately resourced education support beginning in early childhood sustained throughout regular schooling and into vocational and higher education settings these programs should support indigenous peoples aspirations including the maintenance of cultural integrity 19 factors beyond the school gate that support indigenous engagement with the education process are also critical we know that pathways to disadvantage in education begin in the early years with high proportions of indigenous children already behind their nonindigenous peers in academic performance from their first year in schoola deficit that continues throughout primary and high school 20 higher rates of school absenteeism and lower levels of parental education may contribute to the widening disparity in academic performance over time for indigenous children and the resources and role models for scholastic learning that often exist in nonindigenous homes may be largely absent in many indigenous households 21 given these trends closing the higher education gap between indigenous and nonindigenous young people will require a major change in policy approach and patience it must be recognized that changes made today to improve young peoples readiness for school will take years to result in higher rates of university completion this suggests that flowon effects of higher employment and incomes may be even further away any suggestion that gaps in socioeconomic outcomes can be eliminated in the near future seems unrealistic without significant increases in the proportion of young indigenous people completing higher education these gaps will remain indefinitely in developed economies populationwide improvements in income are mostly related to improvements in educational achievement and opportunities for employment our study suggests both canada and new zealand are starting to improve income disparity issues for their indigenous people though each is still some way from achieving parity the situation for indigenous australians is far less encouraging the health and wellbeing of indigenous populations in these countries has been a key aspect of national public policy for some time in addition to important legal changes regarding the recognition of traditional rights governments have engaged in various efforts to improve conditions for indigenous peoples including education health and employment programmes and policy changes for example most recently the government of australia has made closing the gap in human development outcomes between indigenous and nonindigenous people an explicit goal of national policy 22 and the government of canada and assembly of first nations joint action plan has a focus on increasing access to education and employment opportunity 23 while new zealand has used a closing the gaps theme for policies aimed at social justice issues for māori 24 adding to this already complex policy environment is the observation that these countries have seen some growth in indigenous populations across the reference period in addition to that from births due to changing patterns of selfidentification in their census 25 26 27 limitations there are several limitations to the methodology employed in this study it is known that across time there has been a change in the propensity of people to identify as indigenous in all three countries 25 26 27 this means for example that the composition of the indigenous population of 1981 is likely different to that of 2006 for all age groups which may have influenced some of the results seen in this study another issue is that the scope of national census questions may be too limited to explain some of the differences in outcomes between indigenous and nonindigenous persons for example there may be sound cultural reasons for why an indigenous person does not seek to participate in certain educational or employment spheres but we cant measure that with census data lastly as census data are only gathered once every five years we are unable to track economic and social change as closely as something like a longitudinal survey with annual followup conclusions australia canada and new zealand represent nations with some of the highest levels of human development in the world yet our research shows that their indigenous populations were almost as disadvantaged in 2006 as they were in 1981 relative to their nonindigenous populations on three key social determinants of health these ongoing disparities represent a major public policy concern and a growing focus for science and human rights organizations given the breadth of scientific inquiry the public spending and good intentions of successive australian canadian and new zealand governments regarding indigenous health and social advancement since 1981 the fact that relative progress on key social determinants of health has been practically static for indigenous peoples is alarming despite absolute improvements on these indicators continuing disparities suggest that existing approaches to addressing indigenous inequality are not as effective they need to be they also suggest that achieving equity may take several more decades especially as the young adult populations described here are the ones in which more progress was expected to have occurred across these domains surely indigenous peoples in these nations would be within their rights to expect a narrowing of these gaps to occur over the coming 25 years along with improvements in health outcomes science and policy are yet to provide viable solutions to this enduring social equity issue if closing the gap in health and socioeconomic disparity between indigenous and nonindigenous people remains a goal it would seem that completely new approaches are required to achieve success otherwise indigenous persons in these developed nations are being consigned to a future of entrenched inequality for generations to come competing interests the authors declare that they have no competing interests authors contributions fm and mc had the original idea for the study developed the analytic concept and acquired the data dp and em compiled the data and performed the analysis fm mc and dp wrote the first draft dl eg and srz contributed to all subsequent drafts and revisions all authors read and approved the final manuscript

background australia canada and new zealand are all developed nations that are home to indigenous populations which have historically faced poorer outcomes than their nonindigenous counterparts on a range of health social and economic measures the past several decades have seen major efforts made to close gaps in health and social determinants of health for indigenous persons we ask whether relative progress toward these goals has been achieved methods we used census data for each country to compare outcomes for the cohort aged 2529 years at each census year 19812006 in the domains of education employment and income results the percentagepoint gaps between indigenous and nonindigenous persons holding a bachelor degree or higher qualification ranged from 66 new zealand to 109 canada in 1981 and grew wider over the period to range from 195 new zealand to 252 australia in 2006 the unemployment rate gap ranged from 54 canada to 169 australia in 1981 and fluctuated over the period to range from 66 canada to 110 australia in 2006 median indigenous income as a proportion of nonindigenous median income whereby parity 100 ranged from 772 new zealand to 452 australia in 1981 and improved slightly over the period to range from 809 canada to 544 australia in 2006 conclusions australia canada and new zealand represent nations with some of the highest levels of human development in the world relative to their nonindigenous populations their indigenous populations were almost as disadvantaged in 2006 as they were in 1981 in the employment and income domains and more disadvantaged in the education domain new approaches for closing gaps in social determinants of health are required if progress on achieving equity is to improve

introduction boundaries fires dont understand them we cant draw a line and say we did our part up to this point and now we are good…its just a bigger picture this forest landowner from eastern oregon recognizes that fire occurs on a landscape scale although he believes people need to manage fire risk beyond their property lines he has not cooperated with any of his neighbors to address hazardous fuel conditions locally we communicated with them…but they have their own balance of what they want to do he explained referring to gulfs in values and priorities for forest conditions and management this landowner thins thickets of trees but leaves brush for deer forage he is concerned that one of his neighbors eliminates too much habitat in his efforts to reduce fuel while another does nothing the importance of managing natural processes and biodiversity at the landscape scale to promote the health and productivity of forest ecosystems is widely recognized doing so howeverespecially when it entails managing across ownership boundariesremains challenging different land ownerships public and private are managed for different goals using different actions with differing ecological effects in the case of fire hazardous fuel reduction on one ownership can reduce the risk of fire on neighboring lands similarly suppression activities on one ownership can cause fire to be excluded from another ownership causing fuel buildups that can lead to uncharacteristically severe fires having dire social economic and ecological consequences where management activities have ecological economic or social consequences beyond ownership boundaries and the efficacy of one landowners actions can be limited or improved by those of nearby landowners cooperation can be an important strategy for achieving landscapescale management goals cooperation is also an alternative to regulation for the management of common pool resources such as forests local residents who develop voluntary selfregulating management institutions may have greater expertise and incentive for managing these resources effectively than regulatory agencies yet the decision to cooperate with others hinges on a balance between altruism and selfinterest and in this case on whether landowners are willing to accept the immediate burden of cooperating with others in exchange for the longer term but less certain benefit of buffering their properties against fire in this paper we explore the relationship between nonindustrial private forest owners perceptions of fire risk including risk associated with conditions on nearby forestlands and their decisions to treat hazardous fuel in cooperation with others our study area is the ponderosa pine ecotype on the east side of oregons cascade mountains where a history of fire suppression grazing and timber harvest has led to a buildup of hazardous fuel and thus fire risk although this area is dominated by federal lands nipf owners own 16th of the forestland in the area much of their land borders or is near federal land creating a mixedownership landscape in which their management practices affect the connectivity of fuel and potential movement of fire between federal wildlands and populated areas given that fire does not observe ownership boundaries and that fuel conditions on one ownership can affect fire risk on neighboring ownerships we hypothesized that owners who perceive a risk of wildfire to their properties and perceive that conditions on nearby forestlands contribute to this risk are more likely to cooperate with others to reduce fire risk across ownership boundaries we expected owners to be motivated by the rationale that cooperation would enable them to accomplish fuel reduction activities more efficiently together than alone yet we also expected that social beliefs and norms about cooperation and private property ownership would influence owners decisions to treat fuel through cooperation with others we investigated the relationship between risk perception and cooperation through statistical analysis of mail survey data we used qualitative interview data to examine how nipf owners perceive fire risk on their own properties and on the wider landscape and communicate and cooperate with other private and public owners to address fire risk interview data also allowed us to explore the influence of individual beliefs social norms and institutions on cooperative fuel treatments and to identify potential models of cooperation after presenting our results we discuss barriers to crossboundary cooperation in hazardous fuel reduction and ways to potentially overcome them the ecological and socioeconomic conditions prevalent in our study area are common throughout the arid west thus this case from eastern oregon may shed light on opportunities for managing fireprone forests using an all lands approach elsewhere in the west literature review risk perception risk perception defined as the subjective probability of experiencing a damaging environmental extreme is considered an important antecedent to mitigation and adaptation behavior according to the natural hazards literature in the case of wildfire and other natural hazards risk perception has been identified as a key variable influencing mitigation behaviors such as taking action to reduce hazardous conditions preparing for a hazardous event or moving to a less hazardous area people form perceptions of risk through interaction with friends peers professionals and the media on the basis of norms world views and ideologies the process of coming to agreement on the causes and consequences of risk and acceptable levels of uncertainty and exposure is influenced by the level of legitimacy and trust between people and institutions cognitive biases also play a role in risk perception as can peoples past experience and objective knowledge however risk perception alone does not always compel mitigation behavior other important variables include believing one is capable of acting to effectively mitigate risk holding oneself responsible for ones welfare and feeling sentimental attachment to a vulnerable community or place moreover decisions to mitigate risk occur under complex socioeconomic conditions that both shape peoples vulnerability to risk and determine their efficacy at addressing risk cooperation cooperation refers to a spectrum of behaviors that range from communicating with others about shared interests to engaging in activities that help others including sharing resources and work the theory of cooperation is based on the benefits of reciprocity to participating parties when combined efforts can achieve more than individual efforts disciplines ranging from evolutionary biology to political science have examined cooperation as a response to adverse and unpredictable environments and as a strategy for hedging against and coping with environmental risk social conditions that foster cooperation among individuals include the presence of common goals and motivations a perception of common problems the use of similar communication styles high levels of trust and expectations and opportunities for frequent exchanges of information and ideas policy environments land tenure arrangements and power relations must also be conducive to cooperation three important antecedents to cooperation including crossboundary cooperation among private landowners are shared cognition shared identity and legitimacy shared cognition refers to sharing a similar perspective or having consensus on a problem or task shared identity means sharing membership in a community or social group legitimacy is when people or organizations are viewed as fair and capable and are empowered by others social exchange theory provides a framework for understanding when crossboundary cooperation by nipf owners might occur social exchanges are interdependent interactions among people that generate mutual benefits and obligations one type reciprocal exchanges consists of interactions that lack terms or assurance of reciprocation reciprocal exchanges are an informal form of cooperation that functions on the basis of reciprocity rules beliefs and norms of behavior reciprocal exchanges entail risk and uncertainty because they occur in the absence of a contract when they are successful they yield trust and commitment which in turn lead to stronger relationships when they are unsuccessful cooperation breaks down in contrast negotiated exchanges are social exchanges that have known terms and binding agreements to provide some assurance against exploitation negotiated exchanges do not entail as much risk or require as much trust as reciprocal exchanges the risks associated with cooperation increase when mismatches occur between the nature of the relationship among the cooperators and the nature of the transaction between them for example when two landowners who have an interpersonal relationship engage in an economic exchange there is a mismatch in such cases people who act to the economic benefit of others may feel betrayed if that economic benefit is not reciprocated and may be reluctant to enter into another such relationship thus neighboring landowners who have an interpersonal relationship and who cooperate in fire risk reduction activitieswhich are economic because they entail investment of one persons resources in the protection of anothers propertyhave a mismatch exacerbating the risks associated with cooperation we return to these observations in our discussion methods definitions our construct of wildfire risk perception among nipf owners includes concern about a wildfire occurring on ones land and concern about hazardous fuel conditions on nearby private or public land contributing to the chance of wildfire on ones land based on miletis definition of risk perception as subjective probability we also included awareness of the ecological role of wildfire in ponderosa pine forests and past experiences with wildfire on ones property as elements of our risk perception construct based on hertwig and others for purposes of our analysis we define cooperation as jointly planning paying for or conducting activities that reduce hazardous fuel we focus on cooperation among nipf owners and between nipf owners and public agencies data collection in september 2008 oregon state university and oregon department of forestry funded and administered a mail survey to owners of a random sample of nipf parcels in eastern oregons ponderosa pine ecosystem the goal of the survey was to learn more about nipf owners wildfire management practices constraints on fire management and how public agencies could design better assistance programs the survey sample was selected by casting random points across a gis polygon created using layers of pixels that represent historical and potential ponderosa pine forests and an ownership layer the nipf polygon comprised approximately 12 million hectares about 50 of all nipf land and 15 of all forestland east of the cascade range in oregon which is consistent with other estimates of the proportion of land in nipf ownership in eastern oregon the point layer was joined with a state tax lot layer obtained from the oregon department of revenue to create a list of owner names addresses and tax lot numbers the survey asked about owners past and intended future hazardous fuel reduction activities including cooperation with public agencies nonprofit organizations private consultants or other private landowners survey questions also addressed owners goals experiences with wildland fire concern about fire risk in general concern about specific hazards and potential losses and demographic characteristics respondents were asked to reference the parcel associated with the tax lot number on their survey the survey was reviewed by 20 natural resource professionals landowners and social scientists and approved by the oregon state university institutional review board prior to implementation the survey was administered to 1244 owners using the total design method an announcement card followed five days later by the survey a second survey to nonrespondents 2 weeks after the first and at week four a thank you card that also served as a final reminder to nonrespondents of the 1244 surveys mailed the survey respondents consisted mostly of retirementage males similar to nipf owners in the american west but more had obtained bachelors degrees earned above the national median household income and were absentee also a high proportion had treated their parcel to reduce the risk of wildfire compared to owners in the west generally they also owned relatively large holdings compared to other owners in the west these disparities reflect the sampling approach and the social and biophysical conditions in eastern oregon where land use rules set large minimum tax lot sizes and arid climate limits productivity favoring forestry and grazing over large areas these and other characteristics of the sample are presented in table 1 we conducted semistructured key informant interviews in 2007 and 2008 with a purposive sample of 60 nipf owners owning forestland in three watersheds in the study area that are considered high priority for hazardous fuel reduction the sprague upper deschutes and upper grande ronde we identified owners having diverse fire experiences management intensities and ownership characteristics with help from local natural resource agencies and organizations each interview included a walking tour of the owners property and averaged two hours questions addressed their management approaches experiences and concerns with fire ecological knowledge and values about fire and forest conditions and perceptions of opportunities and constraints for hazardous fuel reduction most interview informants had treated some portion of their parcel to reduce the risk of wildfire digital recordings of the interviews were transcribed verbatim and entered into atlasti a software program that aids qualitative data analysis the interview sample was similar to the survey sample in terms of demographic characteristics data analysis to analyze the mail survey data we used frequencies to describe respondents perceptions of fire risk and their cooperation behaviors and logistic regression to identify the relationship between risk perception and cooperation on fuel reduction we began the logistic regression analysis with a manual backward stepwise regression of the cooperation variables on the risk perception variables and a set of demographic control variables and then built final models with the variables that were relevant to the hypothesis table 2 contains descriptions of the cooperation response variables and risk perception explanatory variables to analyze the interview transcripts we followed a standard protocol of qualitative analysis we identified and coded quotations in the transcripts that provided evidence for how interview informants perceive fire risk including the probability of fire the hazardous conditions that contributed to the probability of fire and what values they were concerned about losing in the case of fire we also coded quotations that provided evidence for how owners view the barriers and opportunities of cooperation we linked these quotations with additional codes and wrote memos about how wildfire risk perceptions motivated owners to cooperate with others results risk perception and hazardous fuel management we are always concerned about fire our fear every summer is where is the lightning strike going to be and are we going to be able to survive the fire that is one of the reasons we created fire breaks throughout the property and because our neighbors didnt have any comments like this one indicate that some landowners interviewed were aware of fire risk beyond their property boundaries and responded by treating fuel survey responses corroborated this finding 67 of the survey respondents said they were concerned about a fire affecting their property a majority were concerned about conditions on nearby public lands contributing to the risk of wildfire on their property interview informants articulated similar concerns although few were aware of which land management agency controlled nearby public lands you want to see risk theres risk responded one interviewee when asked for an example of hazardous forest conditions like many owners we interviewed he pointed to land on the other side of his fence line in this case national forest land in the sprague river watershed here you can see where it is thinned and then it gets really thick that is a piece of government ground that is the difference between my place and the government ground theirs is jungle figure 2 shows forest conditions we often encountered across property lines owners shared with federal land management agencies some owners were also concerned about fuel conditions on neighboring private lands as evidenced in this comment by another interviewee from the sprague river watershed that is an inferno waiting to happen…hes endangering my property my structures and also my forest however owners were less concerned about conditions on nearby private lands than on nearby public lands only 37 of survey respondents were concerned about fire risk from nearby private lands some interview informants believed that most private owners managed their forests enough that little fuel was left to be of consequence they are logging the living daylights out of that exclaimed one interviewee referring to the surrounding industrial ownership its going to be fine for a lot of years other interviewees were simply more forgiving about the risk associated with private lands than with public lands one owner guessed that her neighbors are doing fine…doing it about the same way we are thinning logging it every few years…the cattle are keeping the brush down 70 of the survey respondents had treated portions of their parcels to reduce the risk of fire between 2003 and 2008 they used a range of forest management practices that can reduce fuel presented in table 3 the median treatment area was 20 acres many interviewees said that they treated their properties to compensate for the lack of hazardous fuel management by their neighbors as one owner in the sprague river watershed explained if we have a higher risk because of heavy fuel buildup on adjacent land…we look at our management philosophy a little bit differently we would do more in our cutting more than we like…to keep a crown fire from spreading indeed in a different analysis of the survey findings we found that owners concern about fire risk and concern about conditions on nearby public land contributing to this risk explained their likelihood of treating fuel risk perception and cooperation most owners worked either on their own or with family members or with private contractors to conduct forest management activities however many had also worked in cooperation with others between 2003 and 2008 34 of the survey respondents cooperated with public agencies 18 cooperated with other private owners and 15 cooperated with nonprofit organizations to plan pay for andor conduct practices that can reduce fuel interview informants provided examples of cooperative fuel treatment particularly with public land neighbors participating in fire management planning with the forest service and the bureau of land management for lands adjacent to their properties communicating with agencies about the need to reduce fuel along shared property boundaries coordinating forest thinning and brushclearing with treatments on adjacent public lands to widen fuel breaks and synchronizing prescribed burns with those on adjacent public lands to take advantage of agency fire fighters and equipment interview informants cited fewer examples of cooperation with private landowners these included allowing neighbors to graze livestock on their properties to reduce grass and brush and planning treatments along shared property boundaries to create wider shared fuel breaks more often they observed the use of new techniques or equipment on each others parcels a number of owners said they had referred interested neighbors to their consulting foresters or operators to request treatments similar to the ones performed on their properties thus some portion of the 41 of survey respondents who had worked with private contractors may have been influenced by or influenced other private owners an indirect form of cooperation owners expressed a greater willingness to cooperate with other landowners in the future to reduce fire risk than they had in the past most survey respondents said they would cooperate with both public owners and private owners to reduce fuel in the future especially if it would release them from liability for fires resulting from escaped controlled burns reduce their share of the cost of treatments or make more public funding available to them for treatments according to the logistic regression tests perceived risk explained cooperation between nipf owners and public agencies but not cooperation between nipf owners and other private owners concern about a fire occurring on ones parcel and concern about conditions on nearby public land contributing to this risk were both associated with whether owners reported having cooperated with public agencies in the past on forest management actions that can reduce fuel whether owners were aware of the historical role of fire in ponderosa pine ecosystems and whether owners had experienced a fire on their land were also associated with whether owners reported cooperating with public agencies in the past to reduce fire risk owners willingness to cooperate with public agencies in the future to reduce fire risk was also explained by the risk perception variables specifically whether owners were concerned about a fire occurring on their parcel were concerned about conditions on nearby public lands and private lands and were aware of the local fire ecology none of the risk perception variables were associated with whether owners had cooperated with other private owners in the past only awareness of the local fire ecology was associated with their willingness to cooperate with other private owners in the future p values and odds ratios for the risk perception variables are presented in table 6 in addition two demographic control variables were significant in preliminary manual backwards stepwise regression tests living on ones parcel and age were associated with whether owners had cooperated in the past and were willing to cooperate in the future with both public agencies and other private owners whereas parcel size ownership size tenure length income education and gender were not our logistic regression test partially confirmed our hypothesis all of the variables included in our risk perception barriers to cooperation although many of the owners interviewed acknowledged the potential benefits of cooperation in fuel reductionparticularly for achieving economies of scale in their effortsthey identified numerous reasons for not cooperating barriers related to patterns of rural social organization were most commonly cited people in the timber sector are in an isolated spot explained an owner of 2500 acres in the sprague river watershed referring to the sparsely populated and mountainous landscape of oregons east side which impedes interaction they dont have many neighbors to cooperate with furthermore the markets and other natural resourcebased economic activities that once provided a basis for interaction and reciprocity despite this topography are now in decline an owner of 10 acres who recently moved to union county in the upper grande ronde watershed explained when this place was small family ownerships primarily there was more talk between people and more helping each other out because they were all managing the land now people arent really deriving a significant amount of their income off the land…so they dont tend to talk to each other or help each other out much as a result of demographic change many newcomers own forestland primarily for privacy and solitude or recreation the isolation such owners seek counters interaction were like two separate little icebergs…we may touch…but only by necessity…its why we live out here explained an owner of 200 acres in the deschutes river watershed a high rate of absentee ownership often associated with recreational use is a barrier to developing the social relationships upon which cooperation is predicated our regression results indicated that owners who live on their parcels were more likely to have cooperated with their neighbors in forest management than those who did not in addition gulfs in values beliefs and motivations regarding the management of fire risk also attributable to demographic change were seen as barriers to cooperation owners who manage for commodities or habitat tended to view fire as a historically important and persistent ecological force they believed hazardous fuel needed to be managed to prevent fire from being overly destructive but did not seek to eliminate fire from the ecosystem in contrast owners who hold land primarily for residential reasons tended to view fire as a threat to their homes and scenic views defining hazardous fuel as anything in the forest that could carry fire differing perceptions of fire and fuel led to conflicting approaches to forest management for example the owners of a 200acre parcel in the deschutes river watershed selectively treated the most hazardous fuels in order to preserve wildlife and scenic beauty differentiating themselves from their neighbors who razed all vegetation within a 150yard radius of their future home we understood their fire concerns but we were also very concerned about how much they cleared out of the winter forage for the deer…we dont want to see our forests be safe for wildfire but good for nothing else conflict was especially apparent around fire treatments some interviewees viewed fire as a tool for reducing risk associated with brushy overstocked stands others viewed fire as the risk itself an owner of 10 acres in the sprague river watershed who managed primarily for habitat had permission to clear and burn brush on the property of his absentee neighbor however another neighbor with less risk tolerance stymied his efforts we had good conditions for burning he explained there were still snow drifts then these neighbors noticed what i was doing got on the phone and threatened legal action one guy threatened to kill me because they were so scared…and if you drive back there now you will see how much fuel there is its scary conflicting values and goals relating to fire risk also impeded cooperation between nipf owners and public land management agencies an owner of 2500 acres in the sprague river watershed was disappointed about a prescribed burn he had jointly conducted with the forest service and attributed the problem to differing scales of risk tolerance he believed the forest service was comfortable losing more trees in the burn than he was they were comfortable with a hotter controlled burn…than i was used to…for them this kind of mortality is nothing they are dealing with thousands of thousands of acres but when you have a limited number of acres mortality has a different meaning social norms about private property ownership and appropriate behavior towards neighbors were also identified by owners as constraints to cooperation despite concerns about hazardous fuel conditions on neighbors lands i kind of try to hint to them said one interview informant when asked why he hadnt encouraged his next door neighbor to address hazardous fuel on his property but that is about as far as you can go because people are set in their ways the owner of 1000 acres in the upper grande ronde river watershed was more direct if you want to have good neighbors you dont mention things like that social norms about reciprocity including the ageold challenge to collective action freeridership also worked against cooperation the trouble with our society explained an owner in his 80s who controls hazardous fuel on his property despite being handicapped is that one person can do the work…and other people will take the benefit in other words if your neighbors reduce fuel on their properties the risk to your property will be reduced without you having to do anything owners were also concerned about potential risks to their autonomy as private property owners associated with participating in formal cooperative groups for example an owner of 650 acres in klamath county recounted i have seen peoplegood friendswho arent speaking to each other today because they are in a big old group…its no longer hey joe come on over and help me fix my irrigation and i will come help you fix yours its no i cant come over because you have an inch more water than i do and i dont want to sue you about iti dont want to get into no organization owners were also worried about participating in formal groups that include public agencies because of bureaucratic or regulatory burdens that might be imposed on them and the discomfort of unequal power relationships an owner of 200 acres in the deschutes river watershed who had experienced frustration cooperating with federal agencies on fuel reduction and fish passage activities explained it doesnt feel good when you are feeling the heavy hand of government coming in saying you shall do this nevertheless about half of survey respondents declared membership in formal natural resourcerelated groups finally some owners mentioned laws that counter cooperation the risk of being legally liable for fires or injuries resulting from negligent conditions or activities on ones property discourages many owners from cooperating on fuel reduction work the problem is the law and the way liability is written explained one owner nobody wants to be responsible opportunities for cooperation we asked interviewees to describe cooperative arrangements for fuel reduction that would be amenable to them based on their observations or experiences and grouped their responses into three informal and three formal models that we then named in the informal over the fence model interviewees described landowners observing each others activities and doing something similar or encouraging other landowners to do more interviewees also suggested that owners could also jointly identify an issue that affects them and address it together in the informal wheel and spoke model contractors and other natural resource professionals help multiple nearby landowners learn indirectly from each others experiences leverage financial resources and access markets and fuel reduction services without negotiating terms of cooperation among the landowners involved in the local group model interviewees described local change agents creating a forum in which landowners come together to address a common problem this informal process can lead to communication cooperation learning and eventual leadership among members of the group a number of interviewees claimed that informal models of cooperation are more effective than formal models because they dont impose terms or require reciprocation which can create adversarial relationships by establishing expectations other landowners interviewed believed formal models of cooperation were more efficient and productive than informal models in the agencyled model interviewees described local natural resource management agencies providing education technical or financial support to help landowners learn from each other and interact around management activities or public funds so that landowners can implement fuel reduction themselves in the collaborative group model participants commit to a process and a product are organized by a coordinator and are guided by policy documents few owners had experience with formal landowner cooperatives however some proposed this model whereby groups of landowners would pool harvests and develop contracts with processers working through a common contractor to increase their leverage in marketing biomass and smalldiameter logs discussion cooperation is predicated on the benefits of reciprocity peoples perceptions of risk can determine how they weigh the benefits and costs of working with others this study finds that the majority of nipf owners in oregon east of the cascade mountains are concerned about fire risk to their properties and beyond their property boundaries at a broad scale those who have cooperated with others in forest management activities that can reduce hazardous fuel are in the minority however concern over fire risk did not appear sufficient to warrant cooperation with other private landowners in particular of course some owners may lack concern about forest conditions on other private properties a smaller proportion of owners were concerned about hazardous fuel conditions on nearby private lands than on public lands and some owners felt protected by heavy management on nearby private ownerships especially industrial holdings nevertheless roughly onethird of owners were concerned about the fire risk associated with other private ownerships and the majority were willing to cooperate with other private owners in the future to mitigate that risk that they have not acted on their concern in the past by trying to influence fuel conditions around them through coordinated planning and treatments with neighbors highlights the importance of other forces that work against cooperation here we draw on the literature presented earlier in this paper to discuss possible reasons for the disjuncture between nipf owners ideals and behaviors regarding cooperation shared cognition shared cognition is an antecedent to cooperation because it reduces the risk of participation when parties to a collective effort perceive consensus among group members about the nature of the problem being addressed the goals of the effort and their commitment to the group they are less likely to defect although most nipf owners surveyed perceived fire risk it was clear in interviews that they did not hold common perceptions of wildfire risk or hazardous fuel this lack of perceived consensus around the constructs of risk and hazard may hinder joint planning and implementation of fuel reduction activities some owners an organization in at least one of the above categories 521 attributed their reluctance to cooperate to conflicting values and goals regarding forest conditions and perceptions of fire hazard and risk however awareness of fire as an important local ecological process was a predictor of willingness to cooperate with other private and public forest owners suggesting that owners who share this view are more likely to cooperate social exchange theory suggests that without shared beliefs about the probability and nature of fire risk hazard and the riskreducing benefits of cooperation owners may face difficulty rationalizing efforts to engage in potentially burdensome social relationships this observation echoes what scholars of cooperation in the context of natural resources have argued without a vision of a common problem or a common future there is little reason to work together other studies of private forest owners have reached similar conclusions about the relationship between congruency of perceptions attitudes and values and joint planning group membership the constraints to cooperation that nipf owners described in interviews were predominantly related to social organization spatial isolation a dearth of integrating economic activities and social norms that inhibit communication and reciprocity among neighbors about fuel reduction survey findings that threequarters of owners do not live on their properties provide additional evidence that social organization is a constraint on cooperation rural sociologists documented early on how topographical relief and spatial isolation influence social organization and how resulting social relations affect the development of sociability rural residents in eastern oregon are spread out and isolated from each other interview informants perceived this isolation as an impediment to sociability and in turn cooperation owners described the deterioration of rural natural resourcebased economies as a barrier to cooperation although formal cooperatives have never been pervasive among nipf owners in the west agricultural cooperatives have served the practical need of connecting isolated rural residents with external markets political processes and each other with the decline in timber cattle and other commodity markets the basis for interaction and reciprocity among rural landowners in eastern oregon has become scarce moreover as communities of place are being incorporated into wider market economies and supplanted by social networks that are not geographically based people may be less inclined to rely on local residents and resources some theories suggest that less bounded contexts discourage cooperation because individuals are less likely to anticipate reciprocity due to remote relationships the demographic change associated with this shift in the rural economy may be further alienating landowners in some areas of oregons east side affluent retired and otherwise mobile urbanites have migrated to rural areas for their amenities bringing new values and expectations for land that can come into conflict with those of locals the more recent rise of property individualism and increasing focus on privacy among forest owners also run counter to cooperation landowners fears of losing autonomy or control of their properties have been welldocumented for some sharing information or inviting people over to discuss forest conditions and management may contradict values for privacy even poking ones head over a fence to comment on conditions about which one is concerned is an invasion of privacy as evidenced in the adage good fences make good neighbors without membership to a common community or social group landowners lack the structural and cultural basis for developing norms of reciprocity without interaction they lack capacity to communicate and social mechanisms for developing trust among individuals these are key conditions for cooperation lack of group identity not only reduces interaction among landowners it may also cause the lack of shared cognition about wildfire risk that owners said make cooperation difficult legitimacy although we found that some cooperation among private forest owners and public agencies occurs many owners we interviewed reported cumbersome bureaucratic processes corrosive expertlay person relationships and a lack of trustworthy leadership in natural resource management efforts that involved public agencies which discouraged them from cooperating other research has shown that nipf owners concerns about allowing government representatives onto their property and agreeing to accept agency assistance lead to struggles over private property rights and undermine cooperation these concerns arise from owners perceptions of the legitimacy of public agencies if people view an institution as legitimate they develop a voluntary sense of obligation to obey decisions follow rules or abide by social arrangements rather than doing so out of fear of punishment or anticipation of reward this feeling of obligation is essential for successful cooperation risks and benefits in social exchange survey results indicated that cooperation in fire hazard reduction does not occur frequently among private owners yet many of the owners we interviewed said they communicated and cooperated frequently with other owners to address other land management problems this discrepancy provides evidence that cooperation on fuel reduction depends on the benefits of social exchange outweighing the costs in reciprocal social exchanges the risk of betrayal is high the potential for misunderstanding or failure to meet expectations of reciprocity may explain why owners infrequently cooperated with each other despite a future willingness to do so perhaps some forms of cooperationsuch as moving cattle and equipment onto each others property and suppressing fires that have ignitedhave benefits that outweigh the risk and inconvenience of working together in contrast the benefits of cooperation in fuel reduction are less certain given the mismatch in the nature of the transaction furthermore it may be easier for parties to agree about things like relocating cattle and suppressing wildfires than about fire risk mitigation which invokes judgments about how well people manage land and protect others from risk although there are substantial risks associated with cooperation between nipf owners and public agencies these social exchanges are generally negotiated with both parties agreeing to a set of rules regarding commitments and expectations in addition substantial incentives exist for privatepublic cooperation for example when federal agencies offer costshare monies administrative and technical support and other opportunities in contrast few policies or programs encourage or reward cooperation among private owners these factors may help explain why owners have cooperated more frequently with public agencies than with each other models for cooperative wildfire risk management the fact that so many owners expressed a willingness to cooperate with other private and public owners in the future despite limited past experience and recognized constraints and the fact that about half already belong to organized natural resourcerelated groups suggests the potential for cooperation in landscapescale forest management perceived fire risk alone may not compel owners to cooperate but other policy and institutional incentives might interview informants identified a range of potential formal and informal models for cooperation the tension between the informal and formal models lies in the need for flexible lowpressure arrangements as well as coordination and efficiency some owners were willing to cooperate on an ad hoc basis others wanted cooperation to be formally organized so that it would be efficient and ensure a benefit owners suggested that among neighbors informal models may be preferable because they are less likely to make people feel rigid and defensive although owners described over the fence wheel and spoke and local group models we found only a few examples of these models operating in the context of fuel reduction in our study despite owners beliefs about the importance of cooperation and in light of the apparent lack of cooperation among owners a less risky approach to cooperation among neighboring landowners may be one in which fuel reduction occurs through formal institutions for example the high cost of removing woody biomass and smalldiameter logs and lack of financial assistance and markets for this material are commonly identified barriers to fuel reduction formal institutional arrangements that enable owners to jointly apply for costshare funds coordinate treatments and collectively offer biomass to the market could increase the economy of scale of management activities owners also identify liability and free ridership as drawbacks of cooperative fuel reduction formal institutions that coordinate management actions and pool risk can offer protection against liability and other risks associated with working with others evidence exists for the emergence of new institutions that may offer an alternative path to addressing fire risk in oregon and elsewhere in the western united states local collaborative institutions can provide an organized process for increasing the efficiency and focus of collaborative efforts without the binding terms that seem to put nipf owners on edge for example community wildfire protection plans established under the healthy forest restoration act are tools for involving communities in fire risk mitigation on federal and nonfederal lands they are funded by states but developed and implemented locally while cwpp planning and implementation efforts dont always reach beyond wildlandurban interface boundaries and engage rural forestland owners they have brought together many stakeholders and built relationships among community members around the issue of fire risk in california fire safe councils have been recognized for their ability to promote innovative fire mitigation activities and build social capital in wui communities in oregon the nonprofit group sustainable northwest is working with landowner associations to expand processing facilities and develop merchandising yards for smalldiameter wood and to promote woody biomass heating systems collaborative institutions such as these create the opportunity for frequent and sustained interaction among landowners having diverse motivations and values a necessary foundation for building shared cognition norms of reciprocity and in cases where public agencies are involved legitimacy other cooperative models that could involve nipf owners include the nature conservancys fire learning network and the us forest services collaborative forest landscape restoration program fire learning networks are regional groups that bring together public agencies tribes and municipal governments to plan and coordinate fuel reduction and forest restoration activities across ownerships the cflrp provides funding to local collaborative groups to plan sciencebased economically viable fuel reduction and ecological restoration activities on select national forest lands although focused on federal lands these efforts may be attractive to private forest owners if they help reduce the costs of or create returns on treatments on other ownerships or decrease the legal risks associated with treatments through memorandums of understanding and formal partnerships future research could explore such models and the opportunities they offer for collective action for landscapescale ecosystem management across ownership boundaries conclusion in articulating his vision for americas forests us secretary of agriculture tom vilsack has emphasized an all lands approach to forest restoration that calls for collaboration in undertaking landscapescale restoration activities cooperation across ownership boundaries in fire prone mixedownership forest landscapes is desirable yet challenging most of the nipf landowners interviewed and surveyed for this study were concerned about fire risk on their lands and hazardous fuel conditions on the properties around them and treated fuel on their properties to reduce this risk although nipf owners indicated a substantial willingness to cooperate with others on fuel reduction activities in the future their past behavior demonstrated limited cooperation perceived risk of fire occurring on ones property and from nearby public forestlands were predictors of cooperation in fuel reduction with public land management agencies risk perception was not associated with cooperation among private landowners the availability of funding and technical assistance from public agencies to help support fuel reduction on private lands the greater social barriers to privateprivate cooperation than to privatepublic cooperation and perceptions of more hazardous forest conditions on public lands relative to private lands may explain this difference interview data suggest that social values and norms about property ownership work against cooperation especially among nipf owners even when they perceive a risk of fire to their properties nevertheless cooperation does occur among private owners in arenas other than fuel reductionand it may occur indirectly through third parties such as private contractors furthermore owners say they are willing to cooperate with one another in the future thus given the benefits of cooperation for landscapescale natural resource management new institutional models of cooperation to manage landscapescale fire risk may hold promise from a policy standpoint building a common understanding of fire risk among landowners including fire risk on lands beyond their own property boundaries may increase the likelihood that landowners will cooperate with others to reduce hazardous fuel promoting this awareness among landowners who reside on their properties may be particularly effective given the positive association between residing on ones parcel and cooperation nevertheless in the absence of policies and institutions that improve the balance between the costs of cooperation and the benefits of protecting ones property from fire cooperative landscapescale management of natural hazards across ownership boundaries will be limited

managing natural processes at the landscape scale to promote forest health is important especially in the case of wildfire where the ability of a landowner to protect his or her individual parcel is constrained by conditions on neighboring ownerships however management at a landscape scale is also challenging because it requires cooperation on plans and actions that cross ownership boundaries cooperation depends on peoples beliefs and norms about reciprocity and perceptions of the risks and benefits of interacting with others using logistic regression tests on mail survey data and qualitative analysis of interviews with landowners we examined the relationship between perceived wildfire risk and cooperation in the management of hazardous fuel by nonindustrial private forest nipf owners in fireprone landscapes of eastern oregon we found that nipf owners who perceived a risk of wildfire to their properties and perceived that conditions on nearby public forestlands contributed to this risk were more likely to have cooperated with public agencies in the past to reduce fire risk than owners who did not perceive a risk of wildfire to their properties wildfire risk perception was not associated with past cooperation among nipf owners the greater social barriers to privateprivate cooperation than to privatepublic cooperation and perceptions of more hazardous conditions on public compared with private forestlands may explain this difference owners expressed a strong willingness to cooperate with others in future crossboundary efforts to reduce fire risk however we explore barriers to cooperative forest management across ownerships and identify models of cooperation that hold potential for future collective action to reduce wildfire risk

obesity hypertension social determinants of health and the epidemiologic transition among traditional amazonian populations the amazon is one of the last ecological frontiers of the planet in recent decades it has been the focus of intense social economic and environmental changes which have led to important epidemiologic implications for the local populations studies about nutrition and health of nonindigenous traditional populations of the brazilian amazon such as cabocloribeirinhos and quilombolas are still limited only recently due to new governmental policies more attention has been given to social economic territorial and health aspects of these groups however because of logistic difficulties and high costs involved with investigations of smaller and more geographically isolated populations research reporting on their health and nutrition situation continues to be a challenge in this article data related to the evaluation of adult health nutritional status and blood pressure for three different rural groups representing an important part of amazonian social diversity are presented these groups are considered vulnerable due to their ethnic and socioecological conditions and here their situation is analysed from a social determinants of health perspective according to rose it is necessary to look at the causes of causes of disease that is to go beyond the disease of the individual to the reasons why people become sick when this is done it becomes clear that the primary determinants of diseases in any population are social and economic rather than simply biologic even though genetic factors may have a strong influence on individual susceptibility genetics alone has little explanatory power over population differences in incidence of diseases marmot argues that many causes of diseases are social and political and looking only at differences between individuals often misses the point that major differences in the incidence of maladies occur between populations considering the impact of the social factors on disease occurrence in march 2005 the world health organization created the commission on social determinants of health with the objective of making the world aware of the importance of social determinants in the health situation of individuals and populations and the need to combat inequities in health created by social disparities according to the who sdh are the conditions in which people are born grow work live and age and the wider set of forces and systems shaping the conditions of daily life these forces and systems include economic policies and systems development agendas social norms social policies and political systems throughout this paper we will attempt to show how different environments and socioeconomic settings impact the health of traditional amazonian populations in order to call attention to the need for the implementation of public policies aimed specifically at these groups research location and populations data comes from research projects developed between 2008 and 2014 in the brazilian amazon basin designed to provide subsidies for debates about the health of rural populations and public policies populations with different historic origins and socioecological settings are evaluated to compare how their lifestyles and body habitus are influenced by the regions social determinants of health data collection was accomplished in areas that represent a large extent of the environmental diversity found in the brazilian amazon morán presents detailed description and analysis of the amazonian ecosystems and dufour et al in this issue provide a general synthesis of the amazon basin and its main geographic and ecological features for this reason we will describe only the specific populations and ecosystems of interest to this research the mamirauá sustainable development reservation is located in the municipal district of tefé amazonas state it was the first conservation unit of sustainable use implemented in brazil which included the idea of environmental protection and shared administration of natural resources between users and the government according to moura mamirauá sustainable development reservation has an area of 1124000 hectares located in the confluence of the solimões and japurá rivers and next to amanã sustainable development reservation in the medium solimões area amazonas state it is recognized by the international conservationist organizations as the largest floodplain protection reservation of the world according to j m ayres biologist and creator of the proposal for the sustainable development reservation the rdsm was created to reconcile the traditional mode of occupation of the amazonian floodplain with the environmental conservation practices and possibilities of providing better living conditions to local populations a recent census counted a total of 492 houses in the rdsm the population is divided into small communities with sometimes 45 and up to 3040 houses usually scattered along the margins of the main rivers of the region as in other riverine areas the exact number of communities is difficult to specify because they split frequently and new ones are created while the old ones are abandoned for several reasons such as religious differences among residents family fights and environmental circumstances such as insect infestations changes in the floodplain geomorphology or shifts in river and lake courses the rdsm is located in a region characterised by extended periods of alternation between floods and dryness and it is an extremely diverse environment in terms of biodiversity the annual floods bring giant amounts of sediments from the andes which create a rich environment responsible for the high biomass productivity of the amazonian floodplains the alternation of wet and dry periods defines the geomorphology of the area the abundance and endemicity of flora and fauna and even the patterns of human occupation human and animal activities are driven by the rhythm of the waters and the seasonal variations the alternation of periods determines access to resources and transit in the reservation during the rainingflooding period there is more abundance of fish and the duration of transportation between different locations and in the direction of the urban centres is reduced in the dry period everything is more difficult from access to clean water and food to the movement between houses and the cities the current occupation of the mamirauá region began in the 19th century by people migrating from the northeast of brazil during the rubber boom the migrants integrated with local native populations and became today´s caboclos or ribeirinhos the term caboclo has many meanings and connotations in this paper we adopt the concept presented in silva and eckhardt where caboclo are trihybrid populations with european african and amerindian ancestry living mainly in the rural areas of the brazilian amazon the participant samples from the rdsm include 76 men and 73 women all adults and residents of 78 of the homes of eight communities representative of the socioenvironmental diversity of that conservation unit data were obtained in a study to identify health and ecosystemic indicators of the amazonian floodplain involving about 550 residents of 88 houses of those localities the caxiuanã riverinecaboclo groups live in and around the caxiuanã national forest a protected area of 330000 hectares covered mainly by upland tropical forests located in the municipal district of melgaço pará state about 400 km from belém the states capital the flona is composed mainly of primary tropical rain forest flooded forests secondary vegetation and nonforested areas this protected area belongs to a black water river system with relatively acidic ph in the caxiuanã bay and the daily tides have little influence on water level in caxiuanã houses are dispersed throughout the flona in clusters varying from 2 to 10 homes but some families live in isolation in houses that are from 500 metres to 5 or more kilometres away from one another a total of 148 individuals were investigated representing about 65 of the adult population resident in the area mamirauá and caxiuanã exemplify traditional rural populations as they originated from and have lived in amazonia since the middle of the 19 th century they are descendants of the encounter of amerindians with european settlers and of africans brought to brazil as slaves but who sometimes escaped from urban centres and farms to distant places in the jungle they have lifestyles strongly dependent on subsistence activities such as agriculture of manioc and beans and corn artisanal fishery for domestic consumption and sale collection of forest products for consumption and sale in the local towns and small animal husbandry they also maintain regular contacts with regional markets and participate in temporary jobs in the ecotourism activities and provide support to scientific research in the last decade these groups have also benefited from several social programs of the federal government such as retirements and rural pensions and bolsa família the impact of these programs on health has not yet been fully evaluated the main differences between the two protected areas are related to their ecological and political settings the first is in a floodplain ecosystem and it was intended that the local communities would be involved in its management with total access to the natural resources and the latter is mainly a forestupland ecosystem legally a national protected area where the families are considered intruders and their access to the local resources is formally limited quilombos are groups formed predominantly by africanderived populations originated in brazil from slave escapees who survived in the amazon basin and other regions making use of common systems of land ownership and tenure although there are no specific genetic studies yet of the groups discussed in this study in general quilombolas of amazonia also present in varied percentages biological and cultural influences of amerindian and european groups even though there is great variation among communities the rural quilombolas are organised in settlements varying from 5 6 to two dozen or more houses close to each other usually ordered in a linear way and near to rivers and other water sources they practice mainly subsistence agriculture fishing extraction of natural products production of handicrafts for sale and small animal husbandry for survival in recent years the quilombolas also started to receive the bolsa família which became an important source of cash to many families overall 351 people from five quilombola communities africa laranjituba santo antonio mangueiras and mola all in the state of pará were included in this analysis encompassing at least 60 of the adults in the participant communities the investigated quilombo residents have subsistence patterns and socioeconomic situations similar to the riverinecaboclo groups except that they are located predominantly in areas of upland closer to the largest regional urban centre and some of them have better access to basic infrastructure such as proximity to highways electricity health centres telephones and primary schools although they suffer constant discrimination due to their assumed slave ancestry quilombolas are included in this study because they encompass a large segment of the rural amazonian populations and hence increase the diversity and range of the sample investigated and because politically they are in the same situation of social and environmental vulnerability as the riverinecaboclo groups being subject to most of the same sdh factors from a biological point of view differences among the investigated populations are possibly smaller than the similarities because of the historical origin of the participant quilombolas other information about the ecologic situation history geography social and economic conditions subsistence and health aspects of the groups and investigated areas are available in previous publications methods all the projects were approved by the institutional committee of ethics in research and the communities involved all participants signed a research consent form following the resolutions cnsbrazil 19696 and 46612 in all groups investigated sampling strategy involved a first contact with the communities to explain the research objectives obtain their group approval for participation and conduct a first population survey this was followed by one or more field trips where individual consent was obtained and personal family and household information was collected at each home of the locality or according to the desire of the community and the time frame for data collection at a central place such as a community health centre or school to where the families converged at a certain date and time previously defined this research design adapted from silva and moura made it possible to guarantee a high rate of participation of adults and children and men and women representative of the overall population of each study area the anthropometric measures were taken following procedures described by weiner and lourie and sisvan the anthropometric measurements were done by the same individuals to reduce interobserver error the anthropometric variables analysed include height weight arm circumference waist and hip circumferences and triceps subscapular and subprailiac skinfolds body mass index was generated from the weights and heights circumference measures were taken with a fabric anthropometric tape following protocols of the world health organization skinfold measures were made with a cescorf caliper according to frisancho the parameters adopted are described in table 1 the percentage of general adiposity and the amount of fat free mass were calculated from the skinfolds according to durnim and womersley the anthropometric measures were compared among sexes through an analysis of variance and the differences considered statistically significant at p 005 to analyse differences among populations a covariance analysis was performed in which the age effect was adjusted statistical analyses were performed using the spss® version 170 general health evaluation was made through a clinical exam accomplished by a physician blood pressure was checked in the brachial artery on the left side using a certified aneroid sphygmomanometer following procedures recommended by the brazilian health ministry which follows the who parameters the parameter values for blood pressure assessment according to the brazilian health ministry are presented in table 2 brasil 2006 sah systemic arterial hypertension systemic arterial hypertension is characterised as systolic blood pressure higher or equal to 140 mmhg and diastolic blood pressure higher or equal to 90 mmhg in individuals not making use of antihypertensive medication individuals with elevated blood pressure between 120139 mmhg of systolic and 8089 mmhg of diastolic tend to maintain pressure above the population average and they are potentially at higher risk of developing sah and associated cardiovascular events being considered in a stage of prehypertension information about the situation of environmental risks labour activities subsistence strategies life and housing conditions and geographiclandsocial conflicts were also obtained through participant observation and interviews as part of the sdh assessment results the studied communities have a diverse set of economic and subsistence activities from agriculture for domestic consumption and sale artisanal fishery small animal husbandry forest management handicraft manufacture and ecotourism to formal work as teachers health agents and municipal technicians this range of activities is similar to other amazonian rural populations in the last decade an important cash contribution from income distribution programs of the federal government has been given to riverine and quilombola families together with rural retirement pensions and temporary contracts of work these have increased their access to consumer goods and affected their diet the investigated communities live in different ecological environments and due to the historical combination of the main groups that contributed biologically and culturally to the formation of the current amazonian population they represent a significant portion of the regional biocultural diversity for which information about health nutrition and the sdh is still very limited all communities present precarious conditions of environmental sanitation lacking basic sanitary infrastructure and piped water and have difficult housing situations with most buildings made of wood with a small number of rooms and many of them without an internal water closet which relates directly to high intestinal parasite loads and other infectious and deficiency diseases found among these groups social and economic activities developed in the rural areas of amazonia mainly in the floodplain are strongly marked by seasonality which directly influences the life rhythm and affects access to health and education increasing the difficulty of reaching the health centres and schools during some periods of the year the sociodemographic situation of these populations is presented in table 3 caboclos and quilombolas show similar socioeconomic conditions particularly in relation to education income and number of rooms in the house however some particularities were noticed such as more accessdependence on government programs among quilombolas likely related to a closer political proximity with the urban centres and better social organisation in associations more consumer goods in mamirauá due to the several projects generated by the mamirauá institute throughout the years and access to cheaper goods from the zona franca de manaus and more residents in the houses in caxiuanã due to the legislation of the flona that limits the expansion of new families the difference in the frequency of kitchens inside or outside the houses is associated with the habits of the riverine populations who traditionally maintain their girau outside the house to facilitate food processing mainly fish and the drainage of waste water the quilombolas prefer the kitchen inside the house especially if there is a faucet with water pumped from an open well with an electric engine which indicates higher social status among quilombolas over 80 of the houses have access to electricity while less than 20 of houses among the riverine do the high number of latrines out of the house in all groups usually wholes dug directly in the ground indicates the lack of access to environmental sanitation and potential contamination of the populations and water sources by fecal materials includes bolsa família retirement pensions rural pensions and other support provided by the governments in the form of cash includes items such as motorboat boat engine gas stove radio tv parabolic antenna stereo dvd player bicycle chainsaw clock sofa sewing machine washing machine shotgun mattress electricity generator in table 4 the median values of bmi adiposity percentage amount of fat free mass and the subscapulartriceps index after adjusting for the age effect are described in the quilombolas all variables present significant differences among the two sexes except the upper arm circumference and the waist the three groups present a similar pattern in which men have significantly higher values in height weight fat free mass and sti and women have significantly higher values of skinfolds adiposity percentage and waist and hip circumferences except in the population of caxiuanã where men present a mean value of waist circumference significantly higher than women comparing the three groups quilombola men are significantly taller than men from caxiuanã and mamirauá mamirauá men have significantly higher adiposity values and percentage of general adiposity hip perimeter and amount of fat free mass in all groups women present statistically significant differences in several variables mamirauá women present height waist and hip circumferences and sti superior to the quilombolas and caxiuanã women the quilombola women present general adiposity values higher than caxiuanã and mamirauá women insert table 4 figures 2 and3 present the obesity values according to who intervals in men and women of the different age groups as the study samples are small because amazonian rural populations settlements characteristically have a small total size we evaluated overweight together with obesity as both are correlated with the elevation of morbidity and mortality rates in men in all age groups the mamirauá population presents higher values than the quilombola and caxiuanã caxiuanã men present lower values than quilombolas and mamirauá males except in the 6075 yearold age group in women the quilombola sample presents higher values than caxiuanã and mamirauá in all age groups except the 1829 and 5059 years in all age groups caxiuanã women present less overweightobesity than quilombola and mamirauá females insert figures 2 and3 the frequency of blood pressure status in the studied populations is shown in table 5 sah is more frequent among the quilombola men and women caxiuanã men have more systolic and diastolic prehypertension than the other men and mamirauá women have a higher frequency of systolic prehypertension than everyone even though this group presents the overall lower frequency of sah discussion obesity arterial hypertension and type 2 diabetes are among the chronicdegenerative diseases of larger demographic economic and social impact nowadays several studies have shown that the prevalence of obesity hypertension and diseases associated with them varies among populations depending on their degree of contact with the western culture socioecological situation impact of the market economy and government policies on their diet and lifestyle and perhaps their biological ancestry according to the brazilian commission on the social determinants of health sdh are the social economic cultural racialethnic psychological and behavioural factors that influence the occurrence of health problems and the risk factors in a population nutritional and cardiovascular diseases are known to be associated with all these factors hence by using a sdh perspective it is possible to look for the causes of the causes of these diseases and propose more adequate public policies to deal with them in brazil most of the epidemiologic studies of nontransmissible chronic diseases have been concentrated in urban areas and in the south and southeastern regions there are only a relatively limited number of studies in the north and those accomplished among rural populations are few more studies are still needed to understand the situation and distribution patterns of the diseases of modernity and to identify the biological environmental and social factors that determine the risk dynamics in these populations several investigations have shown that there is a relationship between infant malnutrition and overweightobesity and their associated diseases in adult life recent long term studies among native americans such as the shuar and the tsimane have also shown that the impacts of socioeconomic changes on health in traditional populations can be fast and dramatic although varied in level according to a number of factors research among caboclo and quilombola populations have already demonstrated high percentages of infant malnutrition and the epidemiologic transition in these groups as has been established in other developing countries the results presented here highlight that more than any single biological factor there is a direct relationship between the situation of socioecological vulnerability and the populations health in relation to both infectiousparasitic as well as chronic nontransmissible diseases both overweight and obesity prevalence in the studied populations is high especially in men from mamirauá and in quilombola women while low weight is not significant in either men or women compared to other brazilian populations men from mamirauá present very high frequencies of overweightobesity only lower than the brazilian urban population while men from caxiuanã present the lowest values on the other hand quilombola women present values as high as the general population of women of the country including from urban and rural areas separately women from caxiuanã present lower values compared to other brazilian groups from a cultural point of view among amazonian rural populations who are used to food insecurity and all types of infrastructure deficiencies there is a widespread perception that fat is healthy and that being a chubby child or adult is an indicator of good life quality according to hu the different perceptions among populations of the meaning of being fat creates in some groups a higher social tolerance to people with overweight and obesity as these are not seen as potentially sick in the investigated groups overweight is not considered a risk for diseases but a sign of health and that the family has financial resources and high social status demonstrating the need to understand the sociocultural dynamics when investigating the epidemiologic situation of these populations besides eating physical activity is one of the decisive factors in weight maintenance and gain the differential patterns of physical activity and eating habits between men and women traditionally present in the rural populations the current reduction in womens physical activity as a function of a smaller number of children the acquisition of industrialised and frozen foods that require little processing for preparation and consumer goods such as gas stove television dvd player and washing machines may have an important role in the differences observed in the frequency of obesityoverweight and hypertension among the investigated groups as gender roles work and daily activities are important sdh more detailed research at the home level is necessary to elucidate the impact of the new consumption patterns on the health of the amazonian rural populations particularly the women in relation to blood pressure the prevalence of sah is higher in the quilombola population than in caxiuanã and mamirauá the overall prehypertension prevalence and sah are correlated with the overweightobesity patterns and are of particular concern among the women who are an especially vulnerable segment of the rural populations although the prevalence of sah is not above that observed in other brazilian rural and urban populations the values show that hypertension is already a public health problem among these amazonian rural populations there are still few investigations of sah prevalence in the nonindigenous inhabitants of the rural areas of northern brazil and the direct comparison with other studies is difficult as different works usually use populations with higher age groups while for this study individuals from 18 years old were considered in a general analysis it is possible to notice that although the overall prevalence observed here is not above what has been reported elsewhere when the high prehypertension and the isolated systolic or diastolic hypertension prevalence in the three groups are also taken into consideration added to their overweightobesity situation and the socioecological precariousness in which they live a complex picture arises which combines epidemiologic and nutritional transitions reflecting the importance of the social determinants in the rural populations health and requiring immediate action to avoid an sah epidemic and its accompanying chronic manifestations generally groups exposed to greater influence of the western culture and those more involved with market economy present higher obesity and sah levels and a stronger association between blood pressure and chronological age although these effects have been observed independently of the place the populations inhabit the association patterns and environmental factors that contribute to the elevation of blood pressure and the obesity levels as well with age and ancestry have been shown to be highly variable as a consequence of the economic ecologic historiccultural and biological factors of each population characterising a strong relation among the socioecological situationthe social and environmental determinants and the healthillness of the investigated populations among the riverinecaboclo and the quilombola the difficulties related to access to potable water environmental sanitation and health services although they have improved in some areas especially mamirauá in the last years are still a matter of concern as they are involved with the origin of many diseases such as diarrhoeas anaemia and infant malnutrition and death which are among the main morbidity factors related to the sdh in the amazon region although brazil has gone through several economic and social turbulences in the last 50 years an accelerated process of nutritional transition is underway which has increased overweightobesity prevalence mainly among women while still maintaining high although falling malnutrition prevalence mainly infantile this puts rural amazonian populations such as the riverine and quilombolas in the vulnerable situation of having a double burden of disease characterising the epidemiologic transition taking place in the country and particularly in amazonia in the states of the north circulatory system diseases are currently among the main causes of death in adults while neonatal and infant mortality continues to be among the highest in the country on the other hand the amount of disease and death underreporting and registered as causes poorly defined make the existing statistics difficult to believe possibly underestimating the real health situation of the region the population of amazonia had the lowest gini index in the country in 2013 and the second smallest per capita income of the nation in that year the groups investigated here reflect that index as in other areas of brazil poverty the precariousness of environmental sanitation and of other basic infrastructure conditions illiteracy unemployment and racismdiscrimination affect mainly the selfdeclared pardo and negro and the poorer rural segments of the population where the quilombolas and the riverinecaboclo can be included further characterising their socioecological vulnerability studies indicate that in northern brazil obesity affects the poorest and lower educated population mostly and mainly women in some rural populations sah prevalence is higher among them as well and there is higher mortality among black and brown women due to circulatory diseases however as there is limited data on sah or obesity prevalence in rural populations their true impact on the several vulnerable groups of amazonia are still ignored the investigated populations fit in all the social and environmental vulnerability descriptors making it clear that they are especially vulnerable to the sdh and that specific public policies ought to be implemented urgently to improve their quality of life and health conclusions there are still few studies about the human biology of riverinecaboclo and quilombola populations this group of investigations is pioneering in the simultaneous interdisciplinary study of the morbidity situation for chronic diseases and the sdh of these combined populations it was identified that overall the precarious socioecological situation in which the studied populations live exposes them to a double burden of disease the caxiuanã population more isolated physically with less access to financial resources and more precarious infrastructure present the shortest and thinnest individuals and intermediate pre and sah levels compared to quilombolas and mamirauá quilombola men are taller and the women present higher overweightobesity prevalence both men and women have higher pre and sah prevalence among the three populations mamirauá women are the tallest the men have higher overweightobesity and there is smaller pre and sah prevalence in general the differences observed among the groups can be attributed to factors such as psychosocial stress cultural behavioural patterns more access to cash and the proximity to urban centres found among the quilombolas the intense work of the mamirauá institute for sustainable development to improve infrastructure the epidemiologic and the income situation of the resident families in mamirauá and to the particularly precarious conditions of survival sanitation health in general and almost total absence of the state in caxiuanã overall there is a strong connection between what has been defined as the sdh and the epidemiologic situation of these groups further studies in these and other populations using an sdh framework will contribute to the proposition of future measures seeking to reduce the double burden of disease associated with the epidemiologic transition and prevent among the amazonian rural populations the high mortality rates due to cardiovascular disorders observed in the urban areas in the development of our projects dialogue with the communities the local health and education professionals and the researchers has been prioritised this is to promote knowledge exchange and local empowerment as the riverine and quilombolas have been historically kept out of national public policies these research endeavours also motivated discussion with community and municipal health managers about their health knowledge and needs contributing to public policy planning aimed specifically to them we believe the information presented here can also be of use to policy planners elsewhere throughout the amazon basin where some of the worlds most vulnerable rural populations survive in different countries and are exposed to similar problems

background the health and nutritional situation of adults from three rural vulnerable amazonian populations are investigated in relation to the social determinants of health sdh and the epidemiologic transition aim to investigate the role of the environment and the sdh on the occurrence of chronicdegenerative diseases in these groups subjects and methods anthropometric blood pressure and demographic data were collected in adults from the rds mamirauá am n149 flona caxiuanã pa n146 and quilombolas pa n351 populations living in a variety of socioecological environments in the brazilian amazon results adjusting for the effect of age quilombola men are taller f985 p 0001 and quilombola women present with higher adiposity f2043 p 0001 and are more overweightobese men from mamirauá present higher adiposity f958 p 0001 mamirauá women are taller f555 p 001 and have higher values of waist circumference and subscapulartriceps index quilombolas present higher prevalence of hypertension in both sexes and there are significant differences in rates of hypertension among the women x 2 1745 p 001 the quilombolas are more dependent on government programs people from mamirauá have more economic resources and the group from caxiunã have the lowest sesin these populations the sdh play a key role in the ontogeny of diseases and the diseases of modernity occur simultaneously with the always present infectoparasitic pathologies substantially increasing social vulnerability

introduction the estimated number of new human immunodeficiency virus infections among men who have sex with men in the united states in 2010 was 29800 black msm accounted for the largest proportion of infections although the number of new hiv diagnoses among black msm increased 22 between 2005 and 2014 the upward trend appears to be slowing in recent years increasing less than 1 between 2010 and 2014 while estimating the rate of hiv among msm has proven difficult one study in new york city estimated that the case rate per 100000 among nonlatino black msm was 8781 between 20052008 compared with 3221 among latino msm and 1241 among nonlatino white msm unfortunately of the estimated 647700 msm with hiv in the us at the end of 2011 only about 85 had been tested for and diagnosed with hiv this suggests that continued efforts to diagnose msm with hiv promptly are needed to curb the hiv epidemic in this group the general population of msm with hiv experience better outcomes along the hiv care continuum when compared with other risk groups however black msm with hiv experience the lowest rates of linkage to hiv care retention in care prescription of antiretroviral therapy and viral suppression compared with msm from all other racialethnic groups and compared with their male heterosexual counterparts while predictors such as black race homelessness msm disclosure life stressors and msmrelated stigma have been associated with hiv testing and delayed diagnosis among msm less is known about predictors of delayed diagnosis among specific racialethnic groups of msm particularly those factors at the neighborhood level therefore the objectives of this study were to examine racialethnic disparities in delayed hiv diagnosis among msm and identify specific individualand neighborhoodlevel determinants of delayed hiv diagnosis for each msm racialethnic group in florida methods datasets deidentified hiv surveillance records were obtained from the florida department of health enhanced hivaids reporting system cases age ≥13 who met the cdc hiv case definition during the years 20002014 and had a reported hiv transmission mode of msm were analyzed cases with missing or invalid data for zip code at time of hiv diagnosis and missing month and year of hiv diagnosis and cases diagnosed in a correctional facility were excluded cases diagnosed in a correctional facility were excluded because they are not representative of the hiv population in the neighborhood where the facility is located and because they have different access to care than the general population with hiv infection the 20092013 american community survey was used to obtain neighborhoodlevel data using zip code tabulation areas zctas are used by the us census bureau to tabulate summary statistics and approximate us postal service zip codes individuallevel variables the following individuallevel data were extracted from ehars ethnicity race hiv diagnosis year sex at birth age at hiv diagnosis hiv transmission mode birth country hivtoaids interval in months residential zip code at time of hiv diagnosis and whether the case was diagnosed at a correctional facility data on mode of hiv transmission were selfreported during hiv testing reported by a health care provider or extracted from medical chart reviews cases were coded as usborn if they were born in any of the 50 states district of columbia puerto rico or any us dependent territory delayed hiv diagnosis was defined as an aids diagnosis within 3 months of hiv diagnosis neighborhoodlevel variables thirteen neighborhoodlevel socioeconomic status indicators were extracted from the acs to develop an ses index of florida neighborhoods percent of households without access to a car percent of households with ≥1 person per room percent of population living below the poverty line percent of owneroccupied homes worth ≥ 300000 median household income in 2013 percent of households with annual income 15000 percent of households with annual income ≥ 150000 income disparity percent of population age ≥25 with less than a 12 th grade education percent of population age ≥25 with a graduate professional degree percent of households living in rented housing percent of population age ≥16 who were unemployed and percent of population age ≥16 employed in high working class occupation income disparity was calculated as the logarithm of 100 times the percent of households with annual income 10000 divided by the percent of households with annual income ≥ 50000 and was used as a proxy for the ginicoefficient all neighborhoodlevel indicators were coded so that higher scores corresponded with higher ses they were then standardized to calculate the ses index we started by conducting a reliability analysis the cronbachs alpha for all 13 indicators was 093 we selected 7 indicators based on the correlation of the indicator with the total index and the cronbachs alpha if the item was deleted the 7 indicators selected were percent below poverty median household income percent of households with annual income 15000 percent of households with annual income ≥ 150000 income disparity percent of population age ≥25 with less than a 12 th grade education and highclass work the resulting cronbachs alpha increased second we conducted a principal component analysis with and without varimax rotation which revealed one factor with an eigenvalue greater than 1 this factor accounted for 7349 of the variance in the indicators because all the factor loadings were high we retained all 7 indicators finally we added the standardized scores for the 7 variables and categorized the scores into quartiles to categorize zctas into rural or urban we used categorization c of version 20 of the ruralurban commuting area codes developed by the university of washington wwami rural research center statistical analyses individualand neighborhoodlevel data were merged by matching the zip code at time of hiv diagnosis of each case with the zip codes corresponding zcta we compared individualand neighborhoodlevel characteristics by raceethnicity we used the cochranmantelhaenszel general association statistic for individuallevel variables controlling for zcta and the chisquare test for neighborhoodlevel variables multilevel logistic regression modeling was used to account for correlation among cases living in the same neighborhood through a random intercept using zcta crude and adjusted odds ratios and 95 confidence intervals for delayed diagnosis were calculated comparing cases by raceethnicity first we estimated crude odds ratios then we controlled for individuallevel factors finally we controlled for individualand neighborhoodlevel variables to identify unique predictors of delayed diagnosis for each group separate models were estimated stratifying by race ethnicity adjusting for year of hiv diagnosis age usforeignborn status injection drug use socioeconomic status and ruralurban status sas software version 94 was used to conduct analyses multivariate models were adjusted for year of hiv diagnosis to control for likely changes in hiv testing behaviors and hiv testing strategies over the 15year study period the florida international university institutional review board approved this study and the florida department of health designated this study to be nonhuman subjects research results characteristics of participants of 91867 hiv cases reported in florida 20002014 42493 had msm listed as a mode of hiv transmission of these 1311 were diagnosed in a correctional facility 1785 had missing data on zip code at time of hiv diagnosis and 176 had missing data on month of hiv diagnosis no cases under the age of 13 reported transmission mode as msm of the remaining 39301 cases analyzed in this study 273 were diagnosed late this represented a downward trend that started at 384 in 2000 and decreased to 185 by 2014 racialethnic disparities in delayed hiv diagnosis the proportion of cases diagnosed late decreased from 20002014 for all racialethnic groups in crude logistic regression models latino msm had lower odds of delayed diagnosis compared with white msm after controlling for individuallevel factors black msm had higher odds of delayed diagnosis compared with white msm and the protective effect of latino msm disappeared the higher odds for delayed diagnosis among black msm remained after controlling for neighborhoodlevel ses and ruralurban status predictors of delayed hiv diagnosis by raceethnicity hiv diagnosis during 20002009 compared with 20102014 and diagnosis at 20 years of age or older compared with 1319 were predictors of delayed diagnosis for black latino and white msm among black msm being foreignborn compared with usborn and living in a rural area compared with an urban area were additionally associated among latino msm only residing in a rural area at time of hiv diagnosis was independently associated with delayed hiv diagnosis among white msm being foreignborn compared with usborn was protective discussion twentyseven percent of hiv diagnoses in florida 20002014 with a reported mode of hiv transmission as msm were diagnosed late after adjusting for individualand neighborhoodlevel factors black msm were at increased odds of delayed diagnosis compared with white msm among black msm being foreignborn and residing in a rural area at the time of hiv diagnosis were risk factors rural residence was also a strong predictor of delayed diagnosis for latino msm neighborhoodlevel ses was not associated with delayed hiv diagnosis among any racialethnic msm group in florida the proportion of late hiv diagnoses among msm in florida for the years 20002014 was 273 decreased from 384 in 2000 to 185 in 2014 the decline may be partially due to revised recommendation for hiv testing such as the 2006 cdc and 2013 us preventive services task force guidelines for optout screening of adolescent and adult patients in healthcare settings while several studies have examined racialethnic disparities in delayed hiv diagnosis among the general hiv infected population few studies have examined these disparities among msm one study of msm diagnosed in 33 us states between 19962002 found significant differences in the proportion of black msm and latino msm who were diagnosed late compared with white msm however the study included the earlier years of the epidemic and used aids diagnosis within 12 months of hiv diagnosis to define delayed diagnosis in our study black msm had higher odds of delayed diagnosis compared with white msm after adjusting for individuallevel factors black msm tended to be younger with over 70 diagnosed between the ages of 13 and 39 compared with 47 for white msm differences in age as well as year of diagnosis and nativity appear to confound disparities in delayed diagnosis between black and white msm conversely the apparent advantage among latinos when compared with whites in the crude model appears to be related to differences in individuallevel factors it remains unclear why black msm are more likely to be diagnosed late with hiv previous studies and a metaanalysis suggest that black msm have higher rates of hiv testing however a populationbased study suggested that msmrelated stigma among blacks and black msm is high and higher than among whites and white msm and that unfavorable attitudes toward msm are associated with no prior hiv testing a quantitative study comparing msm who tested late for hiv with those who did not test late found that being black and homelessness disclosing malemale sex to 50 or less of people in social circle having 1 sexual partner versus more than 1 sexual partner in the past 6 months and experiencing multiple life stressors were associated with delayed hiv testing and diagnosis further black msm experience more homelessness and higher rates of depression than white msm may be less likely to disclose their msm status to others and may have or perceive less social support over 50 of black msm resided in neighborhoods in the lowest quartile of ses compared with 35 of latino msm and 20 of white msm in our study the disparity in delayed diagnosis between black and white msm decreased but remained after adjusting for neighborhood ses and ruralurban residence our results suggest that a comprehensive index of neighborhood ses and ruralurban status explain a portion of the observed disparities between black msm and white msm and do not account for the disparity that remains after controlling for individuallevel factors being foreignborn was associated with delayed hiv diagnosis for black msm our results are similar to those from a national study of 33 us states that found a higher proportion of delayed hiv diagnosis among foreignborn black msm compared with usborn black msm our population of foreignborn black msm was primarily born in haiti jamaica and the bahamas in the national study mentioned above by johnson and colleagues the proportion of caribbeanborn blacks diagnosed late was 442 higher than the proportion of africanborn blacks a study of 1060 blacks in massachusetts found that foreignborn blacks were less likely to report hiv testing compared with usborn blacks ojikutu et al found that hivrelated stigma was higher and knowledge was lower among foreignborn blacks compared with usborn blacks particularly among caribbeanborn participants than among subsaharan african participants they also found that over 50 of foreignborn blacks reported that their most recent hiv test was part of an immigration requirement the hiv testing requirement for immigrants was lifted in 2010 and has likely impacted testing patterns among immigrants after adjusting for individuallevel factors and neighborhood ses rural residence was a predictor of delayed diagnosis among black and latino msm fortyone percent of both black msm and latino msm who resided in rural areas were diagnosed late compared with 27 and 25 of their urban counterparts a previous populationbased cohort study of florida hiv cases reported that 35 of blacks in rural areas were diagnosed late compared with 29 in urban areas this suggests that not only do black msm in rural areas have a higher risk of delayed hiv diagnosis when compared with black msm in urban areas but also when compared with both the rural and urban general hiv infected black population it is possible that high levels of hivand msmrelated stigma and higher risk of loss of confidentiality in rural areas compared with urban areas are preventing msm from routine hiv testing particularly for racialethnic minorities fear of being the target of a violent crime due to hostility against msm has been reported in a qualitative study of msm in rural wyoming of note rural areas in wyoming are likely very different and more isolated from larger cities than rural areas in florida a study in europe found that msm who resided in smaller cities reported higher internalized homonegativity compared to those who resided in larger cities and that higher homonegativity was associated with decreased likelihood of hiv testing a limitation of this study is related to our definition of late diagnosis it is possible that some individuals who had aids within three months of hiv diagnosis were not diagnosed with aids until after three months however we believe that the possibility of misclassification is small given that cases with aids likely had symptoms that encouraged prompt hiv care seeking behavior furthermore hiv reporting was not mandated in florida until 1997 it is possible that cases diagnosed prior to 1997 were later reported as new hiv diagnoses and therefore mistakenly appear to have a shorter hivtoaids time interval nevertheless it is worth noting that our rate of delayed diagnosis for msm was nearly identical to national estimates additionally our dataset did not allow us to examine important variables such as individuallevel ses access to health insurance and hiv testing patterns and barriers finally the small number of rural cases limited our ability to stratify racial ethnic groups by ruralurban status to identify unique predictors of delayed diagnosis in rural areas most cases of late hiv diagnosis can be prevented it is estimated that only 3613 of infections are due to accelerated disease progression therefore regular hiv testing as per the current guidelines offers an opportunity to diagnose individuals prior to developing aids however barriers to the implementation of routine testing exist creating disparities across racialethnic and other groups our findings warrant future investigations on potential cultural barriers to hiv testing among foreignborn black msm as well as on the contextual differences between rural and urban culture that appear to affect hiv testing among msm strategies such as using social networks to increase hiv testing have shown promising results among black msm and may also be effective among foreignborn and rural populations of black msm

only about 85 of men who have sex with men msm with hiv have been tested for and diagnosed with hiv racialethnic disparities in hiv risk and hiv care outcomes exist within msm we examined racialethnic disparities in delayed hiv diagnosis msm males aged ≥13 reported to the florida enhanced hivaids reporting system 20002014 with a reported hiv transmission mode of msm were analyzed we defined delayed hiv diagnosis as an aids diagnosis within three months of the hiv diagnosis multilevel logistic regressions were used to estimate adjusted odds ratios aor of 39301 msm 27 were diagnosed late after controlling for individual factors neighborhood socioeconomic status and ruralurban residence nonlatino black msm had higher odds of delayed diagnosis compared with nonlatino white msm aor 115 95 confidence interval ci 108123 foreign birth compared with us birth was a risk factor for black msm aor 127 95 ci 112144 but a protective factor for white msm aor 077 95 ci 068087 rural residence was a risk for black msm aor 179 95 ci 136235 and latino msm aor 187 95 ci 124284 but not for white msm aor 126 95 ci 099160 hiv testing barriers particularly affect nonlatino black msm social andor structural barriers to testing in rural communities may be significantly contributing to delayed hiv diagnosis among minority msm

background the increasingly elderly population in many western countries has created an increased demand for high quality medical and social care services this includes nursing home care referring to facilities providing 24h functional support and care for persons who require assistance with activities of daily living and who often have complex healthcare needs 1 achieving quality in nh care is complicated by the fact that care quality is multifaceted difficult to define and measure and may be perceived differently by different stakeholders 2 regulatory agencies thus often struggle to identify factors most important in achieving highquality nh care 3 a particular challenge in regulating quality in nh care is that it is in many regards a soft service in which the individual experiences of the nh residents is an important dimension of quality while many aspects of quality must be considered in order to achieve a wellrounded assessment of the care provided at a given nursing home some scholars have argued that resident satisfaction may be the most appropriate assessment of quality in nh care 45 in health care investigations of patient satisfaction are abundant 67 while studies measuring nh resident satisfaction are less common this may be due to the suggestion that elderly patients with cognitive weaknesses have difficulty reliably answering surveys 5 though studies have shown that patients in cognitive decline are capable of answering surveys particularly if they are designed with their needs in mind 8 9 10 11 given that the satisfaction of residents is an important dimension of quality in nh care the question becomes how this is achieved that is to say what factors are most important to focus on when seeking to improve the satisfaction of nh residents the most commonly used analytical framework for understanding how quality is generated in health and social care is donabedians structureprocessoutcome model 1213 a central distinction in donabedians model is that between structural and processual quality factors which are seen as potential explanatory factors behind quality outcomes structural factors refer to the physical attributes of the setting in which care is provided including the number and qualifications of staff equipment and physical facilities 13 processual factors denote the manner in which the care services are delivered eg whether care routines follow set guidelines and the extent to which residents are involved in decisions about their care quality outcomes can be measured in many ways both objectively in the form of health status or subjectively in the form of patientresident satisfaction 12 a central unresolved question posed in donabedians work is whether structural or processual measures are most important for generating outcome quality and precisely how these factors interact to produce the desired outcomes the literature on medical quality in nh care in terms of for instance mortality and adverse event rates has investigated numerous explanatory factors including staffing ownership care routines and the size of facilities 14 15 16 17 such studies are particularly abundant in the united states where collection of the minimum data set provides a robust basis for performing broad studies of clinical outcomes there are considerably fewer investigations of the determinants of resident satisfaction previous studies have investigated structural factors including staff satisfaction 18 and job commitment 19 with both studies finding positive associations with resident satisfaction a broader study of the influence of organizational factors found that nh ownership staffing levels and the provision of family councils were important predictors of nh resident satisfaction 20 others have investigated specific interventions related to processual quality factors such as improved meal time routines 21 personcentered care initiatives 22 and social activity programs such as gardening 23 while generally finding positive effects on resident satisfaction these interventional studies are narrow and differ in terms of setting and methodology making them difficult to compare taken together the prior literature on what factors are associated with resident satisfaction in nhs is largely limited to evaluations of specific interventions and there are few studies investigating the relative influence of structural and processual factors particularly in the european context in sweden several public investigations have pointed to quality deficiencies and a lack of systematic knowledge about factors leading to improved quality 2425 the issue of nh care quality has increased in significance in swedish public debate as reforms have led to an increasing number of homes contracted out by local governments to private often forprofit firms in 2017 one study found that about one fifth of the swedish nhs were run by forprofit providers 26 this study as well as another recent investigation of danish nhs found that overall privately operated homes outperformed public and nonprofit homes in terms of process measures while underperforming in terms of structural measures 2627 neither of these studies investigated resident satisfaction however in sweden there is good availability of data on various aspects of nh care due to comprehensive data collection efforts by the swedish national board of health and welfare annual surveys measuring satisfaction are sent by the nbhw to all nh residents and surveys assessing processual and structural measures of quality are sent to every nh in sweden so far however the use of these data for research has been limited one exception is a study by kajonius and kazemi 28 which investigated differences in satisfaction among nh residents at the municipal level finding that processual quality factors such as respect and access to information appeared to be more important for residents than structural factors such as staffing and budget in this study we aim to evaluate which structural and processual measures of quality have the strongest associations with overall nh resident satisfaction in doing so we hope to provide policymakers and researchers with a broader picture of the determinants of resident satisfaction as nhs than has previously been available methods setting in sweden all citizens have access to publicly funded nh services at heavily subsidized rates the eldercare system in sweden is decentralized with responsibility for service provision resting with the nations 290 municipalities municipalities are obliged to offer nh care to those determined to have a need for such care based on national criteria the municipality may provide services themselves or contract out service provision to private entities 29 in 2016 there were in total 88886 individuals 30 living in ca 2300 nhs in sweden 31 with 205 of residents living in nhs operated by private providers 30 while marketization reforms have led to an increase in the proportion of privately managed nhs they remain publicly funded 32 all nhs both public and private are subjected to the same national quality reporting requirements user safety regulations and auditing measures 33 this study includes all nhs in sweden providing care to individuals over 65 years of age in 2016 excluding facilities offering only shortterm care data collection two nationally representative surveys conducted in 2016 both developed and administered by the nbhw serve as the primary sources of data the first survey is a user satisfaction survey distributed yearly to all individuals over 65 years of age receiving elder care services including nh care this survey consists of 27 separate items to be rated on a fivepoint likert scale relating to their satisfaction with a variety of aspects of elder care services as well as their health status among those living in nhs the survey had a response rate of 56 in 2016 resulting in a total of 40371 responses 34 the second data source is a survey sent directly to all nhs in sweden by the nbhw which assesses a number of processual and structural measures of quality this survey is completed by administrative staff at each nh and had a response rate of 93 in 2016 resulting in 2153 responses 35 in addition to quality measures the unit survey provides data on the type of services provided by the nh the number of residents in each home and whether the nh is operated by a public or private entity while the nbhw has a long experience of developing and administering surveys and assessments of lossto followup in the user survey have been performed 36 the psychometric properties of these surveys have not been published in the publicly available literature observations in the two nbhw survey datasets for 2016 were matched based on the nh name and municipality this involved both an automated matching process and a subsequent manual review of unmatched records municipalitylevel variables were extracted from the national municipality and county council database kolada 37 and merged into the dataset variables variables for analysis were aggregated from the two surveys based on their conceptual meaning and the results of an exploratory factor analysis which may be found in additional file 1 p 17 the extracted variables are detailed below and a summary of the categorization is available as additional file 2 dependent variable upon exploratory factor analysis it was found that questions in the user survey were highly correlated and was a poor candidate for approaches based on extraction of distinct latent variables as such we chose to extract a single composite measure of satisfaction from the user survey for use as the dependent variable consisting of questions 519 2125 and 27 to generate a composite measure for use as the dependent variable the percent of residents at a nursing home responding positively to a given survey question was normalized by subtracting the average percentage of patients responding positively to that question in the population and dividing by the standard deviation of the population resulting in a standardized zscore zscores were then averaged across all included survey items to result in a composite score with equal weights for each question independent variables the nbhw divided the unit survey into 12 conceptual categories a factor analysis showed that the individual questions generally loaded well onto the categories proposed by the nbhw and it was therefore chosen with a few exceptions to retain this categorization as the basis for the independent variables used in the analysis based on the donabedian model the independent variables were divided into structural and processual variables processual variables the first seven variables related to different processual factors such as mealrelated routines or physical or social activities questions 1 and 1a in the unit survey related to the ability of residents to participate in resident councils where residents regularly meet to voice concerns in the nh issues raised during resident councils may for instance include the planning of common activities or menus for the coming weeks these were aggregated and reported as the variable participation in resident councils questions 2 and 3 in the unit survey concerned the existence of and the residents participation in the creation of action plans concerning the care needs and wishes of the resident these action plans contain information about how various care activities are to be carried out and should be updated every 6 months the questions were combined into the variable individualized action plans questions 4 and 5 addressed the existence of mealrelated routines and the documentation of meal preferences in the residents action plans such meal routines are to be based on the five aspects meal model proposed by gustafsson et al 38 and should be updated every 24 months the questions were combined into the variable mealrelated routines and plans questions 6ac in the survey related to the existence of formal routines for handling resident safety issues such as threats violence and addiction while the nbhw grouped question 7 into this category it did not load well onto a common factor and is conceptually quite distinct and was therefore excluded the remaining questions were combined into the variable patient safety routines questions 8 and 8ab in the unit survey related to facilities for and availability of exercise and social activities we excluded question 8 which had a weaktomoderate factor loading so as to interpret this variable as a purely processrelated measure the remaining questions were combined into the variable availability of exercise and social activity questions 9 and 10 related to the existence of routines for planning care in cooperation with other healthcare providers and whether residents involvement was documented similarly questions 11 and 12 related to routines for medication reviews and whether resident participation is documented in the medical record we reported these as the variables care coordination routines and medication review routines respectively structural variables the structural variables included indicators of staffing ownership and size three factors relating to staffing from the unit survey including the ratio of nurses per resident nonnurse staff per resident and the portion of staff with an adequate education for their position were identified these are reported as the variables nurses per resident staff per resident and staff with adequate education respectively and weekday and weekend staffing levels were weighted at a 52 ratio to represent average daily staffing levels while staffing ratios are fairly straightforward to calculate the definition of what constitutes an adequate education is more complex adequacy is determined by the amount of healthcarerelated training completed by nonnurse staff based on a point scale established by the nbhw 39 the number of beds available at each nh was reported as size of nursing home the nhs ownership status ie whether it was run by a private or a public provider was reported as the variable private ownership controls several variables were included in the analysis to control for population health differences between the nhs included in this study selfrated health has been found to be an excellent predictor of clinical outcomes 4041 and we used questions 13 and 20 in the user satisfaction survey which asked about the residents physical and mental wellbeing to control for health status the type of facilities available at the nh was also controlled for it was further deemed necessary to control for demographic factors for which data was only available at the municipal level this refers to different demographic economical and political conditions which may vary significantly between the 290 municipalities a set of controls were adapted from previous studies 264243 including per capita income levels population density age profiles political control and expenditures the details of which may be found in table 1 data at the municipality level was collected from the kolada database 37 statistical analysis as the large number of quality measures made available by the nbhw was unsuited to direct inclusion in a regressionmodelling framework an initial exploratory factor analysis was performed to reduce the dimensionality of the dataset as described above data from the user satisfaction survey and the unit survey were aggregated at the nh level we sought to minimize bias in the estimation of the effects of the investigated quality measures by drawing upon the approach to causal modelling first described by pearl 44 using the assumptions of causal directionality described by the donabedian model of healthcare quality 1213 the donabedian model asserts that a causal relationship exists between structural and processual aspects of healthcare quality and we assumed that the satisfaction of nh residents would be confounded by their health status to control for confounding due to these causal relationships the effects of processual measures of quality were modeled controlling for resident health and structural measures of quality we present coefficient estimates for structural measures including controls for other measures of structural quality though the direction of causality within the selected set of structural measures is in many cases unclear in addition to these full models we present additional nested models estimating bivariate associations and models controlling only for resident health in this framework variations in the regression coefficients between the full and nested models allowed for the interpretation of the impact of health status and structural factors on the effect of the quality measures the aggregated variables were first analyzed in a classical ordinary least squares regression framework using the huberwhite sandwich estimator to account for heteroscedasticity and clustering as implemented in the rms r package 45 hierarchal models including municipalitylevel controls with random intercepts for municipalities were implemented using a partial pooling approach to account for clustering and confounding due to municipallevel factors 46 as implemented in the lme4 r package 47 confidence intervals were generated using basic parametric bootstrap resampling in this analysis we report our results in terms of standardized regression coefficients while this allows for direct comparison of the importance of each independent variable in predicting resident satisfaction it makes interpretation in terms of absolute effects cumbersome given the low rates of missing data at the unit level multiple imputation was not deemed to be necessary and cases with missing values were deleted listwise in the relevant models all statistical analyses were performed using r version 350 and a reproducible accounting of our reported findings is included as additional file 1 a number of sensitivity analyses investigating the impact of various model specifications potential biases due to loss to followup and assumptions made in the main analysis are also included in additional file 1 source code and the data necessary to reproduce these findings are available on mendeley data 48 results data from both surveys were aggregated at the nh level resulting in 1921 records in the user survey and 2189 records in the unit survey 1711 records could be automatically linked based on municipality and nh names and an additional 87 records could be matched through manual review resulting in a dataset containing 1798 nhs an analysis of nonmatched records may be found in additional file 1 p 78 an analysis of the association between survey response rates and the investigated variables was performed we found a positive association between response rates and resident satisfaction as well as a negative association between response rates and nursing home size and an effect indicating that private nursing homes had higher response rates generally residents of nhs were quite satisfied in the 2016 survey 83 answered that they overall were fairly or very satisfied with the care they received descriptive data descriptive statistics were generated for each of the variables included in the analysis and are presented in table 1 we found that the average nh in sweden has space for 43 residents a resident to staff ratio of roughly 351 a resident to nurse ratio of 301 and that 83 of nonnurse staff had an adequate level of education as defined by the nbhw criteria 19 of included nhs were operated by private providers 80 of nhs offered general care services while 60 offered dementia care services and only 5 had assisted living facilities these sum up to over 100 as a single nh can offer more than one type of service with regard to municipality level statistics we see that about 21 of swedes are over the age of 65 4 of whom live in nhs where the average age of residents is 83 the average annual perresident cost for the municipality is 838 thousand sek while average per capita taxable income is 188 thousand sek regression analysis figure 1 presents the summarized results of each of the models developed to characterize the independent variables created from the unit survey 1a presents the results using a classical ols regression framework while 1b presents the results of hierarchal mixedeffects models controlling for municipal level effects in terms of overall predictive value an ols model including all covariates achieved an adjusted r 2 of 0182 while the conditional r 2 value 49 of the multilevel model containing all predictor variables was 0254 in the multilevel framework we found that variation between municipalities accounted for 10 of the total variation found between nhs a total of 12 processual and structural variables were extracted from the unit survey for analysis as independent variables upon analyzing the results variable groupings were identified post hoc based on similarities with regard to effect sizes and conceptual meanings which are used to simplify the discussion of our findings and are labelled on the righthand side of fig 1 the variables in the first group labelled individualized care are all related to the individual care process they include the variables participation in resident councils individualized care plans and mealrelated routines and plans this group had an average effect size of 006 in our fully controlled models and while 95 confidence intervals in the main model consistently excluded zero after adjusting for municipalitylevel covariates the significance of the variables in this group varied upon sensitivity analyses however see additional file 1 p 22 23 24 25 the next group labelled safe care includes the variables patient safety routines care coordination routines and medication review routines they are all related to the existence of formal guidelines dealing with various aspects of care as seen in fig 1 none of these variables displayed significant correlations to resident satisfaction the final group in the processual category consists of only one variable availability of exercise and social activity this variable labelled activity displayed the highest degree of correlation with overall resident satisfaction among the process variables with an effect size of 011 in our fully controlled model and was robust across a range of sensitivity analyses turning to the structural variables another three variable groups were identified we identified no significant effects in the ols model with regard to ownership status upon controlling for municipalitylevel variables a significant positive correlation with a magnitude of 006 in the fully controlled model was found though the significance of the association was sensitive to variations in model specifications the size of the nh was by a significant margin the most important predictor of resident satisfaction in this analysis with the negative coefficient suggesting that smaller nhs are associated with more satisfied residents a small decrease in the effect of this variable could be noticed upon controlling for municipality level effects suggesting that larger nhs may be more common in municipalities where residents are on average less satisfied with their nh care the effect of size was robust in our sensitivity analyses the third group of structural variables included nurses per resident staff per resident and staff with adequate education and was labelled staffing the group as a whole had an average effect size of 005 among the fully controlled models with the exception of nurse staffing ratios 95 confidence intervals consistently excluded zero in the main models but the significance of the effect was sensitive to varying model specifications taken together the results of the analysis presented in fig 1 show that the structural measure size of the nh was the most important predictor of resident satisfaction followed by the processual availability of exercise and social activity variable the effects of the processual individualized care variables and the structural staffing variables were similar in magnitude as was the effect of private ownership upon controlling for municipalitylevel effects these effects were also sensitive to alternate model specifications the processual safe care variables were not found to have any significant association with resident satisfaction finally a comment on the significant effects found among our control variables is in order in our fully controlled model selfrated health was found to have a strong positive correlation with satisfaction suggesting that healthier residents reported considerably higher levels of satisfaction among the municipality level controls average nh resident age had a positive correlation with satisfaction and average per capita taxable income had a negative correlation with satisfaction interestingly no significant relationship between the amount spent per resident and satisfaction was identified full model summaries along with a table reporting the data upon which fig 1 is based may be found in additional file 1 p 1215 discussion in this study we investigated a total of 12 variables representing different aspects of care quality reported in the nbhw unit survey of these seven were considered to represent processrelated quality and five to represent structural quality our main findings were that the size of a nh had the greatest impact on resident satisfaction followed by the processual measure availability of exercise and social activities the processual variables concerning individualized care and the structural staffing and private ownership all had similar weakly positive effects on resident satisfaction the processual safe care variables had no significant effect on resident satisfaction we found no clear differences in terms of effect sizes between processual and structural variables below we discuss these findings in order of the effect size identified in our results the fact that nh size was the best predictor of resident satisfaction suggests that smaller nhs in sweden had more satisfied residents than their larger counterparts a recent literature review surveying studies examining the impact of nh size on quality outcomes showed size to be an important predictor of quality with smaller homes generally having better quality outcomes 15 none of the 30 studies investigated the relationship between size and resident satisfaction though five investigated similar composite quality of life measures there are however some indications that larger nursing homes may be associated with better clinical outcomes such as lower hospitalization risks 50 and lower rates of antipsychotic medication use 51 nh quality is a multifaceted concept and it is not necessarily the case that the determinants of quality will affect all aspects of quality in the same way as such while this study does add to the evidence that smaller nhs are associated with the type of soft quality which resident satisfaction may be said to represent the results should not be interpreted as saying anything regarding harder measures including clinical outcomes the determinants of which may be quite different while size may be an important predictor of satisfaction in and of itself it is also likely that there are causal mechanisms behind this association which mediate the effect of size previous research has for instance indicated that staff turnover may be lower 52 and staff continuity higher 53 at smaller nhs the findings of this study thus emphasize the importance of identifying the more proximal mechanisms by which smaller nhs generate higher levels of satisfaction the interpersonal aspects of nursing home care which these measures reflect are however difficult to measure and investigating the mechanisms behind these softer dimensions of nursing home care may require a more qualitative approach the availability of exercise and social activities was found to have the strongest association with resident satisfaction among the processual variables previous research has found that physical activityrelated interventions can improve the subjective health status of nh residents 54 although other studies have found weaker or even negative effects 55 our results suggest that overall nhs which offer more frequent opportunities for exercise and social activity have higher levels of resident satisfaction the effect of activity was not diminished by controlling for resident health or nh structure rather the effect increased slightly suggesting that the provision of such activities may be even more important at nhs with poorer structural preconditions particularly with regard to facility size three other variable groups had weaker effects with regards to resident satisfaction individualized care private ownership and staffing the individualized care variables included participation in resident councils the use of individualized care plans and the use of meal routines we identified no previous research regarding the impact of resident councils or the use of individualized care plans on satisfaction in the literature though lucas et al 20 did identify a positive impact of similar family councils our findings suggest that these quality improvement measures may indeed be associated with higher levels of resident satisfaction although more directed studies are necessary to confirm this there is some evidence that interventions to improve mealrelated processes are effective 5657 and our results are consistent with a positive impact of such improvements on resident satisfaction the structural measures related to staffing had effect sizes similar to those found among the processual individualized care measures staffing as a determinant of care quality has been well researched in a review of 70 articles castle 58 found a preponderance of evidence suggesting that increased staffing levels are positively associated with several measures of nh care quality more recent studies by castle and anderson 59 hyer et al 60 and shin and hyun 61 point to similar results however none of these studies investigated effects on resident satisfaction we found that both nonnurse staffing ratios and education levels were associated with resident satisfaction in all models while nurse to resident ratios were significant upon controlling for municipallevel factors and effect sizes were reduced upon controlling for other structural factors our results are thus consistent with a positive relationship between staffing levels and nh care quality regarding the effect of ownership the main results suggest a higher level of resident satisfaction among privately operated nhs after controlling for municipal level covariates that is to say while there was no overall difference in absolute levels of satisfaction a difference was identified upon taking into account that public and private nhs are not evenly distributed across sweden and that when the effects of this nonuniform distribution was accounted for a difference could be identified the somewhat counterintuitive effect could at least in part be explained by the tendency of private care providers in sweden to establish themselves in municipalities with higher income levels where resident expectations may be higher this supposition is supported by the finding that average per capita income had a significant negative association with resident satisfaction the significance of ownership status was not robust in sensitivity analyses however and as such constitutes quite weak evidence for the superiority of private over public nursing homes with regards to resident satisfaction while we found no association between measures of safe care and resident satisfaction it stands to reason that the processes which these measures represent are not immediately visible to residents and are thus less likely to influence satisfaction studies investigating the impact of these measures on clinical outcomes may well find that they do have an effect with regards to quality in that respect taken together the findings of this study indicate that nh residents are more satisfied in smaller nhs and nhs with frequent opportunities for physical and social activity only weak effects were identified with regards to processual individualized care measures private nursing home ownership and staffing levels formal routines had no effect on the satisfaction of residents another contribution of the study is the comparison of the effect of structural and processual variables on satisfaction in contrast to a previous study on swedish nh care 28 this study did not lend support to any firm conclusions regarding the superiority of one type of quality measure over the other rather it was demonstrated that both structural variables such as size staffing and ownership and processual variables including individualized care and activities play a role in determining resident satisfaction the difference in results between the two studies could be explained by the fact that the processual and outcome variables in the kajonius and kazemi study were both drawn from the resident survey while the structural variables they were compared with were drawn from a separate statistical database lacking this overall correlation it is thus likely that the differential effects identified by kajonius and kazemi are an artefact of how the authors chose to operationalize the processual and structural measures furthermore in the study data was aggregated at the municipal level thereby investigating only differences in resident satisfaction between municipalities which we found to account for only 10 of the total variation in satisfaction between nhs strengths and limitations this study was a secondary analysis of two nationally representative surveys collected for quality improvement purposes a strength of the study is thus that the results are likely to generalize well to other contexts similar to that of sweden and the wide scope of these surveys allowed us to investigate and compare a broad range of factors a limitation of the study was that the validity and reliability of these surveys has not been established in the publicly available literature although the nhbw has analyzed the impact of loss to followup in the user survey 62 and performs ongoing internal quality assurance of the surveys it conducts another risk involved in the secondary analysis of data is the proliferation of researcher degrees of freedom arising from the numerous decisions which must be made in transforming and analyzing such data 63 to ameliorate these risks we sought to define our analysis strategy a priori and provide the resources necessary to fully reproduce our results 48 another limitation is that the aggregate data used in this study precludes the interpretation results in terms of individuallevel effects and readers must be careful to not commit the ecological fallacy of interpreting effects operative at the nh level as applying to individuals among other simplifying statistical assumptions including those of additivity and linear effects we assumed that each question in the survey was equally important to residents in generating the composite measure used as the dependent in our analysis weighting each question equally would seem to be a reasonable assumption to make in the absence evidence regarding resident preferences and the main findings regarding nursing home size and availability of activities were robust to a range of sensitivity analyses and alternate survey question weights it was common for the satisfaction surveys to be completed with the assistance of third parties which could potentially influence reported outcomes and while the rate of missing data was too high to include this variable in the formal analysis a sub group analysis of homes reporting data on this variable may be found in additional file 1 p 2122 based on our findings we do not expect this factor to be a threat to the validity of our results we also analyzed the associations present within the user survey data between nh level response rates and the quality measurements reported in the study we identified a positive correlation between response rates and satisfaction rates as has been found in previous studies of this phenomenon 6465 we also identified effects suggesting that response rates were higher at smaller nursing homes and at private nursing homes previous studies have suggested that low response rates are likely to result in an overestimation of satisfaction 64 as such bias resulting from the systematic differences in response rates would likely be in the direction of underestimating the association of size and private ownership with satisfaction conclusions of the quality factors investigated nh size had the most prominent association with satisfaction followed by the availability of exercise and social activities processual measures relating to individualized care such as participation in resident councils and the formulation of individualized action plans had a weak association with resident satisfaction as did other structural factors such as staffing ratios and staff education the results also suggested that privately managed nhs had a slightly higher level of resident satisfaction though the effect was similarly weak and appeared only after adjusting for municipalitylevel covariates the results in this study suggest that both structural and processual quality factors matter in determining resident satisfaction with nh size and the availability of exercise and activities having the greatest impact implications for policy and practice while the findings in this study suggest a direct link between offering more activities and a higher rate of satisfaction more research is needed to determine why residents appear more satisfied at smaller homes it may be that the proximal causes of satisfaction at smaller nhs could be replicated at their larger counterparts for instance by improving staff continuity and turnover if so this could be a costeffective alternative to building smaller nursing homes qualitative studies using methods such as interviews and participant observation may be most appropriate to investigate such effects in more depth another policy implication is that activities for residents should be a priority in nh care and in cases where nhs care is contracted out offering physical and social activities should be a requirement supplementary information supplementary information accompanies this paper at 1186s1291301946949 additional file 1 analysisnotebook this document provides additional details regarding the factor analysis undertaken to reduce the dimensionality of the data prior to regression analysis additional details regarding the main analysis and a number of posthoc analyses undertaken to evaluate the sensitivity of the findings and investigate a number of interesting findings suitable for pursuit in further research additional file 2 surveyquestions this document details the specific questions from the two nhbw surveys constituting the aggregate variables included as independent variables in the regression analysis reported in this manuscript abbreviations famm five aspects meal model iqr interquartile range nbhw national board of health and welfare nh nursing home ols ordinary least squares regression sek swedish krona authors contributions ds uw and pb conceived of and designed the study ds performed the analysis and drafted parts of the manuscript yl performed data cleaning record matching and drafted parts of the manuscript all authors provided substantial input and revisions and approved the final manuscript funding the study was funded by the swedish research council for health working life and welfare dnr 201405134 the funding body had no role in the design of the study or collection analysis and interpretation of data or in writing the manuscript open access funding provided by uppsala university competing interests the authors declare that they have no competing interests

background resident satisfaction is an important aspect of nursing home quality despite this few studies have systematically investigated what aspects of nursing home care are most strongly associated with satisfaction in sweden a large number of processual and structural measures are collected to describe the quality of nursing home care though the impact of these measures on outcomes including resident satisfaction is poorly understood methods a crosssectional analysis of data collected in two nationally representative surveys of swedish eldercare quality using multilevel models to account for geographic differences results of the factors examined nursing home size was found to be the most important predictor of resident satisfaction followed by the amount of exercise and activities offered by the nursing home measures of individualized care processes ownership status staffing ratios and staff education levels were also weakly associated with resident satisfaction contrary to previous research we found no clear differences between processual and structural variables in terms of their association with resident satisfaction conclusions the results suggest that of the investigated aspects of nursing home care the size of the nursing home and the amount activities offered to residents were the strongest predictors of satisfaction investigation of the mechanisms behind the higher levels of satisfaction found at smaller nursing homes may be a fruitful avenue for further research

introduction worldwide nearly 20 million children suffer because of sam every year half of the global childhood mortality is caused by malnutrition and onethird of these deaths are caused by sam alone 1 south asia and subsaharan africa show the highest rates of underweight and stunting 23 almost 78 of wasted children belong to the three southasian nations pakistan bangladesh and india 4 as every sixth person in pakistan lives in poverty 56 the rate of child malnutrition in the country is higher than those of other southasian nations 7 previous evidence around the globe shows that supplementary programs have reduced moderate and severe acute malnutrition in children 8 9 10 11 recently governments across the world adopted multisectoral strategies to address the problem of malnutrition these strategies combine nutritionspecific and nutritionsensitive indicators however evidence showed that the multisectoral solution strategy remained less successful in achieving the desired results 1213 in pakistan a nutritionspecific cmam therapeutic program was set up in southern punjabs povertystricken and floodaffected districts to deal with sam under the cmam program moderate as well as noncomplicated sam cases are treated with readytouse therapeutic food whereas complicated sam children are referred first to the nutrition stabilization center by lhws once complicated sam cases become stabilized by using specialized medical milk 75100 they can use rutf ingredients in rutf depend on the local acceptability availability and cost but a standard rutf is made up of milk powder peanut butter vegetable oil vitamins minerals and sugar the advantage of the product is its long shelflife without refrigeration but its demerit is its import as it is not prepared locally a sufferers experience is a social product shaped by structural violence which may be defined as violence built into the structure and shows up as unequal power and consequently as unequal life chances 14 kawachi et al 15 observed that unequal health hazards for individuals are the product of social economic cultural and political processes in society because health outcomes are curtailed by the exploitative apparatuses of resource distribution power and social control structural violence is indirectly exercised by different parts of the social machinery of oppression and is apparently nobodys fault 16 similarly quesada hart and bourgois 17 defined structural vulnerability as a product of classbased economic exploitation and cultural gendersexual and racialized discrimination and processes of symbolic violence and subjectivity formation that have increasingly legitimized punitive neoliberal discourses of individual unworthiness state institutions and programs ignore certain individuals based on caste gender and class thus subjecting them to indirect violence this results often in the failure of development programs 18 and children and mothers with lower social and cultural capital bear the brunt of this structural violence 19 as these development programs often fail to achieve their stipulated targets a lasting impact of such programs is that the poor in the target population becomes indifferent to similar interventions in the future they tend to deprioritize health and normalize disease and malnutrition 20 rather than seeking to benefit from government intervention due to their negative experience of these programs the legacies of underdevelopment stigma and discrimination along with insufficient public healthcare systems lead to poorer health outcomes for rural poor and ethnically marginalized households state institutions development and poverty alleviation programs often ignore the individuals belonging to poor rural and lower castes 21 inequalities based upon castes gender and class in south asia have failed development programs because they marginalized poor and weaker members 1819 which resulted in maternal and child health disparities 19 in south asia the poor often face difficulties becoming beneficiaries therefore evidence 22 suggested that area gender caste and class determinants of social exclusion must be advised for program objectives eligibility criteria of clients and the selection process social capital is required to access medical settings 23 along with it studies have explained that the corruption within the governments medical settings in pakistan and india showed a lot of parallels 24 25 26 this study gives the narratives of healthcare providers and mothers of sam children seeking treatment from the therapeutic program in the district of rajanpur of punjab province in pakistan this qualitative study contributes to the literature by describing barriers and resources while accessing nutritionspecific services the study focuses on the issues of health sector corruption structural inequalities and the role of social capital it adds to critical medical anthropology and the public health literature it also investigates challenges and barriers to health and therapeutic coverage why the government lacks interest in the implementation of the nutritionspecific program and how the poor are generally secluded materials and methods data collection the qualitative data for this study were collected during fieldwork in the rajanpur district of south punjab from january to may 2017 this area was selected purposefully because it was floodaffected povertystricken and where female illiteracy and maternalchild malnutrition rates were highest in the whole province development infrastructure such as healthcare facilities was also scarce and where rural poor women face disparities this exploratory study was based on a purposive selection of key stakeholders involved in the cmam program including healthcare providers and mothers of malnourished children after reviewing the available literature and using keywords such as social barriers and structural challenges to therapeutic coverage 10 27 28 29 a semistructured interview guide was developed for interviewing which was pretested with a few respondents and also updated from time to time whenever more information about the issue was revealed during the fieldwork exploratory research as a methodological approach investigates those research questions that have not previously been studied in depth exploratory research is often qualitative involving a limited number of respondents but is indepth in nature therefore only the most relevant stakeholders were interviewed healthcare providers first because they might have been cooperative in introducing other key stakeholders ie mothers of malnourished children enrolled in the therapeutic program thus in the next phase mothers of malnourished children were interviewed for this study first key informants interviews with key officials of the district health authority were conducted face to face by the principal author who has experience in public health nutrition and knowledge of medical anthropology secondly a focus group discussion with lhws was conducted in a healthcare facility by the two qualitative researchers in the group discussion 10 participants were maximally allowed to take part participants of this discussion were inquired about the major difficulties barriers and challenges that hampered therapeutic coverage at the district level finally healthcare providers helped to identify and communicate with mothers having sam children the mothers of malnourished children were identified by the nutrition assistants appointed at scs and lhws involved in the cmam program to seek consent to take part in this research 30 mothers were informed about the nature of the study however consent could be agreed upon by 20 mothers we chose the respondents places deliberately so that they felt safe and comfortable audio recorders were not used owing to locals comfortability and cultural sensitivity indepth interviews were in a flexible format ranging from one to two hours all interviews were conducted facetoface in the local language the openended indepth interviews continued until experiences and essences were repeated and until information saturation was achieved through 10 mothers the majority of the mothers of sam children were either uneducated or had a few years of schooling along with minimal sociocultural capital and disadvantaged economic status data analysis without delays researchers translated verbatim all the qualitative data obtained from group discussions semistructured interviews and field notes from the local language to the english language then we reviewed all the raw data available and labeled all sentences and text into different colors and codes to find out the common meanings after this we grouped similar codes to create broader categories next we had to crossverify the narratives and remove the inconsistencies vagueness and discrepancies lastly codes and categories were analyzed and different themes that affected therapeutic coverage were identified using inductive research methods in total seven prominent subthemes subsequently emerged from the whole exploratory qualitative data in the end all conspicuous challenges barriers and difficulties were subsequently assembled into five leading themes politicoeconomic or financial administrative and planning logistical social or cultural capital and behavioral or interactive data analysis without delays researchers translated verbatim all the qualitative data obtained from group discussions semistructured interviews and field notes from the local language to the english language then we reviewed all the raw data available and labeled all sentences and text into different colors and codes to find out the common meanings after this we grouped similar codes to create broader categories next we had to crossverify the narratives and remove the inconsistencies vagueness and discrepancies lastly codes and categories were analyzed and different themes that affected therapeutic coverage were identified using inductive research methods in total seven prominent subthemes subsequently emerged from the whole exploratory qualitative data in the end all conspicuous challenges barriers and difficulties were subsequently assembled into five leading themes politicoeconomic or financial administrative and planning logistical social or cultural capital and behavioral or interactive ethical considerations the ethical approval for this study was acquired from the advanced study and research board of quaideazam university islamabad in its 307th meeting held on 20 october 2016 the board committed to approving the endorsements of the dean of the faculty of social sciences to accept the current qualitative and ethnographic research in the department of anthropology in addition to this the department of health district rajanpur also approved the study protocols and tools all the participants were thoroughly informed about the nature and purpose of this study before taking their formal consent to be part of this exploratory qualitative research as the majority of mothers were illiterate oral consent was provided according to their wish and comfortability after taking informed verbal consent from all study participants we promised to ensure their anonymity privacy and confidentiality results our overall qualitative findings revealed the emergence of multiple financial administrative logistical and behavioral difficulties that challenged the cmam therapeutic program for the treatment of severely malnourished children in the southern punjab region of pakistan financial barriers health priorities at the microlevel are influenced by macrolevel incentives funding for different national or provincial health or nutrition programs determines the focus of health staff funding and priorities of health bureaucracy the national polio eradication program being the most favorite program was prioritized by the health bureaucracy the health department used most of its energy in this program and deprioritized others although the nutrition program has been functional for many years the staff isnt free to run this at the district level the health office gives importance to their routine matters and does not let this kind of vertical program be implemented in full scale and strength work burden on lhws lhws coordinate between the community and health department therefore they were involved in almost every program whether provincial or national they frequently complained that they faced extra work pressure and burden particularly from the polio eradication program their primary duty was to cover and coordinate with more than two thousand pregnant and lactating females in their concerned outreach areas overinvolvement reduced their concentration in their original work about child and mother work the overinvolvement of lhws deprioritized nutrition activities by the health department lhws are involved in other programs especially polio after working three to five days in the polio campaign one lhw would not go into the field because she is already tired similarly in measles lhw is fully engaged for 12 days and becomes so fatigued and rarely visits the field for some days and demands rest when the department asks working overly and extensively how she can fill the high gaps created in the nutrition program this pressure is regular polio and other activities are unfinishable funding availability in the polio eradication program was the leading cause of why the health department punjab always engaged lhws for only this at the stake of another important program because their funding was low or none it was owing to this fact that lhws always wandered for polio drops and skipped nutritional screening and education in southern punjab several lhw posts were vacant according to reports of the district health information system out of a total of 900 only 650 lhw seats were filled which showed that the coveredup population in the district was 44 lhws felt dissatisfaction with the lower salary packages and other allowances logistical and cultural hurdles along with extra workload jointly restricted their will and motivation on many occasions many of them took this duty as no more than a formality just because they could not merely refuse orders from the department as a result they ignored visiting assigned households regularly due to low salaries and poor economic incentives many lhws were not well trained in anthropometric measurements of mothers and children for screening purposes unfortunately these lhws in the least developed areas were not appointed or even remained absent many of these lhws reported that their performance was perfect and they tried to justify their role they always report that everything was going well one official remarked lhws are called almost every week sometimes for meetings sometimes for training or sometimes for another task she has to maintain and carry multiple registers i mean its a serious matter that needs to be seen and fixed the patients from remote rural and tribal areas are missed sam cases are from remote areas where there is a water problem and access is limited so cases mostly come from rural areas administrative and planning failures the training of field staff screening referral of sam cases and distribution of therapeutic food are compromised due to the weak administration of the program improper utilization of nutrition field staff lack of training in 2008 the government of punjab recruited health and nutrition supervisors at the bhu level to screen and train the community on common health diseases and nutritional issues however many of the remote bhus missed them as there was no infrastructure since their creation they have barely taken part in any significant nutrition intervention in the district their role in cmam was never acknowledged until recently when the multisectoral nutrition center at the provincial level anticipated their future participation in the province of punjab in a report in 2017 they were not fully trained on nutritional issues and hence lacked relevant knowledge about the causes and treatment of malnutrition it was reported that an international organization had trained them on the importance of micronutrient iodine for mothers and children therefore these supervisors were mostly assigned monitoring duties for polio epi and dengue prevention programs instead of nutrition however they were properly trained on malnutrition for the first time in 2017 after 9 years of recruitment which showed the lack of coordination and failure of the precise job description this also showed a weak commitment to combatting malnutrition lack of vision and relevant policy failures the staff appointed at remote health units rarely performed duties because of insecure environments a lack of monitoring mechanisms dilapidated hospital buildings damaged roads and a lack of transport facilities these isolated areas are those where more attention is needed most recently new district coordinators were recruited by the multisector nutrition center who also need training on nutrition issues there are gaps as the district coordinator of the malnutrition addressing committee has only one or two meetings with the deputy commissioner of the district also msnc established by the planning and development commission of punjab province has recruited district coordinators but they are new and have no significant work to do nutrition supervisors are also not so trained and involved nor can they help measure and refer malnutrition cases but their involvement is limited to the polio program although all these have been appointed they have no work to do except work on special weeks recently we called nutrition supervisors on nutrition week they were assigned to distribute multinutrient sachets in their schools as area incharges but they are not really in much coordination weak referral indifference and interpersonal conflicts among staff intrahospital or staff interpersonal politics at the basic health units level emerged as one of the most significant reasons behind the weak referral of sam cases to the sc at district headquarters hospital it was remarked that the cases which reach dhq without a referral are admitted right away but sam referral is constrained and slow especially people from remote rural areas are in great need because of the weak and poor referral system to the stabilization centre every month lama cases are increasing 45 sam cases are admitted daily totaling approximately 120150 in one month most of these cases are located at the basic health unit level for the treatment of sam it is very difficult to screen a child with a complication from the field by these lhws through mid upper arm circumference lhw refers these sam cases to lady health visitor who has to verify muac and complications and forward complicated sam cases to dhq by an 1134 ambulance service after the anthropometric screening lhws generally referred malnourished mothers and children to bhus and rural health centers however many mothers were kept waiting unnecessarily by lady health supervisors appointed at bhus many poor and illiterate mothers left health units because they felt they were being ignored unattended and devalued by these lhss lhw and lhv are often at odds with each other sometimes lhs dislikes an lhw who insists on checking children immediately every lhw expects that she has hardly convinced and referred parents of sam case to bhu so now lhs should give priority so that it could be further referred to stabilization centre at dhq lhs asks lhw to wait outside and does not attend to the case even after hours this is how sam cases leave hope for treatment and run away and this is why referral of severely malnourished children with complications is minimum however a child specialist and nutrition staff specified for this work only are readily available at sc therefore sam cases are measured and admitted without trouble however people from only nearby areas can reach directly to sc but cases from remote areas have to be ignored lack of monitoring and medical corruption the presence of formula milk companies inside hospitals and the sale of notforsale rutf were two significant factors although banned theoretically representatives of the multinational formula milk were reported to move freely in the sc bhus and rhcs for advertising and selling formula milk to the poor parents of severely sam children soon after recovering from complicated sam mothers were motivated to try their products the company trains its agent to remain alert and keep an eye on every person monitoring and conducting research they are well trained in rapport building with medical staff and patients attendants for convincing them to use their products after the advertisement nobody ever restricted such active advertisement and sale therapeutic food was reported to be sold out at the hands of some lhws these packets of therapeutic food are not for sale it was informed by community members that the plumpynuts were being sold out at some places at the price of pkr 2030 per sachet by a few lhws a mother indicated i requested our lhw to give some food but she refused i threatened one such lhw who used to sell it by saying give some sachets for my son or else i would complain against you that you sell off the therapeutic food illegally never were any actions taken against such complaints by the concerned authorities the distribution of therapeutic food is not altogether transparent and fair health staff often prefer and prioritize their relatives and close ones first whenever the task of providing therapeutic food is given to them lack of social and cultural capital among poor mothers relationships with those who control power access to information and interpersonal skills necessary to communicate are essential requirements for becoming beneficiaries of development programs ruralurban disparities accessing therapeutic program when asked whether the field staff visited your area or household and what were the impacts of therapeutic food most respondents agreed that the milk provided at the stabilization center and rutf had a good impact on the sick child the majority of the enrolled mothers in cmam showed that their children were recovering gradually in their opinion the specialized medical milk and rutf brought a positive impact on their severely malnourished children when asked how mothers came to know about the treatment of severely malnourished children at stabilization centers or cmam most parents revealed that they were referred by the medical community or people from urban centers told them about this program and suggested visiting the nutrition stabilization centre at dhq to obtain special milk for malnourished babies doctors lhws and active community members helped to refer us to the cmam program and sc for therapeutic 75 milk for the severely malnourished baby lhws visited our area and told us to bring milk from cmam staff vaccinators also visit and inform us about the program lhws do not visit our area but vaccinators do once a year so we sometimes bring our children to the hospital for immunization and sometimes not people from the city informed us about this program they suggested us to visit stabilization centre because milk 75100 was being distributed there only a few parents reached the sc without any referral which implies how different local forms of social capital or relationships helped mainly urban or periurban families to become beneficiaries and isolate and seclude the majority of the most deserving remote rural illiterate and lowerincome families with lower social capital we the females are carrying this unfortunate child without any help from other family members i am a mother how can i leave him alone in this condition only my heart knows how much disturbed i am no one can realize the state of my heart i cannot see my child suffer i am in profound psychological distress when will my child feel normal and healthy i dont know i have tried my best to make him healthy and nourished we have wandered everywhere here and there to find if someone could suggest a better way recently a person from our neighborhood informed us about this program i requested my mother to test this place stabilization center too logistical difficulties treatment of complicated sam children requires their mothers and other caregivers to stay at the sc for some days until the child is stabilized and can come to the simple rutf stage however most mothers complained they had to leave medical advice due to logistical hurdles geographic seclusion difficulties in traveling the poorest of the poor mostly live in risky far remote and underdeveloped areas geography is one of the central causes of inequities in health and nutrition results showed that distance emerged as a substantial barrier to coverage and access to health and nutrition programs logistical problems emerged as the most significant reasons for low access the bad transportation long travel times damaged roads and long distances to the site were the major determinants of little coverage females are less empowered in these settings due to the lowest access to healthcare facilities and literacy and employment opportunities one mother stated we are tired and we still have to travel the mother informed that they reached the stabilization center after much difficulty and running errands the nutrition stabilization center is very far from our village and it took hours to get there we had to catch several types of transport the first motorcycle from our community to another town then an autorickshaw to the main highway after it we had to catch a bus from the road to reach the district bus stand from the bus stand to the hospital we had to hire an auto again after wandering here and there madly in the hospital building we reached the stabilization center by asking for addresses with the help of so many people we got tired when we arrived here and we still have to travel well have to go back home as it is not allowed to stay without permission problems related to staying at the stabilization center many mothers insisted on the hospital staff that they wanted to treat the complicated sam children at home sc staff had objections to this idea because the condition of the severely malnourished children was unstable and they were required to stay until the children became stable in the center the punjab government previously claimed to set up scs at the subdistrict level but activities at the scs were being limited at the district level and at any time the program may come to an end unicef in pakistan has recently intended to study the bottlenecks in the cmam program this indicates that these programs are still under the control of un agencies and the government lacks ownership convincing parents about the treatment at sc is a very complex task mental preparation of family and parents is essential for this because a mother or someone from the family has to stay for at least four days they have to prepare their basket or bag the other strong reason for low therapeutic coverage was the loss of income if the mother and father were to stay at the sc receiving the treatment for only one severely malnourished child and ignoring the rest of their children this made them indifferent to complete treatment therefore most grandmothers had to stay at the sc mothers could not stay longer because no one could take care of the rest of the children at home during crop season poor rural mothers could rarely afford to give proper time for treatment and healthseeking some domestic servants also complained about working hours as they could not escape from their duty they delayed checkups and treatments of complicated sam children if mothers had to stay they had to bring all of their kids along with them to the sc at the district headquarters hospital as children were unaware of crossinfections at the sites they were playing in the hospitals wards touching the floor with their hands and eating foods there without handwashing behavioral problems with nutrition staff another critical factor of low coverage of the therapeutic program in rural and southern districts of punjab province in pakistan involves the elements of stigma respect and dignity stigmatization of patients and attendants many poor parents felt stigmatized and complained of being unattended at the hands of the hospital and nutrition staff illiterate people with low socioeconomic status had low confidence to communicate with hospital staff and feared being insulted by the doctor and staff the behavior of the staff was not supportive sometimes staff felt irritated by the poors dirty clothes cmam staff was often reported to have been rude to mothers of severely malnourished children multiple times mothers indicated taunts and offensive remarks and the mothers felt ashamed of this embarrassing situation for example on one occasion a nutrition assistant at the sc vocalized to a mother you are always here to get this milk once a female nutrition staff member threw the packets of formula milk 75 toward a mother in a very disgusting mood and said angrily hold this packet and get out in another instance when a poor mother brought her child to the stabilization center for the treatment of sam the onduty staff responded take your dirty luggage from here it smells stinky not being attended complaints about not being attended to by lowincome parents were much more common mothers explained how the staff at the nutrition stabilization center was indifferent careless and rude we would wait all day and night but no person attended a little the sick child used to cry all night as they would give our child nothing to eat and drink we were worried when the doctor and staff would pay attention to our child leaving such treatment of indifference and disgust would be better than just wasting time in wait here my husband said to sc staff my child is hungry and you pay no attention i do not want to leave my sick child as hungry all night nurses complained about my husband to the head doctor who called him and insulted him my husband got disheartened and finally decided to quit the treatment at this center discussion this study discovered mothers interactions with the biomedical treatment and therapeutic system of the cmam program and nutrition stabilization center it specifically explored how poor illiterate and rural women were often incapable of navigating the therapeutic coverage and politics with institutions these difficulties were perilous for many women mainly from remote and secluded areas who were illiterate and lacked the required minimum cultural assets and social skills to negotiate the complex and unfamiliar setting 29 womens communications with the health and nutrition staff illuminated how the administration strengthened health and nutrition inequities barriers related to geography income fears of maltreatment and discrimination emerged as most striking and significant for the rural poor struggling to receive therapeutic care through the public healthcare system 2030 many families could not access the cmam program owing to multiple sociocultural and logistical reasons 2728 the staff of development programs often secluded poor mothers and children due to multiple power dynamics 222331 families who had some links within local power circles received better chances of coverage to combat the problem of malnutrition the government needed to change priorities at the primary level deprioritization of the nutrition program in comparison with the polio eradication program resulted because of heavy international funding for the latter this suggests that the government must increase funds for nutrition 32 further the burden and pressure on the lhws must also be curtailed by focusing their attention on maternalchild health and nutrition programs in remote areas seats for the lhws ought to be urgently allocated 33 nevertheless all these steps require road construction and infrastructure provisions at basic health facilities human development infrastructure at the local level is also required in south punjab which is always facing regional or ethnic inequalities 34 the poor rely on traditional treatment methods because of their low income stigmatization and the trust deficit of the poor in government departments are strong indicators of low biomedical service utilization along with expensive and uncontrolled private clinicians prevalence that need urgent policy decisions this study showed that the medical staff did not care much about the marginalized victims of social stigma and ignored the poors feelings 35 the future design and implementation of government programs must be made more socioculturally sensitive plumpy nuts are effective only in emergency contexts but not in chronically poor settings and such programs also create a dependency of lowincome states on international companies which prepares such foods in addition therapeutic food is not available in usual and regular circumstances even though people need it the permanent solution therefore lies not in treating the individual body but in searching for a cure for a social body through politicaleconomic means of social justice and equity 36 evidence showed that nearly half of the population in several rural districts was not covered by lhw especially in the most remote and the poorest areas 3738 unicef 39 has highlighted that the neonatal mortality rate was reduced in lowcaste groups where lhws made weekly visits in rural indian punjab recent studies 4041 similarly demonstrated that sufficient training financial compensation and close supervision of community health workers are imperative for the successful delivery of sam treatment along with the adequate quantity of readytouse therapeutic food some respondents revealed that therapeutic food was being sold off by lhws and representatives of formula milk producers were free to move into hospital settings there is evidence that formula milk companies ignore the laws and continue marketing their products inappropriately 42 the literature from pakistan and india shows that corruption within medical settings restricts government services 2643 while drawing upon the anthropology of the state along with the perspective of structural violence gupta found that funds hardly reach their anticipated beneficiaries but mostly reach people with political acquaintances cultural capital and financial influence 44 inaccurate systems of information based on statistics conflict and widescale corruption in indian bureaucracy systematically isolate and ignore the poor similarly examining the government of papers in pakistan hull 45 analyzed how the bureaucratic processes and management of records crafted partnerships among people as the core apparatus and governing emblem of the official measurement of bureaucracy for him papers should be seen as mediators that shape the significance of the linguistic signs inscribed on them 45 which shows that postcolonial bureaucratic records are materialized under the colonial policy of keeping government and society isolated many poor illiterate and rural mothers indicated that they faced rude behavior and stigma in medical settings in a study in the kenyan context analogous shame stigma and discomfort at health clinics related to malnutrition and fear of mistreatment at the hands of the biomedical staff were noted as the most significant barriers to treatment for childhood acute malnutrition 46 which potentially constrained their access to the cmam program chary et al 20 argued that childhood diseases are treated incompletely because of the perception that the child is not being attended to they linked the phenomenon of not being attended with healthcare inadequacies our findings showed that mothers faced logistical difficulties evidence in guatemala similarly showed that poor women suffered from running errands 27 similar evidence showed that therapeutic programs in five african countries failed because of the low awareness about the program long distances the handling of rejection at sites 29 30 31 and the centralization of the program 47 the studys findings corroborate that distant communities remained potentially disadvantageous to be covered by therapeutic programs particularly for the treatment of complicated sam because caregivers had to stay for many days at the therapeutic center 29 more often adjacent to the childrens hospital evidence 48 from the adjacent sindh province of pakistan also showed that remote areas were less exposed to the therapeutic program and the common barriers included the low awareness of malnutrition and its services the childrens disapproval of rutf long distances and high opportunity cost this study also found that remaining in the program until full recovery was difficult this article monitors mothers interactions while accessing the nutritionspecific cmam program in doing so it proposes that a politics of neglect is at play in these programs in neglecting the social body and poorer sections of society in the programs target areas these interventions do not consider processes of power and exploitation and ignore the complex and unequal social relations the narratives showed how the poor often faced structural inequities and social exclusion due to a lack of social or cultural capital evidence showed that the poorest of the poor and lowcaste families with the lowest social capital in punjab were excluded from the cash transfers program at the will of local political leaders 49 some of the literature found similar results that only people with approaches and links to local politicians could be successful in becoming beneficiaries of the income support program in pakistan 50 families with lower sociocultural capital suffered the most because of the lack of transparent and impartial social protection policies and social safety nets the literature from other contexts on socalled bureaucratic hurdles has highlighted such misery of poor women facing structural inequalities and the indifference of bureaucracy toward the poor people who have no relationships with influential notables 51 the lack of social and cultural capital deprives the poor of their due rights despite deserving them on the other hand people with such capital were witnessed on several occasions becoming beneficiaries even if they did not deserve it well according to bourdieu 52 cultural capital plays a vital role in taking benefits from society when they are guided to adopt specific procedures illiterate mothers cannot remember the steps and names of officers the poverty eradication or development programs preferably target the betteroff ignoring many poor of the poorest who have never been taken seriously by the bureaucratic structure of the development programs when resources are limited competition is high therefore the humanitarian apparatus has to be narrow in its scope leaving many deserving and potential beneficiaries far behind 53 in pakistan poverty is extensive the poorest are deprived because they lack links and relationships with people in power pakistan is not a place where resources are equitably distributed and where the population is also under control this bureaucratic structure does not let the poor and weaker enter their offices unless an officer lawyer politician or any other notable accompanies them the poor often endure social and structural difficulties in the process of being beneficiaries so knowledge about social exclusion is fundamental to advise on program objectives eligibility criteria of clients and the selection process 53 in addition cmam is a shortterm curative measure especially in emergency contexts not aligned well with local sociocultural realities the shortterm global technical solution in the form of rutfs and cmam was implemented under neoliberal governments and facilitated an increasingly inequitable economy with minimal state involvement in an increasingly individualistic social environment 54 however the permanent longterm sustainable solution to maternal child undernutrition lies in females socioeconomic emancipation and their health or nutrition literacy 55 56 57 58 59 in addition the inclusion of training of medical staff on respectful care is imperative conclusions the cmam program in southern pakistan encounters multiple social economic and structural obstacles first funding in nutrition as compared with other programs deprioritizes officials interest in nutrition and involves lhws in other multiple tasks that increase their work burden and divert their attention from maternalchild health and nutrition in addition the corruption in food distribution and the unethical sale of rutf by lhws are reported which need strict monitoring and fair dispensation the normalization of social exclusion has roots in politicoeconomic and structural inequalities the study includes the following recommendations prioritizing more funding for nutrition proper training of field staff improving screening skills and referral of sam cases providing traveling incentives to needy illiterate and rural mothers devolving the child stabilization service at the micro level distributing rutf fairly by lhws treating parents politely finally vacant lhws seats in remote rural areas demand urgent allocation data availability statement not applicable acknowledgments the input contribution and support of all those who provided generous data for this study are acknowledged here informed consent statement all respondents were informed about the nature and purpose of the study before taking their formal oral consent in addition we strictly ensured the privacy anonymity and confidentiality of all study participants

severe acute malnutrition sam is a serious public health problem in many lowand middleincome countries lmics therapeutic programs are often considered the most effective solution to this problem however multiple social and structural factors challenge the social inclusion sustainability and effectiveness of such programs in this article we aim to explore how poor and remote households face structural inequities and social exclusion in accessing nutritionspecific programs in pakistan the study specifically highlights significant reasons for the low coverage of the community management of acute malnutrition cmam program in one of the most marginalized districts of south punjab qualitative data are collected using indepth interviews and fgds with mothers and health and nutrition officials the study reveals that mothers access to the program is restricted by multiple structural logistical social and behavioral causes at the district level certain populations are served while illiterate and poor mothers with lower cultural capital from rural and remote areas are neglected the lack of funding for nutrition causes the deprioritization of nutrition by the health bureaucracy the subsequent work burden on lady health workers lhws and the lack of proper training of field staff impact the screening of sam cases moreover medical corruption in the distribution of therapeutic food long distances traveling or staying difficulties the lack of social capital and the stigmatization of mothers are other prominent difficulties the study concludes that nutrition governance in pakistan must address these critical challenges so that optimal therapeutic coverage can be achieved

the coronavirus disease imposes an unusual risk to the physical and mental health of healthcare workers and thereby to the functioning of healthcare systems during the crisis this study investigates the clinical knowledge of healthcare workers about covid19 their ways of acquiring information their emotional distress and risk perception their adherence to preventive guidelines their changed work situation due to the pandemic and their perception of how the healthcare system has coped with the pandemic it is based on a quantitative crosssectional survey of 185 swiss healthcare workers directly attending to patients during the pandemic with 22 of them being assigned to covid19infected patients the participants answered between 16th june and 15th july 2020 shortly after the first wave of covid19 had been overcome and the national government had relaxed its preventive regulations to a great extent the questionnaire incorporated parts of the standard questionnaire on risk perception of an infectious disease outbreak which were adapted to the case of covid19 clinical knowledge was lowest regarding the effectiveness of standard hygiene knowledge of infectiousness incubation time and lifethreatening disease progression was higher however still significantly lower than regarding asymptomatic cases and transmission without physical contact 70 of the healthcare workers reported considerable emotional distress on at least one of the measured dimensions they worried significantly more strongly about patients elderly people and family members than about their own health adherence to preventive guidelines by the government displayed patterns such that not all guidelines were followed equally most of the participants were faced with a lack of protective materials personnel structures processes and contingency plans an increase in stress level was the most prevalent among the diverse effects the pandemic had on their introduction several types of human coronaviruses with low pathogenicity had been studied before the severe acute respiratory syndrome emerged in 2002 in china sars spread to at least 29 countries in asia europe and north and south america with a total of 8098 infections and 774 sarsrelated deaths reported the virus that causes the presently spreading human coronavirus disease named covid19 was first noticed in wuhan china in december 2019 and it resembles the prior sars the infected typically experience symptoms similar to those of a common flu with an estimated 80 showing only mild symptoms as of 22nd december 2020 76023488 cases and 1694128 deaths have been reported due to covid19 worldwide for switzerland there have been 402264 cases and 5981 covid19related deaths reported to this date compared to a resident population of 8606 million the first covid19 case in switzerland was registered on 25th february 2020 the first wave of the pandemic took place in late march and early april 2020 by 23rd march the effective reproductive number 1 had decreased below one as depicted in figure 1 and the first wave was overcome by late may 2020 in the sense that daily new cases had decreased to single digits shortly thereafter the survey was conducted from 16th june until 15th july 2020 the subsequent second wave has recently grown significantly more severe than the first wave with a maximum 7day average of 8064 daily new cases reported on 2nd november 2020 which equals 94 daily cases per 100000 inhabitants the covid19 pandemic has induced a global crisis with unusual healthrelated and economic challenges it has been claimed to have caused a significant global shock and has even been named catastrophic as a consequence the psychological health of individuals and families has been greatly affected particularly regarding issues such as stress states of shock fear existential anxiety and grief switzerland is no exception the first wave of the covid19 pandemic led to drastic measures by the swiss federal government including the mobilization of several thousand swiss citizens through the militia system of the swiss army the most restrictive phase took place from 16th march until 26th april 2020 which has popularly been referred to in swiss media as the lockdown registered unemployment increased from 121018 to 153413 people between january and april 2020 after the precautionary measures had been gradually relaxed following 26th april the federal council and the federal office of public health intensified the measures again in october 2020 in reaction to the second wave several branches of the swiss economy have been under considerable pressure and prognoses for the near future remain unfavorable by the end of november 2020 153270 people were registered as unemployed amounting to an unemployment rate of 33 accordingly the pressure on the economy is still high as is the strain on the psychological health of the population given this ongoing phase of restricted public and private life economic uncertainty health hazard and loss healthcare workers are a primary group on which the covid19 pandemic has imposed extraordinary challenges this has clearly been recognized in the international literature as first responders in providing care they have been exposed to feelings of stress and uncertainty while working long hours and often not being fully protected against an infection the risk of testing positive for covid19 is high among healthcare workers which combined with the responsibility they bear for their patients has exposed them to ethical dilemma as private citizens they have also had to cope with posing an increased infection risk to their social environment even being depicted as heroes by the media can in fact be counterproductive as it increases their perceived pressure this situation can significantly affect their mental health and even lead to workrelated trauma many healthcare workers have been documented to have developed mental issues for which they require psychological support this is a clear indication that besides infrastructural considerations also the individual capacities of healthcare workers including their psychological wellbeing are a crucial ingredient in facing a pandemic of the magnitude of covid19 shortly before the first wave of covid19 in switzerland northern italy a direct neighbor experienced a severe overload of the healthcare system due to covid19 particularly of hospitals and intensive care units this provided an alarming example to swiss healthcare workers the international council of nurses documented both the high rate of infection among healthcare workers in northern italy who then needed to be isolated outside of the workforce for 14 days as well as the physical and mental exhaustion of them and their colleagues who were stillagain in service in midoctober 2020 as the second wave of covid19 infections had already emerged the swiss society of emergency and rescue medicine switzerland emergency care and the swiss association of paramedics together issued an open call to the swiss government for support they stated that the health of swiss healthcare workers which had already deteriorated due to the first wave was at considerable risk of getting worse if the government did not apply consistent measures across the entire country beyond these challenges the pandemic has exposed the vulnerability of people among them also healthcare workers towards receiving flawed information through popular media which may affect their judgment the conveyed information may be imprecise or even misleading and it may originate within media outlets themselves or merely be transmitted by them the notion of vast flows of information on a hot topic coming from all kinds of sources of which it may not always be clear to the readerlistener which are proven facts and which are opinions is known as infodemics filtering information by assessing its source is therefore a necessity particularly for healthcare workers with the physical and mental health of healthcare workers being at stake insight on their perspective and identification of their crucial challenges as they perceive them are greatly needed it is a first step towards sensibly protecting them for their own sake as well as for them to remain effective and efficient in their services during a time when they are most needed by society a rapid and effective response as well as healthcare staff that is still able to take leadership are pivotal in successfully handling the pandemic lessons from the first wave of the pandemic are therefore needed and firsthand empirical data is key this study presents a quantitative survey of swiss healthcare workers conducted shortly after the first wave of the pandemic its aim is to provide evidence of their clinical knowledge about covid19 their emotional reaction their adherence to preventive guidelines and the impact on their work situation for such insight to be accurately drawn understanding the context is essential therefore the circumstances under which the first wave impacted the healthcare workers need to be considered which to a large degree depend on how the government and the healthcare system were prepared for and reacted to the pandemic a few recent studies have provided quantitative evidence of the knowledge of healthcare workers on covid19 wahed et al have studied egyptian healthcare workers showing that knowledge was higher among the more highly educated individuals as well as among those below the age of 30 years zhang et al in their survey of chinese healthcare workers concluded that knowledge was sufficient in 89 of them honarvar et al have provided evidence of the knowledge of the general public on certain covid19related issues for the case of iran similarly abdelhafiz et al have assessed the knowledge of the egyptian general population to our knowledge no study has been published so far specifically focusing on the clinical knowledge of swiss healthcare workers and their media use our study therefore fills in this gap in the literature several studies in the international literature have given insight on personal protective equipment specific work risks for healthcare workers related to covid19 and psychological coping mechanisms further studies have shed light on risk perception and attitudes towards covid19 however when considering risk perception and attitudes many of the available studies refer to the general population instead of healthcare workers in particular exceptions are given as follows spiller et al who focused specifically on a sample of swiss healthcare workers found no substantial changes in anxiety or depression over the course of the covid19 pandemic aebischer et al who surveyed 227 resident medical doctors and 550 medical students through snowball sampling in switzerland found that those medical students who were involved in the covid19 response displayed higher levels of emotional distress than their noninvolved peers and lower levels of burnout compared to the residents dratva et al analyzed generalized anxiety disorder scale7 in a sample of 2429 swiss university students 595 of which were students of health professions they found three classes of individuals regarding the perceived impact of the covid19 pandemic with large differences in the odds of increased anxiety they concluded that preventivecontainment measures against covid19 had a selective effect on anxiety in students however these analyses were not differentiated across professionsfields and therefore no results specific to healthcare workers or students of health professions were available puci et al showed that the risk perception of getting infected with covid19 was high among italian healthcare workers they also reported sleep disturbances in 64 of the participants and that 84 perceived a need for psychological support abolfotouh et al in their survey of saudi arabian healthcare workers found that three in four respondents felt at risk of contracting covid19 at work and that 28 did not feel safe at work given the available precautionary measures predictors of high concern were among others younger age undergraduate education and direct contact with patients in a study of ethiopian healthcare workers risk perception due to the pandemic was measured by ten items on a fivepoint likert scale the mean score of perceived vulnerability was higher for covid19 than for the human immunodeficiency virus the common cold malaria and tuberculosis wahed et al studied a sample of egyptian healthcare workers finding that 83 were afraid of being infected with covid19 therein a lack of protective equipment fear of transmitting the disease to their families and social stigma were the most often named reasons two further studies are currently in their preprint phase firstly weilenmann et al investigated mental health in physicians and nurses from switzerland considering work characteristics and demographics as explanatory factors they concluded that support by the employer as perceived by the physicians and nurses was an important indicator of anxiety and burnout while covid19 exposure was not strongly related with mental health secondly uccella et al identified specific risk factorsgroups among workers of public hospitals in italy and switzerland regarding psychological distress such as being female and working in intensive care having both children and stress symptoms was associated with the perceived need to experience psychological support accordingly while several studies are available regarding specific measures of psychological deterioration such as anxiety or depression and also regarding risk perception quantitative evidence for the specific case of healthcare workers in switzerland is still rare furthermore the mentioned studies of risk perception referred to the situation at the time of the respective surveys during the pandemic meaning that the available preventive measures and policies varied substantially by contrast the participants of our study were instructed to quantify the risk of covid19 independently of the specific precautionary measures that were in place at the time that is they answered for the scenario in which no other precautionary measures were taken during the first pandemic wave other than the usual measures against common influenza albeit hypothetical this allowed for a more general assessment of the threat imposed by covid19 making it more comparable to other health hazards the precautionary health behavior practices of ethiopian healthcare workers were assessed by girma et al with a tenitem questionnaire the items covered dimensions such as the frequency of wearing gloves or wearing a mask zhang et al surveyed the implementation of four mandatory practices in hospitals among chinese healthcare workers concluding that 90 followed them correctly our survey contributes to the literature by using a different set of guidelines which were legally nonbinding and issued by the national government towards the general population thereby the study covers the adherence of healthcare workers also in their private life and is specific to the case of switzerland several studies have recently examined the responses to the covid19 pandemic in different countries they adopted different perspectives analyzing the effectiveness of governmental policies epidemiological responses testing contact tracing and isolation lockdown policy preparation of the healthcare sector as well as key learned lessons however empirical studies of how such measures are perceived by the healthcare staff and of how the pandemic has affected their work situation from their own perspective are still scarce spiller et al compared two demographicsmatched samples of healthcare workers which were collected at two different points in time at the height of the pandemic versus two weeks after the healthcare system had started its transition back to usual operations they found that working hours were higher at t1 compared to t2 and still higher at t2 compared to prepandemic levels uccella et al found that healthcare staff working in intensive care experienced an increase in working hours the study by wolf et al investigated the effect of policies such as the swiss lockdown on dental practices and social issues such as unemployment and practice closures assuming on a more economic perspective abolfotouh et al found broad approval among healthcare workers of the following the suggestion that the national government in saudi arabia should mandate the isolation of covid19 patients in specialized hospitals travel restrictions within the country and curfew our study contributes by providing evidence of how the work situation of healthcare workers had been impacted from their own perspective and of how they perceived the measures that were implemented by the government this study provides insight on several psychosocial factors that in combination are relevant to the role of healthcare workers in the current pandemic they are not specific psychological diagnoses or concepts of psychological deterioration like depression anxiety or burnout but concern a broader spectrum of issues relevant to the mental wellbeing and the capability to act of healthcare workers this supports policymakers in pragmatically fostering their comprehensive view of the situation and in designing policies to sustainably protect the wellbeing of healthcare workers in addition the healthcare workers named the specific lessons that needed to be learned from their perspective when facing further pandemic waves materials and methods study setting this crosssectional survey was conducted from 16th june to 15th july 2020 with swiss healthcare workers who regularly worked in direct contact with patients the healthcare workers were also pursuing a professional development course at careum weiterbildung or had attended such a course within recent years careum weiterbildung situated in aarau is one out of several institutions in switzerland offering extraoccupational courses of professional development to healthcare workers these courses vary in duration from 1 day to several days per month over several years and cover a broad range of practiceoriented topics and specializations within healthcare and social sciences they are often multidisciplinary and they are aimed at improving care by teaching methods of caregiving knowledge of practical procedures communication and organizational skills attending such professional development courses is highly common among healthcare workers of all specializations and hierarchical positions in the swiss healthcare system participation was strictly voluntary and anonymous2 according to swiss regulations no approval by an ethics committee was required for this study the participants were surveyed under the following circumstances after the final day of the abovementioned lockdown during the first wave in switzerland on 26th april 2020 the preventive measures had been gradually eased by the national government from 27th april businesses offering personal services with physical contact such as hairdressers beauty shops and others had been allowed to reopen as well as florists and hardware stores from 11th may primary and lover secondary school had resumed and restaurants markets museums and libraries had been allowed to reopen along with sport events without physical contact from 28th may religious events with larger groups of people could be held again from 6th june private and public events with up to 300 people had been reallowed and touristic facilities could reopen on 15th june the borders with many countries within the euefta had been completely reopened with the survey starting on 16th june the participants answered the questionnaire after the first wave of covid19 had been overcome and shortly after the government had relaxed preventive measures to a great extent data collection the data were collected by twostage cluster sampling inviting all current and recent attendees of careum weiterbildung for voluntary participation in the survey a standardized online questionnaire was delivered to 1747 attendees addresses on 16th june via email 381 of the delivered messages were opened and for 364 thereof the link to the survey was followed as controlled by mailworx software a reminder was delivered to 1684 attendees addresses on 30th june which was opened in 329 of the cases and for 291 thereof the link to the survey was followed a total of 194 participants completed the questionnaire 185 of which directly attended to patients and therefore belonged to the population of main interest completion took 181 min at the median the questions were posed with given answer options predominantly in multipleanswer form and some in multiplechoice form thereby parts of the standard questionnaire on risk perception of an infectious disease outbreak by the municipal public health service rotterdamrijnmond and the national institute for public health and the environment were adapted to the case of the covid19 pandemic the answer option other was frequently included which if selected led to a request for text input for specification by the participant questions were posed across the different parts of the questionnaire as follows knowledge about covid19 the participants were presented with eight claims about covid19 as stated in table 2 they were asked to choose for each claim whether it was correct incorrect or unknown to them the correct answers shown in table 2 were taken from the following sources day mullard morawska and cao 2 those on which they needed more detailed information than they had at the time sources of information and means of communication a first multipleanswer question on who should provide them with the necessary information on covid19 as well as a second multipleanswer question on how they preferred to receive this information measured their preferred media use furthermore the participants rated their use of each of five given types of media on a sixpoint likert scale ranging from daily to never emotional distress and risk perception the first question was how worried do you feel because of the possibility of the respective scenario the three scenarios of getting covid19 yourself familyfriends getting covid19 and numerous cases of death among elderly and sick people due to covid19 were each rated on a fourpoint likert scale ranging from very worried to not worried at all as listed in graph a of figure 2 for the questions on risk perception a hypothetical scenario was introduced by the wording please answer for the scenario in which no extraordinary measures were undertaken in switzerland other than the usual measures against influenza for this scenario the question would covid19 be a threat to was asked in the five specific respects of your own life the life of your family members or friends health professionals attending to covid19 patients the swiss population and the global population the answers were given on a fourpoint likert scale ranging from very serious threat to no threat at all as listed in graph b of figure 2 as a followup the identical questions were asked a second time with the answers on a discrete rating scale as described by studer and winkelmann the discrete rating scale ranged from zero to ten and only the extremes were verbally labeled this allowed for the application of different methods of analysis as described in the section data analysis perception of and adherence to preventive guidelines the participants rated the likelihood of a second wave of covid19 in switzerland before the end of 2020 on a sixpoint likert scale ranging from certainly to certainly not they also rated the likelihood of a different pathogen causing another pandemic of equivalent or greater magnitude within the upcoming 20 years on the same scale table 5 lists the precise wording of the question and the answer options note that for the intermediate levels of the likert scale the resulting frequencies are presented in cumulative form as described in the section results in the questionnaire the likert scale was included in typical fashion without cumulative meaning the participants repeated the assessment of the same two questions but this second time with the answer options being on a discrete rating scale ranging from one to ten with only the extremes having a verbal label they were then shown six preventive guidelines these guidelines were in place in switzerland during the lockdown phase and some of them were relaxed afterwards however they had the status of recommendations by the federal government not of legally binding rules the participants indicated how strictly they followed them on a sixpoint likert scale ranging from always to never the precise wording is given in table 6 like in table 5 while the resulting frequencies for the intermediate levels are presented in their cumulative form this was not the case in the questionnaire where the ordinary likert scale was used the participants were the six answer options were certainly very likely rather likely rather unlikely very unlikely and certainly not ≥rather likely encompasses all individuals who answered rather likely very likely or certainly ≤rather unlikely encompasses all individuals who answered rather unlikely very unlikely or certainly not ci stands for wilsons confidence interval further asked to indicate how strictly they expected to follow the same guidelines in the future as listed in the lower part of table 6 there the sixpoint likert scale ranged from presumedly forever to 0 to 1 month and the alternative option of dont know was added to evaluate these guidelines the participants were asked which of the following claims apply to the abovementioned guidelines referring to guidelines a1 and a3 through a7 they were presented with the multiple answer options most of them are exaggerated for persons not working with patients or elderly people most of them are exaggerated for persons working with patients or elderly people most of them are ineffective and none of the answers above apply finally the participants indicated whether they currently had any plans of traveling abroad for private reasons before the end of the year 2020 and whether they would have had such plans if the covid19 pandemic had not occurred impact on work situation for each of four claims regarding preparation it was asked whether the claim was true or not by item p5 the choice was offered that none of the claims p1 through p4 were true which if chosen implied that p1 through p4 could not be selected as well the question how hashad covid19 affected your work situation was then asked with eleven answer options of which the last option excluded all other ten reaction by the government the sentence the measures implemented by the government between 17th march and 26th april were could be completed with either exaggerated adequate or not strict enough too late too short in duration the followup question was which of the following claims applies to the gradual steps of relaxation of these measures which are in place since 27th april and which are planned for the future the multiplechoice answer options were the measures should have been relaxed earlier more strongly the relaxation plan is adequate and the measures should have been relaxed later less strongly key lessons the question which lessons need to be learned and what should be different in case another pandemic should happen in the future was asked with ten answer options of which the last one excluded all other options presumed cause of the pandemic the participants were presented with a multiplechoice question phrased as shown in figure 4 at the end of the questionnaire the participants could enter any comments regardless of their previous answers data analysis confidence intervals of proportions as shown in table 2 through table 7 as well as referred to in the text of the results section were calculated by wilsons method fishers exact test was used for testing the equality of proportions pairwise rank correlation was calculated by spearmans method and classified according to cohen for any tests of hypotheses whether univariate or within a multiple regression model a typeone error probability 005 was considered as statistically significant in the same regard alternative hypotheses were twosided by binary logistic regression the effects of multiple predictors on a binary outcome were modeled the results were computed as average marginal effects representing percentagepoint differences in the probability of the outcome being positive by fractional logistic rating scale regression the effects of multiple predictors on an outcome on an elevenpoint discrete numeric rating scale were modeled the results were represented as ame representing differences on the 010 scale for an explanation of this method see eg studer and winkelmann each regression model was optimized such that systematic factor elimination minimized bayes information criterion 4 the following models were 4 the initial set of predictors for which factor elimination was performed comprised the following items for which onesided causality could be assumed w2 through w5 knowledge about covid19 a binary logistic model of item k4 being answered correctly emotional distress and individual part of a covid19 risk group answered the questionnaire before 20th june 2020 in some cases minimization of bic led to a reduction of the model to a single predictor as reported in the results section risk perception three binary logistic models one for each of the three dimensions depicted in graph a in figure 2 of the respective outcome being at least worried versus a fractional logistic model of the perceived threat to ones own life on the 010 discrete rating scale as well as another fractional logistic model of the perceived threat to the life of family members and friends on the same scale perception of and adherence to preventive guidelines three binary logistic participants were asked will you travel abroad for private reasons before the end of 2020 and would you have traveled abroad for private reasons before the end of 2020 if the covid19 pandemic had not occurred respectively models one each for the items a1 a3 and a4 of the respective outcome being at least almost always three binary logistic models one each for the items a13 a14 and a15 conducted for those participants who claimed to adhere to the respective guideline at least predominantly at the time of the survey thereby the probability of continuing the individual level of adherence at least until a vaccine would be available was modeled a binary logistic model of currently having plans of traveling abroad before the end of 2020 given the pandemic as described in figure 3 reaction by the government a binary logistic model of the question which of the following claims applies to the gradual steps of relaxation of these measures which are in place since 27th april and which are planned for the future being answered by the measures should have been relaxed later less strongly for each of these bicoptimized models all of the predictors and their estimated effects are reported in the results section one of the tested predictors in the abovementioned models concerned a specific public announcement by the swiss federal council which requires specific explanation it was made shortly after the start of the survey during the day of 19th june 2020 the federal council announced that most of the national preventive measures in place at that time would be abolished or relaxed on june 22nd in particular organized events with up to 1000 people would be legalized again the recommended physical distance between people would be reduced from 2 to 15 meters masks would not be mandatory in public transportation and home office would no longer be a recommendation the federal council further announced that the handling of a potential second wave would be the duty of the swiss cantons which are the member states of the swiss federation it thereby undertook a fundamental change of policy which it underlined by suspending the national coronavirus task force notably these steps were not known to the broad public before 19th june hence the governments future plans changed on the 19th of june to being significantly more liberal than before as far as public knowledge is concerned from 16th june until 19th june 107 of the total of 185 participants had already answered the survey naturally by the time the survey had started on 16th june no question specifically referring to the announcement of 19th june could have been included in the questionnaire for reasons of consistency the questionnaire was not altered after the start therefore the day of participation in the survey was used as a predictor of the answer to whether the participants agreed with the steps of relaxation undertaken since 27th april and planned for the future results knowledge about covid19 knowledge was high regarding the unavailability of a covid19 vaccine the ineffectiveness of influenza vaccines against covid19 the occurrence of symptoms and transmission without physical contact with over 92 over 87 answering correctly 76 of the participants answered correctly that covid19 was more infectious and 72 that it had a longer incubation time than common influenza 69 correctly indicated that covid19 cases more often had a lifethreatening disease progression than common influenza however 36 falsely believed that if hygiene standards such as frequent washing of hands and sneezing only into tissues were met an infection with covid19 would be virtually impossible another 7 answered that they did not know the answer to this question hence knowledge on the latter item was significantly lower than on any other tested item it was even lower among participants who as a result of the pandemic worked more hours than usual additional information on treatment was most frequently desired followed by incubation time severe disease progression infectiousness transmission between people preventive measures and symptoms 28 claimed not to be needing any further information on covid19related topics even though knowledge was comparably low regarding the effectiveness of standard hygiene the topics of preventive measures and transmission were rarely named as topics for which further information was perceived to be needed in fact among those participants who did not provide the correct a items a2 and a12 of the questionnaire were not used in this survey top row within each cell shows pairwise correlation of items a1a7 referring to present adherence at the time of the survey bottom row within each cell shows pairwise correlation of items a11a17 referring to expected duration of adherence the meaning of the items is listed in table 6 p 005 p 001 p 0001 answer to this item 85 claimed to be needing no further information on preventive measures and 86 claimed to be needing no further information on transmission between people similar results were found for other topics of the participants who did not answer correctly on lifethreatening disease progression 74 claimed to be needing no further information on the topic of the participants who did not answer correctly on incubation time 45 claimed to be needing no further information on the topic of the participants who did not answer correctly on infectiousness 73 claimed to be needing no further information on the topic this is clear evidence that although knowledge was fairly high on some topics many participants overestimated their knowledge sources of information and means of communication the vast majority of the participants expected the government to be their source of necessary information on covid19 as shown in table 3 while 63 wished for scientistsuniversities and 61 wished for their employer to take on that role any other sources were significantly less often named the most preferred means of communication by which to receive the information were public television radio and newspaper articles of those participants who wished to receive the information by their employer 93 required to receive it in writing and only 27 orally accordingly television and radio were the most popular media in order to keep informed on recent news in general not only related to covid19 still more than half of the participants read articles by daily newspapers at least several times a week news automatically suggested by web browsers were significantly less popular than the other mentioned media emotional distress and risk perception merely 18 of the participants felt at least worried about getting infected with covid19 themselves by contrast 52 felt at least worried about possibly the same happening to their familyfriends 60 felt at least worried about the possibility of numerous deaths among elderly or sick people hence the participants were significantly more often at least worried about other people being at risk than about themselves participants working in longterm care were more likely to feel at least worried about contracting covid19 themselves participants who had passed the majority of their education in germany were more likely to feel at least worried about their familyfriends contracting it and both participants working in somatic care and participants working in nursing homes were more likely to feel at least worried about deaths among elderly or sick people the provided answers on how severe of a threat covid19 was for specific groups are illustrated by graph b in figure 2 this pertains to the hypothetical scenario without precautionary measures because of covid19 other than the usual ones against a common flu 90 claimed an at least serious threat for the global population and 86 claimed so for healthcare workers who directly attended to covid19 patients 85 claimed an at least serious threat for the swiss population and 76 claimed so for the life of their family members and friends only 49 claimed an at least serious threat for the global population again a pattern showed according to which the participants significantly more often saw other groups than themselves as threatened which is analogous to the observed pattern of emotional distress the results of the assessment on the discrete 010 rating scale were consistent with those on the likert scale the proportion of participants who estimated a strictly lower threat of covid19 to their own life was 65 compared to the global population 64 compared to healthcare workers directly attending to covid19 patients 57 compared to the swiss population and 51 compared to their own family and friends vice versa the proportion of participants who estimated a higher threat to their own life than to another group was a singledigit percentage furthermore 38 claimed that there was a greater threat to the global population than to the swiss population and only 4 claimed vice versa the observation that healthcare workers who directly attended to covid19 patients were predominantly estimated to be more threatened than ones own life calls for closer consideration it applied even among those participants who themselves attended to covid19 patients this is remarkable as the majority therein claimed a lower threat for themselves individually than for others even though they belonged to the very group they were comparing themselves to while this may appear somewhat paradoxical at first glance it is another occurrence of the abovementioned pattern this time within the group of their peers participants who themselves were part of a risk group regarding covid19 because of their health condition estimated the threat to their own life to be higher which is unsurprising the same participants also estimated the threat to the life of their family members and friends to be higher perception of and adherence to preventive guidelines table 5 tabulates the cumulative distribution of the perceived likelihood of a second wave of covid19 and of another pandemic in the future note that this is the cumulative distribution over the likert scale which is split in its middle such that the left side of the table cumulates frequencies from high to low likelihoods starting on the left with the highest and the right side of the table cumulates frequencies from low to high likelihoods starting from the right with the lowest 78 estimated a second wave of covid19 to be at least rather likely and 89 estimated such a likelihood of another pandemic in the future on the discrete 010 rating scale 39 estimated the likelihood of another pandemic to be strictly higher than that of a second wave of covid19 vice versa only 23 estimated the likelihood of a second wave of covid19 to be strictly higher table 6 shows how strictly the participants claimed to be following certain preventive guidelines at the time of the survey like table 5 the upper part of table 6 is split in its middle such that the left side of the table cumulates frequencies from high to low likelihoods starting on the left with the highest and the right side of the table cumulates frequencies from low to high likelihoods starting from the right with the lowest strict adherence was most frequent regarding coughing and sneezing only into a tissue or the inside of ones own elbow not shaking hands and not leaving home in case of a cough or fever and contacting the hotline or a physician via phone 56 claimed to always refrain from public transportation during rush hour while 8 did not refrain from public transportation during rush hour at all 36 disinfected or washed their hands with soap after each physical contact only 8 were able to always keep a physical distance of at least two meters all the time which is not surprising given that all of the participants regularly worked with patients for each of the five covered preventive guidelines the proportion of participants who followed them at least predominantly lay above 80 participants in leading positions were more likely to refrain from public transportation during rush hour participants living by themselves were less likely to keep a physical distance of two meters from people except their closest family and participants who were part of a risk group regarding covid19 because of their health condition were more likely to disinfect or wash their hands with soap after each physical contact the lower part of table 6 shows for how long the participants expected to continue to follow the guidelines with the same intensity in the future that is following the survey the following proportions of participants expected to continue indefinitely or until a vaccine would be available 92 with coughing and sneezing only into tissue or inside their elbow 55 with disinfecting or washing their hands with soap after each physical contact 47 with not leaving home in case of a cough or fever and contacting the hotline or a physician via phone 45 with not shaking hands 35 with not using public transportation during rush hour and 31 with keeping a physical distance of at least two meters from everyone except their closest family while not leaving home in case of a cough or fever and not shaking hands were both followed with high adherence at the time of the survey roughly half of the participants expected to keep it up for a year or less only and to not necessarily wait until a vaccine would be available these two guidelines concern socially and culturally relevant behaviors staying at home may be perceived as an act of social isolation depending on the situation and shaking hands is a common gesture of greeting in switzerland refusing an offered handshake without providing a reason such as a health hazard can be considered as a sign of disrespect the analysis of those participants who claimed to adhere to the guidelines at least predominantly at the time of the survey showed that participants of age 45 to 54 were more likely to continue keeping a physical distance of two meters until a vaccine would be available and that participants of age 55 and above were even more likely to continue keeping a physical distance of two meters with both age groups being compared to participants of age below 45 furthermore participants who had passed the majority of their education outside of switzerland were more likely to continue disinfecting or wash their hands finally participants of age 55 and above were more likely to continue not shaking hands and participants who answered the survey on 20th june or later were more likely to continue not shaking hands table 8 lists the pairwise rank correlation of the reported adherence to the guidelines within each cell of the table the upper coefficient refers to adherence at the time of the survey and the lower coefficient refers to continued adherence in the future following the survey correlation across the different guidelines was rather low at the time of the survey even though mostly significantly different from zero the effects were of small or moderate size according to the classification by cohen except for the two pairs of a3a4 and a3a5 this means that an individual typically did not follow all guidelines to a uniform extent but instead differentiated between the guidelines and followed some of them more strictly and others less strictly by contrast correlation was high among continuation in in the future here the effects were mainly strong with coefficients up to 0707 and only a few of them were moderate hence an individual typically differentiated herhis behavior across the guidelines initially and then intended to continue the pattern for a certain duration without strongly readjusting it over time by relaxing on a part of the guidelines earlier than on others please note that the correlations regarding continuation in the future were calculated for the subsample of the 95 participants who did not answer with dont know if the correlations regarding adherence at the time of the survey were computed for the same subsample the effects were even smaller than the ones shown in table 8 of the mentioned preventive guidelines two participants claimed that most of them are exaggerated for persons working with patients or elderly people and 14 claimed that most of them are exaggerated for people not working with patients or elderly people figure 3 depicts the participants plans of traveling abroad before the end of the year 2020 had the pandemic not emerged 83 would have traveled abroad given the pandemic only 31 still had plans of traveling abroad at the time of the survey unsurprisingly participants who had passed most of their education in germany were more likely to still have plans of traveling abroad given the pandemic one participant commented that shehe had elderly relatives abroad and therefore had to follow a familial obligation impact on work situation table 7 shows the participants assessment of the initial preparation for a viral pandemic before the outbreak how covid19 had affected their work situation and which lessons should be learned from its first wave the participants largely indicated that before the covid19 pandemic had broken out the preparation by the government and the healthcare sector for a viral pandemic had been insufficient 91 deemed preparation insufficient regarding the availability of disinfectant and protective masks 86 regarding personnel 77 regarding structures and 70 regarding processes and contingency plans more than half of the participants claimed that in none of these four areas preparation had been sufficient following the outbreak 44 of the participants felt more stressed than usual because of the pandemic 38 worked unusual tasks as a result of the covid19 pandemic and 32 worked more hours than usual 28 indicated that not all materials and structures necessary to effectively protect the healthcare staff from an infection with covid19 were available and 19 thought that not all the decisions necessary to do so were being taken respectively 92 of the participants reported multiple effects of the pandemic on their work situation only one participant concluded that the first wave of the pandemic had no effect on herhis work situation at all if a participant selected the item labeled other they were asked to specify these other effects among these text answers the most frequently mentioned issue was the handling of visitors of patients which grew more challenging due to more restrictive preventive measures and visitor hours as well as due to visitors not abiding to them and even verbally abusing the staff three participants again emphasized a severe lack of protective equipment one of them described chaotic circumstances in which masks had been forbidden to be used by nurses until the first confirmed case had occurred within the institution and with no measures of isolation afterwards three times it was claimed that wearing the protective material particularly masks made work more difficult or more exhausting three reports were given of increased psychological strain among the staff and the patients another three statements were made that organizational challenges were high because changes needed to be implemented within very short time and without a test run single mentions were the introduction of tracking a lack of personnel economical aspects dominating the healthcare system and employers threatening employees with consequences in case they should introduce covid19 into the institution one participant reported to actually have less work because fewer patients were present in herhis institution due to the pandemic reaction by the government the vast majority of 72 found the preventive measures implemented by the federal government between 17th march and 26th april 2020 to be adequate another 17 found them to be not strict enough too late too short in duration and 10 found them to be exaggerated 56 concluded that the relaxation schedule from 27th april onward was adequate while 32 would have preferred the preventive measures to be relaxed later less strongly and 11 claimed that the measures should have been relaxed earlier more strongly the abovementioned date of 19th june was predictive of the evaluation the participants made participants who completed the survey after that date were significantly more likely to deem the relaxation plan as too liberal compared to participants who completed the survey up to 19th june in addition participants who had children were less likely to evaluate the relaxation plans as too liberal and participants who had passed the majority of their education in germany were more likely to evaluate them as too liberal key lessons more than half of the surveyed healthcare workers claimed the need for morebetter medical equipment than it was available during the first wave of the covid19 pandemic 40 required better protection of their own physical health and even 44 called for better protection of their mental health 37 asked for more personnel 37 thought that hourly wages should be higher due to the exceptional circumstances 36 required more detailedaccurate information about the covid19 symptoms and 32 called for an earlier warning next time only 14 indicated that the work schedule should be left unchanged due to the pandemic 7 claimed that no lessons needed to be learned as preparation for and handling of the pandemic had been appropriate in their view presumed cause of the pandemic half of the participants identified negligent behavior of humans towards animalsnature as the cause of the covid19 pandemic as depicted in figure 4 six participants concluded that it was instead a willful transfer to humans as a biological attack among other causes mutation of sars improper hygiene in the food sector politics economics overpopulation of the planet and overconsumption of natural ressources ignorance and denial were specified discussion key findings this survey explored the knowledge of swiss healthcare workers on covid19 how the first pandemic wave impacted their work situation and how they reacted both emotionally and regarding their adherence to preventive guidelines assessed after the first wave of covid19 had been overcome clinical knowledge of covid19 was high among healthcare workers on several main topics but not on all of them in particular a large proportion overestimated the effectiveness of standard hygiene as a regime that would virtually exclude any transmission of covid19 this proportion was even higher among those who had worked more hours than usually during the pandemic this misjudgment was prevalent despite most of the respective healthcare workers knowing that covid19 was not only transmitted via physical contact also and this may be critical the vast majority of them nevertheless believed not to be needing any further information on the topics of preventive measures and transmission another topic where knowledge was limited however to a lesser degree was the comparison of covid19 with the common flu regarding infectiousness incubation time and lifethreatening disease progression again a pattern showed according to which the majority of those participants who did not provide the correct answer believed not to be needing any further information this clearly shows that even after the first wave of the pandemic healthcare workers had still not received comprehensive or uniform education on certain essential topics it also reflects the circumstance that covid19 had not only been present in media of specific focus and readership such as scientific media from which to be absorbed by the healthcare institutions but that it had also been dominating the popular media since shortly after the outbreak in this everpresent flow of information from most heterogeneous outlets the distinction of scientific facts or also a lack of scientific facts when it was the case from speculation and opinion became significantly more challenging this raises the question of by whom and through which processes the provision of comprehensive and uniform clinical information to healthcare workers can and should be ensured when managing a pandemic of global relevance according to the healthcare workers they most often expected the government to provide them with the necessary information followed by scientistsuniversities and their employer any other possible sources should play a smaller role according to them they preferred to receive the information by public television in case the employer should provide them with according information they had a clear preference for it to be in writing rather than orally the healthcare workers reported considerable emotional distress caused by the pandemic with more than half of them feeling worried about their family or friends possibly getting infected and about numerous deaths among elderly and sick people respectively about one in five reported to be feeling very worried because of these possibilities while less than ten percent were not worried at all by contrast they were significantly less worried about themselves possibly contracting the disease they were also asked to estimate the threat covid19 posed to different groups irrespective of preventive measures meaning for the hypothetical case in which no other precautionary measures would have been taken than the usual ones against the common flu again they were significantly more concerned about the global and swiss population than about themselves interestingly they were also significantly more concerned about healthcare workers working with covid19 patients than about themselves the latter was true even among healthcare workers who themselves attended to covid19 patients while this finding may appear as a paradox it is in line with the repeating pattern of them being more worriedconcerned about others than about themselves even if they are in the same situation even though this manifests as an altruistic trait which may be lauded as heroic by society or patients it ought not to be forgotten that this attitude serves the shortterm interest of the patients but could be detrimental to the physical and mental health of the healthcare worker the vast majority of the healthcare workers estimated another wave of covid19 in switzerland after the first one that took place in marchapril 2020 to be rather likely a different pathogen causing another pandemic of equivalent or greater magnitude than covid19 within the next 20 years was considered to be even more likely this provides the relatively clear picture that healthcare workers expected global pandemics to repeatedly be a part of human society in the future and not a onceinalifetime event the selfreported adherence to preventive guidelines was such that at least four in five healthcare workers followed them at least predominantly the guidelines of refraining from shaking hands no uncovered coughing or sneezing and staying at home in case of a cough or fever were followed strictly by at least four in five healthcare workers all of the tested guidelines were official recommendations by the swiss government during the lockdown phase of the first wave interestingly the pairwise correlation across these guidelines was insignificant to moderate meaning that most healthcare workers displayed a pattern in which they did not follow all guidelines with the same commitment only between roughly a third and half of the healthcare workers expected to continue their pattern of adherence until a vaccine would be available in case that this would take longer than a year this excluded the guideline of only covered coughing and sneezing where the overwhelming majority expected to keep their adherence until a vaccine would be available with increasing age healthcare workers were more likely to expect to keep their adherence to both social distancing and hand hygiene for a longer period of time after eight in ten healthcare workers had plans of traveling abroad before the pandemic emerged three in ten still kept such plans after the first wave the overwhelming majority of the healthcare workers stated that the preparation by the government and the healthcare sector for a viral pandemic had been insufficient at the time covid19 emerged especially regarding the availability of disinfectant and protective masks but also clearly so regarding personnel structures processes and contingency plans the majority even claimed that preparation had been insufficient in all of these areas it is therefore not surprising that the reported effects of the pandemic on the work situation of the healthcare workers were rather diverse roughly one in three had worked more hours than usual this finding was confirmatory of spiller et al who further found that hours worked were sluggish in converging back to previous levels even before the pandemic excessive labor of healthcare workers had been an oftendiscussed topic in the literature particularly regarding its effect on psychosocial function productivity and working errors in an industry where the margin for error often is small another one in three healthcare workers had worked usual tasks one in four reported that not all materials and structures necessary to effectively protect the healthcare staff from an infection with covid19 were available during the first wave one in six were more pressed for time had an employer showing less consideration for their needs than usual or observed a relevant share of nurses not strictly abiding to the hospitalinstitutionspecific regulations regarding protective masks washing of hands and physical distancing respectively further less frequently named effects were working for another departmentdivision challenging situations with visitors of patients due to increased precautionary measures physical exhaustion due to wearing a mask while working increased pressure by the employer increased psychological strain and implementing new processes within short time and without testing the most frequently reported effect however was an increase in emotional stress level as a result of the covid19 pandemic the vast majority of the healthcare workers found the reaction by the swiss government specifically the lockdown during the first wave to be adequate while one in six found it to be not restrictive enough and one in ten found it to be exaggerated the relaxation plan following the lockdown received significantly less approval with one in three healthcare workers claiming that the preventive measures should have been relaxed later and one in ten claiming the opposite the policy change announced by the national government on 19th june according to which many restrictive measures would be relaxed or abolished the national coronavirus taskforce would be suspended and the management of further pandemic waves in the future would be mainly the duty of the cantons was deemed as too liberal by a significant proportion of healthcare workers a similar result showed in the analysis of their adherence to preventive guidelines in which the healthcare workers who participated in the survey after this change of policy were significantly more likely to expect to continue not shaking hands at least until a vaccine was available compared to healthcare workers who had participated before this change of policy lessons to be learned key lessons were drawn which should be learned according to healthcare workers themselves they should be seen as recommendations for the management of further pandemic waves which have recently developed in switzerland and many other countries according to the surveyed healthcare workers the lesson most often claimed as needed to be learned was the requirement of morebetter medical equipment than during the first wave this again reflects the lack of protective materials at the beginning of the first wave in switzerland as well as the globally ongoing efforts in research for vaccination and therapeutics this can be seen as the first aim of improvement according to healthcare workers while their personal physical and mental wellbeing as well as their ability to fulfill their tasks effectively and efficiently are affected by other factors as well progress towards this first aim can be expected to yield most significant improvement the healthcare workers second priority was better protection for their own mental and physical health a proportion of more than four in ten stated this need this is in accordance with the abovementioned group of medical organizations which together recently issued an open call to the swiss government for support in order to prevent further deterioration of the state of swiss healthcare workers in addition to practical challenges a viral pandemic can cause a moral dilemma of being responsible for patients but thereby also risking getting infected and infecting others which may impose additional mental and emotional strain and even affect decisionmaking irrespective of the covid19 pandemic however the literature has suggested that healthcare workers find themselves in a difficult industry as far as emotional communicational and decisionmaking challenges are concerned which can be psychologically depleting in this sense the covid19 pandemic can be seen as an event which has not only caused new challenges for healthcare workers but which has also emphasized shortcomings that were prevalent beforehand solutions therefore should address both the pandemicspecific as well as the underlying longterm challenges of the industry the third lesson was the need for more personnel to be available to handling the pandemic as well as increased hourly wages during the exceptional circumstances it needs to be kept in mind that during a pandemic healthcare workers getting infected themselves is a twofold risk as it not only threatens the health of the individual but also isolates herhim from the workforce at least for a period of quarantine fourthly more detailed information about the symptoms of the disease was required as well as a system of earlier warning in order to provide room for preparation each of these lessons were named by more than three in ten healthcare workers nevertheless there was a small minority of healthcare workers who claimed that no lessons needed to be learned from the first wave of the pandemic as preparation for and handling of it had been appropriate in their view given all of these results the fifth lesson to be learned is that healthcare workers and their individual situations are considerably heterogeneous they have faced a variety of different consequences and challenges during the pandemic and some have been affected more strongly than others therefore solutions must be specific to varying circumstances and remain adjustable over time limitations the population of healthcare workers who directly attend to patients during the present covid19 pandemic is at the center of the topic to date no randomized sample with mandatory participation has been drawn from this population in switzerland therefore clustered sampling was conducted for this survey contacting the attendees of extraoccupational professional development courses at careum weiterbildung in aarau the vast majority of healthcare workers in switzerland repeatedly attend such courses and most of the institutions offering these courses follow a similar scheme careum weiterbildung encompasses a wide range of attendees from different institutions areas of healthcare and geographical regions across switzerland the sample of this survey therefore was drawn from a very broad population of swiss healthcare workers it needs to be noted however that participation was not mandatory within the cluster of careum weiterbildung therefore randomness cannot be ascertained nor excluded also despite the teaching institutions being of a similar scheme and despite the regions from which they attract students overlapping homogeneity of the clusters is unproven the sample size is limited a larger sample although not necessarily related to unbiasedness could decrease the error probabilities on inferential statistical tests causal effects of the pandemic were assessed by directly asking the participants to do so themselves whenever considered to be expedient eg by asking how has the covid19 pandemic affected your work situation within the crosssectional design of the study concepts such as emotional distress and risk perception could not be tracked over time beforeduring the pandemic as a panel or followup study could have moreover all data was selfreported by the participants emotional distress was measured by four items these were derived by three questions on how worried they were as shown in figure 2 referring to three different groups which the pandemic may threatened by the pandemic with answer options on a fourpoint likert scale also the participants indicated whether they felt more stressed during work because of the covid19 pandemic by answering a yesno question a sevenitem validated scale of the fear of covid19 has been published by ahorsu et al which aims at differentiating emotions more strongly and could yield more detailed insight since this study was conducted for swiss healthcare workers understanding their specific situation at the time was crucial consequently the findings may only be applicable to nationshealthcare systems in which the first wave of the pandemic followed a comparable pattern data availability statement the datasets presented in this article are not readily available because of requirements of anonymity however the raw data supporting the conclusions of this article will be made available by the authors to any qualified researcher excluding the demographic data and the free text answers such that any inference that would breach the anonymity of an individual remains ruled out requests to access the datasets should be directed to mr ethics statement ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest

work situation better medical equipment including drugs better protection for their own mental and physical health more assigned personnel more comprehensive information about the symptoms of the disease and a system of earlier warning were the primary lessons to be learned in view of upcoming waves of the pandemic

introduction coronavirus disease 2019 has attracted global attention since december 2019 and was declared a pandemic by the world health organization on march 11 2020 according to scheid et al in 2020 after being declared a pandemic covid19 believed to have originated in wuhan china has now spread to more than 200 countries the number of daily covid19 cases worldwide continues to increase this virus has become a pandemic because it has spread throughout the world including indonesia covid19 can cause mild to severe symptoms and even death mild symptoms commonly seen in covid19 patients are fever mild cough headache anosmia runny nose and sneezing respiratory frequency 1220 times per minute according to who data as of january 27 2021 the number of covid19 cases worldwide was 99864391 positive cases of which 2149700 people died first the most covid19 cases in southeast asia positive cases in indonesia reached 1024298 people and 28855 people died in indonesia as of monday august 22 2022 the number of patients infected with covid19 increased a total of 3300 new cases of corona bringing the total number of people infected with covid19 to 6112658 people active cases decreased by 48803 cases to 1697 from the previous day while the death toll was 157396 based on research data from the central bureau of statistics of pasuruan regency the number of patients infected with covid19 in 2020 was 6836 cases in 2021 the number of patients infected with covid19 increased to 1034 cases research shows that although wearing a mask can protect themselves and others from covid19 infection 355 of people rarely use masks and 67 do not use masks infection can be at risk for everyone but also for relatives of patients who are in the hospital area according to the results of a preliminary survey conducted around bangil hospital pasuruan regency of the 50 families who visited and treated patients at the hospital as many as 60 used masks incorrectly 26 used masks correctly the remaining 14 did not wear masks the increasing number of positive covid19 cases may be due to the easy spread of this disease according to the director general of p2p of the indonesian ministry of health covid19 is caused by the severe acute respiratory syndrome virus coronavirus disease2019 which is transmitted between humans through droplets and contact the condition of the spread of covid19 that affects the economy politics social culture defense and security as well as public welfare requires efforts to overcome covid19 global researchbased mask use continues to provide limited evidence for influenza control and highlights potential problems such as poor mask adherence and improper use a respirator is a respirator designed to protect people from inhaling pollutants or air pollutants a respirator or respirator is not intended to replace an optional method of eliminating disease but rather serves to adequately protect the wearer masks are often used to protect against particles and aerosols that can injure the airways of people who dont wear ppe the dangers of particles and aerosols of varying sizes and chemical properties can harm humans nios advises masks that use filters however the lack of public knowledge and understanding makes the use of masks by the public often neglected even though the correct and appropriate use of masks is one way to prevent the spread and transmission of the covid19 virus according to pmk no 27 of 2017 it is expected that the public can follow the correct rules regarding the correct use of masks according to existing sop instructions because the correct or incorrect use of masks can affect infected or infected people disease if the mask is not used properly the use of used masks cannot work properly and provide optimal protection covid19 mitigation in the behavior change division of the covid19 handling task force is focused on improving 3m compliance namely h wearing masks maintaining distance and washing hands other efforts that can be made by health workers to support the governments appeal on the use of masks can be done by providing clear and appropriate education and information to the public so that the public understands the importance and benefits of using masks correctly governments around the world are also drafting different guidelines the use of a single mask by the whole community is a globally agreed effort recommended to limit the spread of asymptomatic and asymptomatic carriers in the community which can be a major cause of the rapid spread of covid infection 19 based on fmd regulation number 27 of 2017 concerning infection prevention in health services regarding the correct use of masks according to existing instructions and sop rules researchers are interested in studying the behavior of mask use in patients families bangil hospital pasuruan regency method this study uses a qualitative descriptive research design where researchers try to explore as much information as possible about the problem that is the topic of research by prioritizing verbal data the type of research used in this study is a case study the population in this study was all families of patients in the bangil hospital pasuruan regency some of the families of patients who became key informants who were in the inpatient and outpatient rooms within bangil hospital pasuruan regency totaled 50 informants the sampling technique used is snowball sampling the research design used in this study is a case study the variable in this study was the behavior of the patients family in wearing masks finding and discussion table 1 displays the informant characteristic data as follows a respondents knowledge of masks from the results of the interview it showed that out of fifty respondents twentynine respondents had sufficient knowledge in this case respondents were able to understand and know about masks namely mask knowledge mask benefits types of masks how to use masks correctly this sufficient knowledge is obtained through various factors such as books mass media online media counseling from puskesmas and from closest relatives who inform about the covid19 disease from the results of the study it was found that the age of most respondents was over thirtyfive years old where the older the age of the respondent the better he will have a better level of knowledge according to galve et al several studies explain that a persons age in the productive period has the best level of knowledge or cognitive in addition at that age also a person has extensive experience and ability to do activities that will certainly support his knowledge in everything but on the other hand as a person gets older his commitment to something in decision making will also be higher in addition to age judging from the level of education a persons education level can affect knowledge because the acceptance and understanding of someone who has higher education is better than those who have low education knowledge is the result of knowing and this happens after someone senses a particular object most human knowledge is acquired through the eyes and ears knowledge is needed as support in generating selfconfidence as well as attitudes and behaviors every day so it can be said that knowledge is a very important domain for the formation of ones actions according to the researchers assumption sufficient knowledge about covid19 prevention efforts especially in the use of masks will greatly affect public behavior in carrying out covid19 prevention efforts people with sufficient knowledge are expected to make appropriate covid19 prevention efforts awareness will grow in the community to make efforts to prevent covid19 disease if residents have good knowledge b behavior of mask use in the patients family in the hospital environment the results showed that most of the patients families or respondents did not use masks removable masks according to their wants and needs namely as many as 29 respondents according to bloom that behavior is one of the determinants that affect the degree of health behavior is any intentional action of a person for a specific purpose behavior can arise as a result of being influenced by various factors lawrence green revealed that behavior is influenced by predispocing factors such as knowledge values and beliefs and attitudes enabling factors such as availability of funds and facilities time and facilities and also reinforcing factors such as support from family and health workers using masks appropriately is basically to ensure maximum mask effectiveness and to avoid an increased risk of transmission who has also recommended the use of masks appropriately during this pandemic to effectively prevent transmission of the corona virus based on the description above researchers concluded that behavior to improve health is influenced by individual perceptions of behavior to prevent transmission of covid19 disease and how to maintain health by using masks the better their behavior will be to prevent transmission of covid19 disease to others c how to use respondents masks during the hospital environment the results showed that most respondents used masks in an incorrect or inappropriate way namely as many as 33 respondents the masks used need to be ensured to cover the mouth nose and chin perfectly and there are no gaps between the face and mask respondents in this study have not met the recommendations and there are common mistakes such as using masks without covering the mouth and nose perfectly or using loose masks this can provide an opening for viruses bacteria and germs to enter or covid19 virus contamination can occur and can reduce the effectiveness of masks another practice that is not appropriate in using masks in this study is the habit of lowering the mask to the chin this can be caused by respondents feeling uncomfortable in breathing when using a mask so that the mask is often opened and lowered to the chin this result is in line with research by tan et al showing that more than 13 of respondents stated that they often or always lowered the mask under the chin and 412 sometimes hang their masks under their chins in addition based on research by hou et al the virus that causes covid19 is more likely to first infect cells in the nasal cavity because in the nasal cavity there are more ace2 proteins which are the entrance of the corona virus compared to cells in the lower airway this shows that the cells of the upper airway are more susceptible to infection so the use of masks is recommended to cover the nose and mouth perfectly according to who everyone is required to always use a mask both when sick and healthy based on the guidebook on the importance of using masks the purpose of using masks is to avoid the spread of droplets so the mask used must cover the mouth nose to the chin in addition the mask used should not be loose because this can make air enter without being filtered by the mask eventually viruses and bacteria can enter the ducts breathing so that in preventing covid19 it is not just about using masks but the use of masks needs to be practiced properly and correctly so that the effectiveness of using masks is maximized according to the researchers assumption improper use of masks or lowering the mask to the chin is prone to making viruses attached to the outside of the mask move to the face and putting individuals at risk of inhaling harmful particles that stick to the surface of the mask d reasons respondents do not use masks in the hospital environment the results showed that the reason respondents did not use masks while in the hospital environment was mostly because of tightness or difficulty breathing as many as 23 respondents the data from the study shows that there is still a lack of public awareness of the importance of wearing masks the research reflects peoples unfavorable behavior research by siahaineinia and bakara shows that there are several other reasons respondents do not use masks such as because they feel tight uncomfortable feel healthy and do not feel worried about the presence of covid19 and do not know the dangers of covid19 apart from the discomfort factor caused by using masks it is necessary to see far more important benefits in using masks to reduce the spread of covid19 during this pandemic in healthy individuals wearing a mask even for a long time does not produce clinically relevant changes in circulating oxygen or carbon dioxide and does not affect tidal volume or respiratory rate however wearing a mask does produce a slight increase in respiratory resistance caused by the mask material filtering airborne particles and aerosols its discomfort in addition according to maclntyre discomfort can also affect an individuals decision to use a mask a review of respirator performance and standards found that all types of respirators provide a burden of discomfort based on the research above according to researchers in conditions like this the government should continue to straighten the publics perspective that our country has not fully recovered from the threat of the virus and does not mean that it can relax by ignoring health protocols conclusion respondents have sufficient knowledge namely 29 respondents in this case respondents are able to understand and know about masks namely the meaning of masks the benefits of masks types of masks how to use masks correctly the application of mask use behavior in most families of patients or respondents do not use masks removable masks according to their wants and needs namely as many as 29 respondents most respondents use masks in an incorrect or inappropriate way namely as many as 33 respondents ie respondents have not fulfilled the recommendations and there are common mistakes such as using masks without covering the mouth and nose properly the reason respondents do not use masks while in the hospital environment is mostly because of tightness or difficulty breathing as many as 23 respondents this shows that there is still a lack of public awareness of the importance of wearing masks

at the beginning of the 2020 coronavirus pandemic the world health organization who stated that the use of masks was recommended only for sick people not for healthy people however the development of the virus finally prompted who to appeal to everyone healthy and sick to always use masks outside the home in a qualitative descriptive research design with a sample of 50 respondents interview guide with research subjects namely families of patients who are hospitalized or outpatient at rsud bangil as the instrument results based on the interview results the majority of respondents had sufficient information about masks most respondents do not wear masks masks are removed according to their wants and needs because most occur due to stress or difficulty breathing

introduction more than half of americans do not achieve the current recommended levels of physical activity 1 and rural populations are even less likely to meet the guidelines compared to their urban and periurban counterparts 23 geographic disparities in physical activity may be driven in part by environmental factors in rural communities that limit opportunities to be active including poor quality limited availability and inadequate access to recreational facilities as well as geographic and topographic features that inhibit active living and transportation 45 in the past decade there has been a proliferation of interest in understanding the relationship between built environments and physical activity 6 7 8 and identifying effective strategies to promote active living 9 10 11 12 however much of the evidence supporting policy and environmental strategies to encourage active living comes from research in nonrural settings 6 9 10 11 rural communities have several features relevant to the built environment that set them apart from more densely populated areas 1314 including more dispersed populations longer distances between destinations lack of public transportation distinct social norms and cultural practices and different recreational environments further rural communities have higher poverty rates and lower income levels than urban areas 15 which impacts individual opportunities as well as tax revenues and funds available for improving active living structures given the unique physical and contextual challenges faced by rural communities special considerations should be given to them when developing strategies to enhance physical activity participation in rural settings 14 existing policies and strategies to support active living through environmental changes however are mostly urbanoriented for example although national recommendations such as the common community measures for obesity prevention published by the centers for disease control and prevention are in place to guide the improvement of physical activity engagement many of them are not applicable to rural communities 14 these published strategies largely relate to proximity to schools enhanced walking and biking infrastructure improvement of public transportation mixedland use and improved personal and traffic safety where people are usually physically active 16 physical activity is a multifactorial behavior and is influenced by a wide range of factors related to a persons surroundings 17 objective aspects of the environment as well as individuals perceptions of their environment are likely to be important influences 17 as rural communities are highly heterogeneous factors influencing rural physical activity vary substantially across rural built environment studies depending on the geographic and social contexts of the population being studied 8 18 19 20 21 given this it is advantageous to use a variety of data sources to understand the various dimensions and support a more nuanced interpretation of barriers and facilitators focus groups with residents are an effective way to explore a variety of issues in a community that influence behavior 22 while interviews with key informants can be used to gather additional information and provide further insights 23 data from objective environmental audits can elucidate complementary or contradictory aspects of the issues identified from focus groups and key informants interviews 2425 therefore the purpose of the present study was to gather information from built environment audits resident focus groups and key informant interviews to capture different factors that influence rural adults physical activity engagement as building new active living infrastructures often poses resource challenges to rural communities our hope is to identify strategies that could potentially leverage rural communities exiting assets and resources to improve rural health materials and methods figure 1 shows the overall data collection and analysis process data were collected and analyzed between 2014 and 2017 as part of formative research for the strong hearts healthy communities trial a rural communitybased cardiovascular disease prevention program 26 in eight governmentdesignated medically underserved rural montana towns 16 the study was approved by the cornell university institutional review board setting montana is one of the most rural states in the united states with close to two thirds of the population living in rural areas 27 as of 2013 only 233 of the states adult population met the national physical activity guidelines 28 study towns were selected to represent different geographic regions table 1 shows the demographics of the study towns in all towns most people were nonhispanic white and the median household income was below 50000 population density ranged from 213 to 1029 people per square kilometer with a median age between 379 and 554 years 29 to illustrate the rurality of our study towns demographics of new york city are included in table 1 for comparison setting montana is one of the most rural states in the united states with close to two thirds of the population living in rural areas 27 as of 2013 only 233 of the states adult population met the national physical activity guidelines 28 study towns were selected to represent different geographic regions table 1 shows the demographics of the study towns in all towns most people were nonhispanic white and the median household income was below 50000 population density ranged from 213 to 1029 people per square kilometer with a median age between 379 and 554 years 29 to illustrate the rurality of our study towns demographics of new york city are included in table 1 for comparison built environment audits in each town we used a reliable community asset inventory tool 31 inventories for community health assessment in rural towns to assess active living characteristics related to physical activity opportunities the tool organizes built environment characteristics into 11 categories the presence of retail business professional services community services town amenities physical activity facilities town aesthetics condition of sidewalks condition of the town center condition of street and intersections street and intersection safety features and biking facilities as mixed land use and active living characteristics are associated with physical activity 811 the assessment of these characteristics allows the understanding of the strengths and weaknesses of the built environment of the study towns we also assessed the presence of stray animals given previous research indicating their relevance to outdoor activity safety in the midwest united states 18 the ichart tool contains a checklist of items that the researcher looks for and documents during the audit table s1 shows the individual items assessed within each built environment category in all towns meredith l graham and either a local national institute of food and agriculture extension agent or another research team member conducted the audits on different days the audits were completed in two steps a onemile walking tour from town center and a fourmile windshield tour the windshield tour allowed for identification of built environment features that were difficult to observe on foot or may not be within walking distance discrepancies between audits were discussed for consensus resident focus groups nifa extension agents and their local partners recruited overweight ≥ 250 and sedentary adults aged ≥40 years to take part in focus group discussions recruitment strategies included press releases flyers website posts wordofmouth referrals and direct contact with community residents to confirm eligibility we asked potential participants to complete a screening survey with questions about age height weight and physical activity level focus groups were stratified by age and gender as different responses were expected according to different age and gender groups discussions lasted between 60 and 90 min and were facilitated by mlg an experienced qualitative researcher the discussion guide was based on an ecological framework 32 and developed by meredith l graham sara c folta and rebecca a seguin to explore participants attitudes perceptions barriers and facilitators to physical activity prior to use the discussion guide was pilottested and refined participants provided written informed consent and completed a brief demographic and health behavior questionnaire sessions were digitally recorded for transcription participants were compensated 50 table 2 shows a subset of the focus group guide questions that were relevant to the present study key informant interviews in each town we conducted phone interviews with three key informants identified by nifa extension agents key informants represented diverse areas of community leadership including recreation local government public health and healthcare social services community programming and business because of the inherent confidentiality concerns in conducting research in small rural communities key informant characteristics will not be reported in detail the interview guide focused on locally relevant environmental influences on physical activity as with the focus groups we piloted and revised the interview guide prior to use most interviews lasted between 45 and 60 min and all were digitally recorded and transcribed verbatim key informants provided verbal consent and were compensated 25 table 3 shows a subset of the interview guide questions that were relevant to the present study barriers tell me about policies physical or social aspects in this community that make physical activity more difficult facilitators tell me about programs policies physical and social aspects in this community that promote physical activity programming in your opinion what could be done to improve the environment that would make it easier for people to be active what types of opportunities or programs to improve their health might people in this community be interested in analysis we enumerated items identified through the built environment audits by category brian k lo and emily h morgan performed thematic analysis of the qualitative data 33 guided by an ecological framework 32 we developed an initial codebook using a lumping technique to look for overarching themes and coded transcripts into three broad categories of influences related to physical activity participation individual environmental and sociocultural influences 34 brian k lo then used a splitting technique to look for more detailed themes or smaller categories within the three broader categories of influences 34 a subsequent codebook relevant to the present study was then developed and it was continuously discussed and refined among the research team brian k lo and a research assistant independently coded a subset of the data using the refined codebook with an observed agreement 90 between the coders any discrepancies were then discussed among the research team to reach consensus data were then recoded using the final codebook we first analyzed the focus group and interview data separately to identify major and minor themes in each dataset and then compared and contrasted emerging themes we organized themes into five categories of environmental factors guided by the ecological model of active living developed by sallis et al 32 built social organizational policy and natural environments to facilitate data triangulation we transformed results from the built environment audits into qualitative narrative summaries and then compared them with the themes identified in the focus group and interviews we used nvivo to assist coding and analysis results a total of 118 adults aged 4091 years participated in the focus group discussions the socioeconomic characteristics of participants broadly aligned with the composition of the communities in which they lived although all participants were sedentary and outside of the optimal bmi range threefourths rated themselves having good to excellent health figure 2 below summarizes the subthemes identified with each data source results a total of 118 adults aged 4091 years participated in the focus group discussions the socioeconomic characteristics of participants broadly aligned with the composition of the communities in which they lived although all participants were sedentary and outside of the optimal bmi range threefourths rated themselves having good to excellent health figure 2 below summarizes the subthemes identified with each data source built environment audits identified a range of active living assets in each town we identified retail businesses professional services community services outdoor physical activity facilities outdoor lighting aesthetics and clean and wide sidewalks in all towns in many communities we did not observe continuous and even sidewalks street intersection safety features or biking facilities we documented stray animals in six out of eight of the towns the presence of other built environment features such as indoor recreational facilities and trails varied considerably between communities interpretation of built environment audits focus groups and interview data emergent themes within the five categories of environmental influences were described in relation to the observed built environment characteristics representative quotes are presented in table 4 built environment audits identified a range of active living assets in each town we identified retail businesses professional services community services outdoor physical activity facilities outdoor lighting aesthetics and clean and wide sidewalks in all towns in many communities we did not observe continuous and even sidewalks street intersection safety features or biking facilities we documented stray animals in six out of eight of the towns the presence of other built environment features such as indoor recreational facilities and trails varied considerably between communities environmental interpretation of built environment audits focus groups and interview data emergent themes within the five categories of environmental influences were described in relation to the observed built environment characteristics representative quotes are presented in table 4 built environment in all focus groups participants described the presence of physical activity facilities such as sports fields recreation centers swimming pools or gyms confirming the findings of the built environment audits focus group respondents in several communities also described the common use of nontraditional or mixeduse spaces for physical activity such as school athletic facilities and hotel swimming pools although personal connections with facility management were sometimes required for those who lived outside of town distance hindered facility use focus group participants and key informants commonly expressed a desire for larger and more diverse recreational centers with a broader range of physical activity opportunities especially in the winter many participants specified that walking was the preferred form of physical activity participants comments reflected findings of the built environment audits that variation existed in the presence condition and safety of the sidewalks and streets in town centers several focus group and interview participants felt that investment was needed in pedestrianfriendly features and that the lack of sidewalks poor sidewalk quality and the presence of stray animals were major barriers to walking outside in addition town walkability was subject to weather conditions especially in communities where sidewalks were not adequately cleared of snow social environment the audit tool did not capture social environments but the focus groups identified them as crucial to rural residents usage of the available physical activity resources the social environments at recreational facilities influenced some residents physical activity behaviors some participants perceived sports fields and gyms as youth spaces and felt out of place in these spaces several participants described a desire for fitness opportunities with people of a similar age and fitness levels some said that they felt uncomfortable exercising with younger and more physically fit people while others referenced the camaraderie of a peer atmosphere the desire for ageappropriate opportunities was supported by key informants complaints about the lack of adultspecific programs and activities in rural communities the benefits of structured exercise classes with peers was discussed more commonly in focus groups with women than in groups with men to some women a socially familiar environment provided a sense of safety for physical activity organizational environment facility and program schedules strongly influenced use and engagement people who worked business hours or lived far from facilities reported that operating schedules often did not meet their needs when multiple users shared facilities access for children and youth was viewed as the priority to some male residents the quality of facilities was an important factor and outdated equipment was cited as a barrier to use further both residents and key informants agreed that cost was a barrier to participating in some activities for example several participants reported that they enjoyed skiing but found regional ski resorts to be costprohibitive in addition information dissemination influenced participation in scheduled physical activity many participants described social networksfriends and familyas the means by which coordinated opportunities such as pickup basketball games and fitness classes were promoted most often some described feeling excluded because they were less connected to networks in which this information would be shared in addition although many residents were able to identify local programs and opportunities they were not always aware of specific schedules or content key informants suggested that the greater promotion of existing opportunities for physical activity would be helpful policy environment residents cited poor city planning and lack of maintenance of existing facilities as barriers to physical activity these comments often were related to perceptions that local governments do not have funding or interest in promoting physical activity to adults in some towns key informants also expressed this belief however although several key informants criticized the lack of sidewalks and sidewalk quality in one community the key informants reported improvements in these features suggesting differences in political agenda and priorities between jurisdictions natural environment although seasonal factors and the natural geography were not captured in the built environment audits the natural geography of montana including its diverse terrain open spaces and water features was raised in all focus groups and in some interviews as an important facilitator for leisuretime physical activity including hiking running skiing hunting and fishing however while the warmer months favored outdoor activities extreme winter weather was described by focus group participants and key informants as a significant barrier to outdoor physical activity discussion the aim of the present study was to use information gathered from built environment audits resident focus groups and key informant interviews to understand factors that influence physical activity among sedentary overweight midlife and older adults living in rural communities while built environment audits provided a blueprint of the characteristics of the built environment resident focus groups and key informant interviews provided critical contextual information on how the rural built environment encourages or discourages physical activity in the eight towns sampled in this study spaces for physical activity were available but were not always perceived to be activityfriendly for adults for example although some residents expressed their desire to use the athletics facilities at schools these spaces are usually prioritized for use by youth sports competition for physical activity spaces in rural settings has not been discussed extensively in the literature but suggests a need for sharedor openuse policies with schools outside school hours to enable structured physical activity programs that are tailored to adults 143536 in the focus groups and interviews we commonly heard about the use of nontraditional spaces for physical activity through community audits we identified a range of other possible spaces that potentially could be utilized for hosting physical activity programs such as churches libraries and municipal buildings other studies have found that nontraditional facilities such as community centers churches and worksites often are used for both planned and spontaneous physical activities in rural communities 1937 as funding for new construction and facility management is limited attention towards optimal utilization of existing facilities is warranted although previous studies have found social support such as accountability to family and friends company from pets and peer influences to facilitate engagement in physical activity among rural adults 1838 triangulation of our findings adds to the literature that social networks also play a critical role in promoting physical activity opportunities among rural residents events classes and activity groups often are organized informally and publicized by wordofmouth and social media participants also described that local connections and promotions for access to physical activity equipment at private facilities such as those in hotels and hospitals finding ways to broaden promotion of existing and emerging opportunities and to support the operators of private physical activity spaces in expanding access should be considered previous research has found the aesthetics of rural towns to be associated with physical activity levels 3940 all the rural towns in this study had vibrant town centers with pedestrianfriendly features and facilities for physical activity nonetheless poor city planning and inadequate maintenance of facilities were perceived to be barriers for using existing indoor and outdoor spaces for people living outside of town geographic dispersion and a lack of transportation hindered utilization of available assets in town centers instead many favored outdoor activities in the countryside such as hiking skiing hunting and fishing these findings suggest that landuse policies affecting spaces both within and outside of towns are critical for the promotion of physical activity active and early engagement of residents in local planning and management processes may help improve coherence between resident demands and policy decisions 41 this study also identified several important considerations for future built environment research in rural communities first we found the qualitative research extended the findings from the built environment audits and enriched our understanding of how communities perceive and interact with existing built environment features as rural physical activity is complex and multifactorial using a single assessment approach may limit the breadth and application of findings second our findings suggest that some constructs in the built environment audit tool are not relevant to all rural towns for example some street and intersection safety features and biking facilities were not observed and were not mentioned in either the focus groups or the interviews this differed from what has been identified in other rural studies 4243 and could be attributable to the composition of our participant sample our findings also suggest a benefit to collecting more details about recreational facilities and their operational characteristics because of the important role of these factors in facility utilization 3537 additionally in locations where outdoor activity is popular it may be helpful to gather data on natural geography features that provide opportunities for exercise such as trails lakes rivers and mountains third there may be a benefit to adapting rural built environment audit tools to capture more places where residents are physically active for example we observed good to excellent condition of sidewalks in all town centers but learned from local residents that sidewalk maintenance and availability was often suboptimal in certain areas of town where they felt it was needed it is possible that the community audits could be enhanced by separately assessing features in town centers and outside of town or by consulting local residents about the places and spaces that they go before creating the community maps the present study has few limitations first data collection was limited to rural montana however we believe that our purposeful selection of diverse towns likely improved the relevance of the findings to rural communities in regionally proximate states such as idaho north dakota south dakota and wyoming where population characteristics are similar second our research focused on midlife and older sedentary adults it is likely that younger and more active residents may have different perceptions of physical activity opportunities and may interact differently with the environment third as our study was crosssectional it is possible that some seasonal factors may have been missed finally because we did not specify the full range of types of physical activity that we wanted to learn about to study participants they may have limited their discussions to the types of activity that are most often discussed in the popular press conclusions our findings suggest that rural communities have a number of built environment assets that promote active lifestyles but that their potential may not be fully realized given resource constraints and competing priorities building new recreational facilities and structures to support active transportation is unlikely in many rural communities however enhancing existing features and identifying opportunities to maximize their use such as increasing the promotion of classes and available spaces and revisiting scheduling could support physical activity and help build momentum towards larger changes involving residents along with other stakeholders in the city planning process should be a priority our experience suggests that future rural active living research would benefit from use a triangulation approach to enhance understanding of unique characteristics of rural communities and identify relevant strategies for improving physical activity opportunities supplementary materials the following is available online at table s1 individual item availability for the built environment audits author contributions all authors contributed extensively to the work presented in this paper brian k lo and nicolette v jew wrote the first draft of the manuscript brian k lo emily h morgan and laurel f moffat performed the data analysis meredith l graham and lynn c paul implemented the study and collected the data sara c folta miriam e nelson and rebecca a seguin designed the study all authors discussed the results and implications and commented on the manuscript at all stages all authors also provided the approval of the final version of the manuscript

rural populations in the united states have lower physical activity levels and are at a higher risk of being overweight and suffering from obesity than their urban counterparts this paper aimed to understand the environmental factors that influence physical activity among rural adults in montana eight built environment audits 15 resident focus groups and 24 key informant interviews were conducted between august and december 2014 themes were triangulated and summarized into five categories of environmental factors built social organizational policy and natural environments although the existence of active living features was documented by environmental audits residents and key informants agreed that additional indoor recreation facilities and more wellmaintained and conveniently located options were needed residents and key informants also agreed on the importance of agespecific wellpromoted and structured physical activity programs offered in socially supportive environments as facilitators to physical activity key informants however noted that funding constraints and limited political will were barriers to developing these opportunities since building new recreational facilities and structures to support active transportation pose resource challenges especially for rural communities our results suggest that enhancing existing features making small improvements and involving stakeholders in the city planning process would be more fruitful to build momentum towards larger changes

introduction the situation of urban roadway asset management is complicated by the social environmental political and budgetary constraints of transportation agencies making sustainability the primary concern 1 current research on lifecycle assessment of roadways has focused on either material type or pavement overlay the policies and decisions involved with investments on transportation infrastructures interact with exogenous variables of urban density traffic congestion due to specific roadway design and number of lanes 5 however complimentary facilities of onstreet parking and adjacent parking zones 6 must also be considered shoup 6 and hawas et al 7 noted that the decision of commuters to choose between private vehicles and public transport is affected by these factors the choice of travellers to lean towards any mode choice regardless of its private or shared nature is affected by the trip purpose perceived service quality and service attributes which are sensitive to the individuals and are largely impacted by the transit options available in a region social and cultural norms and the tradeoff between perceived service and quality 8 masstransit systems also open a window of opportunity for any urban area to reduce its transportationrelated cost and environmental burdens 9 yet due to the high investment cost requirement and involvement of the public administrative agencies demand that the perception of transportation system functionality and attributes is an integral part of planning a number of studies 1011 have suggested that the attitudes of people towards transportation systems are increasingly becoming complex as their understanding of daily commute safety travel duration and ride quality change this is especially significant since transport authorities have to optimise the public system against multiple competing private shortterm rental shared and ondemand options in a changing transit mode choice environment micromobility integration can affect publictransport attraction compared to other modes particularly in the wake of a return to normalcy after the lifting of covid19related mobility restrictions where increased mobility is expected 12 the importance of an accessibilitybased approach in this context was recently explored in a study by ali et al 13 which highlighted that focusing on accessibility to plan transport solutions is especially significant for resilient transport planning and that transit solutions should be gauged through travel time nonetheless the association between publictransit accessibility and usage frequency is not a recent topic in transport policy research and has been addressed in multiple studies soliciting usage patterns and underlying contributory variables from questionnaire surveys as one of the earliest explorations an empirical study on the association between travel behaviour of urban travellers and scale of the urban neighbourhood was conducted by krizek 14 they found that the reported vehicle miles travelled were reduced if the accessibility of the neighbourhood increased another study focusing on the effect of urban form on the variation of travel behaviour was conducted by pan et al 15 in four selected shanghai neighbourhoods they proposed that if neighbourhoods are designed with denser street networks the increased reliance on private vehicle travel induced by higher incomes may be replaced by bicyclepedestrian trips the reasons for a traveller to choose to drive to work in a small urban english area were investigated by gardner and abraham 16 through 19 semistructured interviews with private vehicle users they found that the decision may be primarily driven by monetary costs effort minimisation origin destination and time spent in journey as the public transport was perceived to be comparatively slower delays in the publictransport system and lack of reliance on its schedule strikes and perceived safety were noted as critical factors private vehicle commuters also highlighted the importance of the publictransport system in dealing with the problem of parking which has been noted by researchers 1718 as responsible for traffic congestion as well as the cost and environmental burdens of a roadway system another early qualitative study to identify the mode choice attitude of car and publictransport users was conducted by beirão and cabral 8 they found that the mode choice is affected by situational variables perceived performance journey type and user lifestyle and characteristics they proposed that the policymaking process should accommodate customer expectations so that the usage of publictransport systems can be increased in the context of transitioning economies grdzelishvili and sathre 19 investigated the travel behaviour of tbilisi residents they identified perceived safety comfort frequency and time as the most important factors that tended to skew the survey respondents towards private vehicle ownership and usage the service quality attributes of public transport and the social dynamics associated with car use and ownership factors were also found to influence the travellers mode choice in a study by javid et al 20 where it was also observed that in order for a publictransport authority to motivate more users towards public bus transport survey responses and service quality attribute optimisation should be conducted in a followup study 21 the authors argued that in a mixedmode use environment where multiple competitive transport choices including private cars public bus transport shared bus transport and shared taxis and carrental services are present it is absolutely imperative to analyse the user satisfaction according to service quality attributes data on bus transport service riders using flexible ondemand service options of two appbased bus services were collected using a questionnaire survey the authors found that waiting time at the bus stop income profile and profession of the travellers vehicle ownership and trip purpose were significant predictors of mode choices by applying factor analysis and structural equation modelling techniques the study also noted that a positive perception of the users affects their usage tendency for bus transport students and privately employed individuals were more inclined to use bus services whereas increases in busstop waiting time and travel time as well as low coverageaccessibility negatively affected usage the city of abu dhabi has witnessed an increase in population accompanied by an increasing dependence of commuters on private vehicle use resulting in traffic congestion in urban abu dhabi localities 22 most studies in the country have focused on road transport from the infrastructural 2324 environmental 2526 cost 2728 or traffic safety 29 perspectives while some 30 extended the research to operational and facility management issues for providing connected pathways from urban communities to city centres and central business hubs and districts however the abovereferred studies hinted that the urban transportation network cannot be solely evaluated by conventional cost and environmental aspects a social aspect should also be considered however very few studies have addressed the travel behaviour and perception of urban publictransport network in abu dhabi city the literature review conducted above highlights that in order to promote public transport among urban travellers in a mixedmode choice environment the critical variables of service quality accessibility and travel time need to be optimised however the definition of the former two attributes is scattered in literature and regionaldependent including aspects such as safety onboard facilities connection facilities and cost for service quality and network coverage service frequency seating and community inclusion for accessibility additionally most studies were conducted in the european region where the publictransport system is welldeveloped and carfree precincts exist that regulatorily and culturally promote sustainable transit options over car use studies conducted in the developing world either focused on ondemand bus mobility options or did not include incomeand employmentrelated variables which affect the affordability and lack of choice parameters potentially rendering travellers incapable of choosing costlier options over publictransport services abu dhabi provides a unique opportunity to investigate the travel mode choice patterns of multicultural residents belonging to different income groups and sociodemographic categories in a highly developed infrastructural yet cardependent urban setting where enhanced publictransport planning informed by public preferences can trigger a positive shift this study attempts to address this by soliciting public responses on a questionnaire survey to establish a clear definition of service quality accessibility and travel time attributes for abu dhabi which can result in publictransport uptake as well as produce insights into the various sociodemographic classes that utilise this mode for their transit needs method this work was conducted to form the basis of a pilot study exploring the application of innovative mass transit over the lifecycle of a transportation infrastructure asset the strategy of this study was intended to primarily focus on capturing the use of public transport specifically bus transport in the urban area of abu dhabi travel behaviour user demographics attitude towards travel and trip distribution are emphasised questionnaire design bus routes and sample size selection the questionnaire used for data collection was designed for soliciting the travel information of bus users perception of existing bus network demographic profile of the service benefiters and their respective attitude towards travelling attributes network coverage quality and satisfaction perception of congestion and potential improvement strategies the questionnaire was limited to 11 multiplechoice questions designed to take less than 5 min the detailed questionnaire including the subquestions and options is provided in the supplementary materials the survey was administered using the capibased surveying methodology for onsite data collection teams of multilingual surveyors administrated questionnaires in both arabic and english along with the capabilities to assist passengers from various ethnic and lingual backgrounds the purpose of study was to target the steady growth in urban abu dhabi as such according to the dot observations the area between corniche and hazaa bin zayed the first street was selected to increase the range of collected samples interviews were conducted on both weekdays and weekends during two 8 h shifts the collected data were collected and tabulated using ms excel a total of 769 interviews on the weekend and 751 interviews on weekdays were completed and all responses with missing or incomplete responses were disregarded according to the exclusion criteria set by the local transport authority responsible for data collection curation and management data analysis an analysis was performed of the survey data collected for the publictransport usage study of the abu dhabi department of transport as part of the abu dhabi governments initiatives to reduce travel dependency on cars and reduce the increasing traffic congestion problems currently being observed in the city logical checking of data consistency was performed of the raw data ms excel files to address data sparseness outliers and missing data interlinking of passenger demographics against travel attributes resulted in minor data revisions the revised data were broken down into three different sections distribution of generated trips for each mode and current level of network coverage the literature review section highlighted that accessibility service quality and travel time affect the mode choice of travellers however the exact distribution and inclusion of variables within these attributes differed across studies in order to investigate this further and estimate the effect of including service frequency perceived congestion onboard situation trip purpose and busstop and coverage facilities on publictransport uptake over competing modes four different regression models were tested with two primary objectives if inclusion of the variables in tsc ta and sdv blocks improved model fit and which parameter is a strong predictor three different variable blocks were created for statistical analysis with the variable description presented in table 1 and comparison method explained in the last three rows the analysis was conducted in spss v22 models were controlled for the reference category in ordinal regression analysis reference categories were selected to identify the comparative influence of independent variable blocks on decreasing the satisfaction level of the publictransport system and increasing reliance on travel by taxis and private cars results and discussion the results of the analysis were tabulated in separate sheets according to respective occurrence on the weekdays and weekends statistical analysis suggests that the majority of the survey respondents were south asians regardless of weekday or weekend moreover the younger male population largely working in the fulltime workforce formed the largest proportion of the respondents according to the previously recorded statistical distribution of the abu dhabi city residents these results are representative of the local population which is predominantly male in the under 34 years old age group with over 50 being of south asian descent 3132 the income profile captured in the survey showed that the majority earned a gross monthly salary of aed 10005000 which is also in line with the findings of these previous statistical studies which found the majority to be fulltime workers earning an average monthly salary of aed 3500 regarding the statistical response distribution of the qualitative data variables the majority perceived bus travel as an uneasy transit mode yet found them to not be very crowded however respondents were unsatisfied with the current distribution of the bus stops on the surveyed networks as they reported spending over 15 min to reach the nearest stop additionally the majority had a neutral perception of current travel time while using public bus services and either had a good or neutral perception of the current conditions of bus stops to address the research question of travel behaviour patterns and what variables define service quality accessibility and the eventual mode choice three multinomial dependent variables were identified frequency of bus travel frequency of car travel and network coverage satisfaction netcovsat was originally recorded on a likerttype scale in the order of decreasing likeability of the dv whereas fct and fbt were arranged with 1 representing more frequent travel and 6 representing the least travel first time the percentage distribution of respondents on each scale was used to reverserecode fbt and netcovsat so as to represent a higher occurrence with increasing numeral order the probability of mode choice for a traveller was affected by several parameters and factors of transportation system characteristics travel attributes and sociodemographic variables as shown in the multistage multinomial logistic regression models summarised in table 2 results from the weekday analysis are presented first followed by the weekend analytical analysis results similarly variables from each block were carried forwards to subsequent analysis except for sdvindependent variable block which was separately performed and the variables were then added in the logistic regression equations to perform the final analysis odds ratios ie the probability that a certain variable may influence the outcome of the model when all other variables are controlled as well as model fit and significance level of the regression models for recorded polychotomous variables are provided in table 2 factors in traveller satisfaction from publictransport network coverage analysis results showed strong correlation between the transportation system characteristics and satisfaction of publictransport system users as also reported in the literature results were generally similar across weekdays and weekends distance to nearby bus stop was only negligibly identified as an obstacle across all four variable blocks with the or remaining in the range of 0981004 signifying a relatively unimportant association strong correlation of traveller satisfaction with frequency of buses and network coverage was also noticed with odds ratios 1 for all variable blocks with high significance implying that as users perceived buses to be more frequent the probability of respondents being satisfied with the network coverage also increased these results are partially supported by findings from similar cultural contexts in literature where service frequency 33 and network coverage 34 were found to define the accessibility parameter yet the direct correlation between parameters was not estimated the second main concern of publictransport users was the journey time where increasing satisfaction with time spent on a trip was associated with a higher rating of network coverage figure 1 also shows this strong association whereby 37 of weekday users and 48 of weekend users were satisfied with the coverage of the publictransport network most respondents were satisfied with the frequency of buses and journey time in general publictransport users were more satisfied with network as these two factors became more satisfactory these results somewhat comply with the findings of gibson et al 35 which compared rapid bus lanes against mixed traffic finding that savings in the user time represented one of the most important benefits and that its relation with network coverage was similar to service frequency following response curves that displayed an exponential or power model style trend eng 2023 3 for peer review 8 coverage was also noticed with odds ratios 1 for all variable blocks with high significance implying that as users perceived buses to be more frequent the probability of respondents being satisfied with the network coverage also increased these results are partially supported by findings from similar cultural contexts in literature where service frequency 33 and network coverage 34 were found to define the accessibility parameter yet the direct correlation between parameters was not estimated the second main concern of publictransport users was the journey time where increasing satisfaction with time spent on a trip was associated with a higher rating of network coverage figure 1 also shows this strong association whereby 37 of weekday users and 48 of weekend users were satisfied with the coverage of the publictransport network most respondents were satisfied with the frequency of buses and journey time in general publictransport users were more satisfied with network as these two factors became more satisfactory these results somewhat comply with the findings of gibson et al 35 which compared rapid bus lanes against mixed traffic finding that savings in the user time represented one of the most important benefits and that its relation with network coverage was similar to service frequency following response curves that displayed an exponential or power model style trend sociodemographic variables of nationality and income showed little effect on the probability of a user to respond favourably with regard to network coverage and only a slight influence of age users were also asked if their mode choice was influenced by travel attributes and closeness to work and family was reported by all users as most important the main reasons stated for dissatisfaction with pt network coverage were crowded buses and traffic congestion this suggests capacity distribution in public buses and traffic congestion on sociodemographic variables of nationality and income showed little effect on the probability of a user to respond favourably with regard to network coverage and only a slight influence of age users were also asked if their mode choice was influenced by travel attributes and closeness to work and family was reported by all users as most important the main reasons stated for dissatisfaction with pt network coverage were crowded buses and traffic congestion this suggests capacity distribution in public buses and traffic congestion on roads as critical issues as also noted by tyrinopoulos and antoniou 36 further illustrating this figure 2 shows that for the travellers that were largely dissatisfied with the current network coverage of the publictransport service in the studied region onboard crowding and traffic congestion were noted as significant variables influencing their perception of the public transport on the other hand figure 2 also shows that the satisfied traveller groups largely considered bus travel as the easier transit mode for their workand familyrelated trips eng 2023 3 for peer review 9 figure 2 perceived obstacles in publictransport user satisfaction level the variable description for the legend is described in table 1 crosslink between travel mode choice and idv blocks anticipated yet contrasting results were obtained for the transportation system characteristics across all variable blocks of travel mode choice models a users choice of mode was relatively unaffected by the distance from the bus station while journey time adversely influenced travel by both car and bus users reported that in bus travel the likelihood of trip frequency tended to decrease with increasing traffic on the other hand increasing quality of ride positively affected the frequency of bus travels as also validated by the trendline shown in figure 3 despite the scattered nature of traveller percentage perceived obstacles in publictransport user satisfaction level the variable description for the legend is described in table 1 crosslink between travel mode choice and idv blocks anticipated yet contrasting results were obtained for the transportation system characteristics across all variable blocks of travel mode choice models a users choice of mode was relatively unaffected by the distance from the bus station while journey time adversely influenced travel by both car and bus users reported that in bus travel the likelihood of trip frequency tended to decrease with increasing traffic on the other hand increasing quality of ride positively affected the frequency of bus travels as also validated by the trendline shown in figure 3 despite the scattered nature of traveller percentage acteristics across all variable blocks of travel mode choice models a users choice of mode was relatively unaffected by the distance from the bus station while journey time adversely influenced travel by both car and bus users reported that in bus travel the likelihood of trip frequency tended to decrease with increasing traffic on the other hand increasing quality of ride positively affected the frequency of bus travels as also validated by the trendline shown in figure 3 despite the scattered nature of traveller percentage urban populations tended to be unevenly distributed towards transport usage patterns as publictransport use tended to skew towards lowerincome brackets the abu dhabi population exhibited similar trends when analysed for sociodemographic variables as shown in figure 4 with the majority of users from the lowermiddleincome bracket for both weekdays and weekends the urban populations tended to be unevenly distributed towards transport usage patterns as publictransport use tended to skew towards lowerincome brackets the abu dhabi population exhibited similar trends when analysed for sociodemographic variables as shown in figure 4 with the majority of users from the lowermiddleincome bracket for both weekdays and weekends the results were also characterised by the observance that most users for both also reported that they either did not own a car or could not afford to travel by taxis results displayed in figure 4 also show that regardless of bus travel frequency respondents highlighted traffic congestion as the main obstacle this finding may further extend the range of critical publictransport service attributes to include not only the quantitative travel time attribute as also noted heavily in the literature 3437 but also the qualitative perceived traffic congestion variable which is comparatively less explored eng 2023 3 for peer review 10 results were also characterised by the observance that most users for both also reported that they either did not own a car or could not afford to travel by taxis results displayed in figure 4 also show that regardless of bus travel frequency respondents highlighted traffic congestion as the main obstacle this finding may further extend the range of critical publictransport service attributes to include not only the quantitative travel time attribute as also noted heavily in the literature 3437 but also the qualitative perceived traffic congestion variable which is comparatively less explored the variable description for the legend is described in table 1 hypothesis model improvement tests across tsc ta and sdv blocks the previous sections exhibited that the inclusion of income profile service frequency and perceived traffic congestion were significant variables influencing publictransport uptake over competing modes in addition to the conventional accessibility quality and travel time attributes this was further investigated in the regression modelling stage as four different models were tested with two primary objectives if inclusion of variables improved model fit and which parameter was a strong predictor in the case of network coverage satisfaction compared with the null hypothesis adding transport service characteristics variables improved the model as the 2 log likelihood decreased showing relatively good fit further addition of travel attribute variables improved model fit as the 2ll further decreased also improving the goodness of fit when both variable the variable description for the legend is described in table 1 hypothesis model improvement tests across tsc ta and sdv blocks the previous sections exhibited that the inclusion of income profile service frequency and perceived traffic congestion were significant variables influencing publictransport uptake over competing modes in addition to the conventional accessibility quality and travel time attributes this was further investigated in the regression modelling stage as four different models were tested with two primary objectives if inclusion of variables improved model fit and which parameter was a strong predictor in the case of network coverage satisfaction compared with the null hypothesis adding transport service characteristics variables improved the model as the 2 log likelihood decreased showing relatively good fit further addition of travel attribute variables improved model fit as the 2ll further decreased also improving the goodness of fit when both variable blocks were removed from the regression model and only the effect of sdv block was tested the parameterised model showed a small improvement while the mcfadden ρ 2 also decreased as can be anticipated adding all three variable blocks simultaneously in the regression equation produced adverse effects on model fit the results show that while both tsc and ta variable blocks were significant predictors of a respondents satisfaction with transport network coverage and even though some sdvs may have also been successful in prediction their effect may have been nullified once tsc and ta variables were present in the logistic regression equations showing that postulating the perceived congestion and frequency for estimating accessibility and network coverage variables improved the prediction abilities of the model mode choice models exhibited slightly different behaviour to the network coverage models where similar effects of the sdv model and expansion of the tsc and ta model to include sdv block were found for the weekend data on the other hand models based on weekday data tended to display optimum fitness for the final models that included all three variable blocks for example models investigating the frequency of bus travel found that the 2ll of the parametrised model containing all three variables was lower than the null hypothesis supported by a higher goodness of fit although the mcfadden ρ 2 was comparatively lower for mode choice models the values were higher for parameterised model with three variable blocks conclusions the analysis results of the collected urban travel survey exhibited that travel attributes especially service frequency closeness to trip origindestination and traffic congestion as well as characteristics of the transportation system are predictors of the accessibility network coverage service quality and by extension the mode choice this shows that while optimising publictransport services particularly in the multicultural developed infrastructure yet carcentric context of the rapidly developing countries in the gulf cooperation council it may not be sufficient to limit the definition of accessibility to extending network coverage or service quality to onboard seating or busstop quality as the perception of a more comprehensive network itself may be affected by underlying variables of trip purpose sociodemographic characteristics traffic congestion while travelling on public transport and service frequency in addition to the more convention ride quality onboard crowding and travel time variables the regression results for the capibased questionnaire survey data responses of urban abu dhabi residents showed that within the tsc block distance of a traveller from the bus station was comparatively unimportant although past research covered in section 1 noted it as a significant factor comparisons of different variable blocks in regression models supported by objective responses of travellers showed that across all datasets network coverage satisfaction was reported to be only influenced by the ta and tsc blocks where increasing congestion and frequency of buses correlated with traveller satisfaction when mode choice behaviour was evaluated expanded models containing all three variable blocks were more suited to explain the survey responses the findings of this study are important for gaining useful information about the perceived importance of several factors in the functionality of a publictransport system as postulated by the system users this abu dhabibased study suggests that there may be a hypothesised relationship between the ultimate decision of a user to travel via urban publictransport network instead of private vehicles and its attributes further research conducted in the field may be more supportive of this association between variables at this stage it should be noted that although this study is one of the few studies analysing the sociodemographic trends and publictransport usage situation in the carcentric traveller mode choice situation of the gulf cooperation countries the united arab emirates and particularly the city of abu dhabi there are several shortcomings and limitations of the study that can be addressed in future work firstly this study only collected responses about public bus transport usage compared to car use and did not consider a mixedmode transit option where multiple competing publictransport modes can be compared to cars as the preferred mode choice secondly it did not consider firstand lastmile choices and responses captured relative to the provision of micromobility options supporting a largescale publictransport network were not considered this might greatly affect the tendency of respondents to lean towards private or public transport regardless of frequency or network coverage as micromobility integration might bridge gaps in the current system it may also be noteworthy that some interaction between different variables and curvilinearity may also exist which this study did not address these shortcomings are acknowledged by the authors and we aim to address them in future research nonetheless this study showed that a future publictransport system needs to target the adverse effects of traffic congestion and crowded buses as well as improve the quality of ride and increase the frequency of buses on the investigated travel routes as such investment decisions taken by stakeholders in publictransport agencies should consider the attributes of the trip as well as the characteristics of the transportation system itself data availability statement data will be provided upon request supplementary materials the following supporting information can be downloaded at

recent years have seen a considerable shift in the focus of public investment agencies from extensive roadway networks to a more planned approach that meets environmental cost and social dimensions more aptly past research has mainly explored the engineering aspect and cost parameters while the human or social component is often neglected this study aims to identify the tripmaking behaviour of residents in an urban area towards bus transport network enhancement abu dhabi the location of study is heavily dependent upon car travel creating much congestion which the local government seeks to address by enhanced public transport this work examined eight publictransport routes in two zones with data collected on both weekdays n 751 and weekends n 769 multinomial logistic regression models showed that respondents highlighted overcrowded buses and traffic congestion as two of the main hurdles pertinent to urban routes in the bus network influencing their mode choice proposals pertinent to the local authority for further consideration need to factor in current low satisfaction with bus transit network coverage low satisfaction with the quality of bus rides inhibiting a mode shift from carstaxis towards buses cumulative income profiles of publictransport users with findings that the lowincome bracket is already at saturation and that reducing congestion needs innovative sociodynamic rather than technical road network publictransport solutions

introduction on 16 april 2014 the ferry sewol which was carrying 476 people including 325 high school students on a school trip capsized and sank off the southwestern coast of south korea this disaster left more than 300 people dead injured or missing the sinking of the sewol severely shocked korean society since the accident it has been suggested that the public can be traumatized by indirect exposure to certain events through various media 1 in fact the scene in which the ferry capsized and sank as crew members were saved leaving most passengers on board was broadcast live the public was repeatedly exposed to this scene for several weeks early studies have consistently found that a disaster can lead to substantial mental health consequences including posttraumatic stress disorder however most of what is known about the mental health consequences of disasters has been derived from studies of focal groups of individuals who were directly exposed to the trauma such as victims their families rescuerecovery workers volunteers and the communities in which they live 2 relatively few empirical studies have examined the effects of a major disaster on the mental health of the general population at the same time interest in public mental health has increased since the 11 september 2001 terrorist attack in new york city most data in this domain are derived from studies assessing the reactions of the general public in the us since the september 11 attacks 34 these studies provide evidence of an association between indirect exposure to disaster through media and shortterm ptsdlike symptoms 3 this association was identified by analyzing data from representative samples and retroprospectively collected social survey data the data collection and assessments of mental health effects were performed several months to many years after the disaster this lapse of months or years may cause biases in psychological research because retrospective studies are influenced by recall bias and the emotional state at the time of assessment 25 therefore these approaches are not effective ways to monitor public mental health for purposes of realtime surveillance or intervention accumulating evidence regarding psychological sequelae and the mechanisms associated with the emotional modulation of cognition suggest that vulnerability to disruptions in emotional equilibrium may be a common denominator of mental disorders 6 it is therefore reasonable to assume that moods longterm patterns of emotional states can reflect mental health in korea which is characterized by a consumer economy the public mood was reflected in the substantial reduction in consumption following the sewol ferry disaster 7 although consumer behaviors are among the most meaningful indirect indicators of the public mood 8 ways to directly monitor this mood would be preferable recently several studies have suggested new methods for measuring public mood using social media data it has been suggested that the analysis of social media data such as weblog texts or documents may be a useful way to identify the public mood 8 this study presents a pragmatic simple method for monitoring the public mood using social media data especially twitter this approach may be a better way to identify the postdisaster emotional reactions in the general population in that it permits tracking of public moods through the use of twitter data we use twitter data to explore how koreans public mood changed following the sewol disaster and offer suggestions based on our findings methods data sources social media data were collected from daily twitter posts from 1 january 2011 to 31 december 2013 and from 1 march 2014 to 30 june 2014 using the social media analysis tool socialmetrics™ the socialmetrics tm system contains social media data crawlers that collect posts from twitter the system also processes text using stateoftheart natural language processing and text mining technologies the nlp module divides input text into sentences and segments the word forms contained in each sentence into a string of morphemes the segmented morphemes are grouped into syntactic units via syntactic analysis once syntactic units are constructed expressions denoting named entities such as people locations and organizations are recognized then association analysis is performed to identify tuples of finally sentiment polarities for topic keywords are determined through sentiment analysis the results of the whole analysis are delivered in a timeseries fashion using an application programmers interface engine to accommodate various queries from users the socialmetrics tm system provides one of the most advanced solutions for the korean language crawling and mining unlike english natural language processing in korean is much more complicated this is due to the fact that the korean language exhibits characteristics of an agglutinative language and thus there has to be more than one morpheme in order to form a phrase in the case of the english language one morpheme is not separated as each word contains a single morpheme however the complexity of the korean language is especially high as morphemes that construct a phrase have to be separated and each morphemes part of speech also has to be distinguished in addition a korean word or phrase can carry a very different meaning when used in different linguistic contexts in order to solve these challenges socialmetrics tm utilizes an extensive semantic classification dictionary that contains over 1 million words the morpheme and phrase analysis used and developed by socialmetrics tm applies a technological method that extracts keywords going beyond the process of merely selecting simple words the twitter crawler utilizes a streaming api 9 for data collection using the socalled track keywords function we tracked several thousand keywords that were empirically selected and tuned to maximize the coverage of the crawler operating in near realtime fashion we estimated that the daily coverage of the twitter crawler was over 80 the collected posts were fed into a spamfiltering module that checks for posts containing spam keywords related to pornography gambling and other advertising the lists of spam keywords and spammers were semiautomatically monitored and managed there is no information that could potentially reveal the identity of social media user namely user confidentiality is maintained keyword selection humanmade disasterrelated keywords a traumatic event elicits a range of negative emotional reactions including anger anxiety and sadness 1011 emotional reactions following humanmade disasters tend to be more focused on anger because there are policies and people to blame 1112 the sewol disaster was a humanmade accident indeed the president apologized the prime minister resigned and all crew members were arrested thus we examined the emotional utterances in reaction to the disaster by analyzing the appearance of three words anger anxiety and sadness on twitter focusing especially on anger suiciderelated keywords the populationlevel suicide risk after disasters may be estimated by tracking the specific mood states associated with suicide using social media data one previous study suggested that specific variables such as suiciderelated and dysphoric weblog entries are significantly associated with national suicide rates 8 the specific mood states associated with suicide can be examined by identifying the emotional words that usually appear with the word suicide we investigated the emotional words most likely to be associated with the korean word jasal and wooul using the accumulated tweets submitted to twitter during the past three years as our database thus association analysis was performed to identify tuples of topic keyword and associated keyword depressionrelated words were considered along with suiciderelated words because depression similar to ptsd increases distress and dysfunction over time following traumatic events 13 additionally it is well known that depression is a major risk factor for suicide generating the keywords time series based on the humanmade disastersrelated keywords and suiciderelated keywords we generated the keyword time series defined as the daily volume of tweets mentioning these keywords first we processed texts collected from twitter using stateoftheart natural languageprocessing and textmining technologies the nlp module divides input text into sentences and segments the word forms contained in each sentence into a string of morphemes second the segmented morphemes were grouped into syntactic units via syntactic analysis finally the volumes were analyzed for every 100000 daily twitter posts mentioning the korean words hwa bulan seulpeum chunggyeok seuteureseu gotong bigeuk bulan jeolmang bunno and apeum in a timeseries fashion all these volumes were normalized results public mood trends were based on daily tweets that reflect public responses to the south korea ferry disaster figure 2 shows the process by which negative emotions unfolded comparing comments before and after the sewol ferry disaster the disaster was immediately followed by emotional reactions on the part of the public with expressions of anger and sadness substantially increasing following the disaster compared with the rates before the disaster the number of posts mentioning anger and sadness sharply increased during the five days after the disaster even though the frequencies of these emotional words gradually decreased after 20 march 2014 their levels during the month following the disaster were notably higher than at baseline in particular the number of posts mentioning anger was much higher than were those mentioning anxiety and sadness during the tracking period furthermore expressions of anger rapidly and sharply increased again when specific events related to the disaster occurred the peak dates for anger and brief descriptions of the most important events are included in the figure below the suiciderelated keywords we identified by association analysis are presented in figure 3 the suiciderelated keywords include several emotional words such as chunggyeok seuteureseu gotong bigeuk bulan jeolmang bunno and apeum individual words inside the blue circle are the words associated with suicide and the word depression is one of these words the link is defined by association these data were collected from daily twitter posts between january 2011 and december 2013 figure 4 shows the trends in suiciderelated words other than anger and anxiety in the general population before and after the sewol ferry disaster chunggyeok seuteureseu gotong bigeuk bulan jeolmang bunno and apeum were the target keywords most frequently associated with jasal and wooul among the millions of tweets submitted to twitter during the past three years surprisingly the disaster led to immediate reactions in terms of suiciderelated postings the frequencies of all suiciderelated keywords fluctuated greatly during the month following the disaster although we observed distinct differences in the emotional dynamics over time the levels of all emotions were much higher during the month following the disaster than at baseline discussion humanmade disasters and negative emotional reactions we have found that the sewol ferry disaster caused negative emotional reactions of the public the pattern of a shortterm negative emotional reaction to a humanmade disaster followed by its gradual attenuation is generally consistent with previous research findings those studies documented a gradual decline over the course of a few months in the ptsdlike symptoms or other stress reactions among members of the general population who experienced the trauma indirectly through media reports 4514 additionally in the early period the number of posts referring to anger was much higher than those of posts referring to sadness and anxiety which is also consistent with previous studies of humanmade disasters 1112 we also found that public anger was easily provoked by various events that occurred in the aftermath of the disaster such as a report on the exacerbation of the tragedy by the governments incompetence which elicited a largescale reaction these findings suggest that the dynamics of emotional arousal and coping in a general population after a disaster can be identified through realtime monitoring of specific emotional words appearing on social networking services such as twitter the sewol ferry disaster and suiciderelated postings there is no a general consensus regarding the relationship between disasters and suicide risk moreover most studies of suicide in the aftermath of disasters have focused on natural disasters 1516 although one study of the aftermath of september 11 found no significant effect of the disaster on the suicide rate of the general population 17 links between traumatic events such as humanmade disasters and national suicide risk require further research the finding of this study suggests that at least in korea where the suicide rate is generally high a humanmade disaster can lead to an immediate increase in the suicidal preoccupation of the general public given that one of the most striking features of contemporary korean society is its high and increasing suicide rate 18 our findings may have major implications for the national suicide risk in south korean society after the sewol ferry disaster it is clear that the use of social media data to identify the moods most likely associated with suicide can be a much faster and easier approach than traditional methods for estimating the suicidality of the general public after disasters or traumatic events lessons possibilities and further challenges even people who are not directly involved in a disaster may nonetheless be affected by it through various channels such as repeated news reports on the disaster on television or other media policy makers need to remember that the general population does not emerge unscathed from traumatic events and the aftermath of these events should be the target of monitoring and intervention previous studies have noted the challenges to identifying the common characteristics of those affected by a disaster 5 historically people directly associated with disasters were considered vulnerable but this study suggests that everyone in society may be vulnerable to such events social media such as twitter blogs and facebook can be venues for the expression of personal emotions once accurate filters and classifiers are developed these media offer novel opportunities for policy makers to monitor the mental health of the general population by tracking the public mood at any time by analyzing posted texts although an initial and wellknown example of utilizing social media data for gauging the public mood came from the prediction of box office receipts 19 and stock markets 20 this methodology is being applied in various healthrelated research fields by tracking the usage of keywords among users of social media services such as estimating general happinesssubjective wellbeing 21 influenza outbreaks 22 and national suicide numbers 8 our recent findings have implications for improving research regarding moods and mental health following disasters tracking public moods through social media as well as selfassessments of mental states using surveys or physicianreported health records can provide links between traumatic events and mental health responses furthermore it may be more pragmatic to use social media to monitor public mental health for purposes of realtime surveillance or intervention than to use these traditional means this approach is more immediate and efficient in terms of cost and time than are conventional approaches relying on surveys moreover information from data collected continuously rather than from crosssectional or sequential designs is more useful for both understanding public mood generation over time and identifying the major determinants of changes in the public mood after traumatic events ultimately these approaches may help policy makers or government agencies find better ways to treat negative public mood or prevent suicide in terms of the future there is no doubt that social media data can play a foundational role as information sources regarding public health 2324 we also suggest that social media data regarding the emotions thoughts and desires of individuals offer opportunities to monitor public moods and perspectives through which the mental health and moods of the public can be understood however the following issues required additional clarification how close to the truth are the data provided by social media and how do we make social media data more dependable that is the development of empirical justifications for knowledge derived from social media and the design of sophisticated methodologies for analyzing data derived from social media are challenges for the future conclusions policy makers should recognize that both those directly affected and the general public still suffers from the effects of this traumatic event and its aftermath the mood changes experienced by the general population should be monitored after a disaster and social media data can be useful for this purpose conflicts of interest the authors declare no conflict of interest

the sewol ferry disaster severely shocked korean society the objective of this study was to explore how the public mood in korea changed following the sewol disaster using twitter data data were collected from daily twitter posts from 1 january 2011 to 31 december 2013 and from 1 march 2014 to 30 june 2014 using natural languageprocessing and textmining technologies we investigated the emotional utterances in reaction to the disaster by analyzing the appearance of keywords the humanmade disasterrelated keywords and suiciderelated keywords this disaster elicited immediate emotional reactions from the public including anger directed at various social and political events occurring in the aftermath of the disaster we also found that although the frequency of twitter keywords fluctuated greatly during the month after the sewol disaster keywords associated with suicide were common in the general population policy makers should recognize that both those directly affected and the general public still suffers from the effects of this traumatic event and its aftermath the mood changes experienced by the general population should be monitored after a disaster and social media data can be useful for this purpose

introduction poverty is a condition in which an individualhousehold lacks the financial resources and essentials access to education healthcare and transport in 2021 it was estimated that 9 of the global population lived in extreme poverty while over onefifth of the global population lived below us 320 and over twofifths lived below us 550 a day poverty can be measured by two levels namely absolute poverty and relative poverty absolute poverty is used to describe a condition where an individualhousehold is unable to meet basic human needs including food safe drinking water sanitation facilities health shelter and education this level of poverty varies from country to country depending on how poor or rich a country is and with each country setting its own standard or measure regarding poverty on the other hand relative poverty is a condition where an individualhousehold receives less than half of what average individualshouseholds get to sustain themselves although not enough to meet their basic needs this level of poverty does not remain constant but can improve when the economy of a country does better which in turn affords citizens the same standard of living and reach their full potential in namibia an individualhousehold is classified as poor if 60 or more of the individualhouseholds total consumption was spent on food this classification was further expanded on to classify an individualhousehold as severely poor or just simply poor using the food poverty line estimated from the 201516 namibia household income and expenditure survey at n 29310 with a rate of us 1n 1323 here the food poverty line was defined as the cost of a basket of food with minimum recommended nutritional intake although food poverty lines are often considered the most extreme measurement of monetary deprivation since the cost of nonfood essentials are not included in their estimation and are mostly estimated from household surveys of the country under consideration the threshold of food poverty line varies depending on the local cost of food and consumption behaviours per country for namibia the food poverty line was estimated with a lower and upper bound estimate of n 38930 and n 52080 respectively this means that if an individualhousehold is unable to spend at least n 52080 per month on basic needs such individualhousehold was considered to be poor while if an individualhousehold is unable to spend at least n 38930 per month on basic necessities such individualhousehold was considered severely poor comparing poverty levels between men and women the united nations estimated that onethird of employed women were living in poverty in 2019 compared with 283 of employed men in leastdeveloped countries with the world bank concluding that the conditions associated with poverty affect nearly 46 of the worlds population with women representing the majority of the poor in most regions although the gender gap is less sharp in europe central asia latin america and other highincome economies it is at its peak in developing regions such as east asia the pacific south asia and africa leading to an overrepresentation of women among the poor globally in addition while europe and central asia latin america and the caribbean and other highincome economies have low female poverty rates among young people east asia the pacific south asia and subsaharan africa were reported to have high female poverty rates however with the coronavirus disease crisis having a disproportionate impact on peoples livelihoods it is likely to worsen these poverty rates findings furthermore it has also become evident that despite being poorer than men women also face managing their households on their own due to changes in the social setup of societies to be precise females in households are now forced to play multiple conflicting roles after losing their spouses and have to work in marginal parttime informal and lowincome jobs due to their lack of access to highpaying jobs sadly changes in demographic and population characteristics social norms and the nature of family structure all appear to be encouraging female headship a femaleheaded household can be defined as a household where a woman oversees and manages the family as a result of divorce separation immigration or widowhood in many developing countries there has been a significant increase in the percentage of femaleheaded households with majority of these women being widowed and to a lesser extent divorced or separated while in the developed countries most femaleheaded households consist of women who never married or were divorced the association between the feminization of poverty and household headship comes from the idea that femaleheaded households represent an unbalanced number of the poor and that they experience greater extremes of poverty than maleheaded households which further results in gender inequality mwangi assessed the impact of poverty on femaleheaded households in kangemi kenya and concluded that femaleheaded households experience stigma and exclusion arising from poverty and marital status while the impact of poverty among women was felt in the pervasiveness of social problems such as child labour prostitution and unwanted teenage pregnancies femaleheaded households were further impacted by poverty because of the traditional gender inequalities that serve to justify and maintain socioeconomic inequalities prompting mwangi to conclude that there was a direct link between poverty and femalehousehold headship furthermore it has been reported that femaleheaded households more often face gender discrimination with respect to education earnings rights and economic opportunities due to women being more vulnerable to poverty and lacking basic necessities as well as access to economic empowerment avenues such as access to credit facilities for business or agriculture expansion moreover women and girls are disproportionately affected by poverty and many have little or no say in the decisions which affect their lives they often suffer from genderbased violence social exclusion and child abuse and are disproportionately affected by poor health and sanitation with many having little or no money of their own which makes them more dependent on others despite several redistributive measures and social protection programs put in place by the namibian government high inequality continues to be evident in the country reflecting a historical legacy of inequality of opportunity according to nsa 433 of namibias population live in multidimensional poverty where an individual or persons can suffer multiple disadvantages at the same time such as poor health or malnutrition a lack of clean water or electricity poor quality of work or little schooling with this poverty higher among femaleheaded households than in maleheaded households thus women more than men are poorer yet this situation is further worsened by women being alone having to take care of children siblings and sometimes parents with no form of assistance as a result an increasing number of femaleheaded households in developing countries including namibia are emerging due to economic changes economic downturns and social pressures among others to date quite a score of studies have been done on poverty in namibia however factors contributing and influencing poverty levels especially among femaleheaded households in the country still need to be sufficiently explored in addition five of the 14 regions in namibia were reported to be headed by females during the 201516 nhies period namely the omusati ohangwena oshana zambezi and oshikoto regions with increased likelihood of being poor this therefore raises questions about what might be accounting for these overrepresentation of femaleheaded households in official accounts of poverty in the country and how this is plausibly changing over time moreover the relationship between gender and poverty is a complex and debatable topic more than ever and thus a potential area for policy makers to focus on for this reasons this study was aimed at identifying the household characteristics that contributes to poverty among femaleheaded households in namibia as well as their effects on the households poverty levels identifying these characteristics can be useful in the interrogation of the coping mechanisms that were put in place to reduce household poverty in the country while findings from this study can further lead to the strengthening of policies with a possibility of incorporating them in poverty eradication programs countrywide especially among femaleheaded households data and methods research design the study followed a crosssectional quantitative research design using data extracted from the 201516 namibia household income and expenditure survey the latest thus far in the country obtained from the namibia statistics agency the nhies is a household based survey designed to collect data on income and expenditure patterns of households and the sole source of information on income and expenditure in the country it is freely available to the public on the agencys website the survey also serves as a statistical framework for compiling the national basket items for the compilation of price indices used in the calculation of inflation and forms the basis for updating prices or rebasing of national accounts among others the implementation of the 201516 nhies was financed by the government of the republic of namibia through the ministry of economic planning sectoral budget technical support in the area of data processing for example the development of data entry and listing applications was provided by experts from the united states census bureau through funding by the united states agency for international development while experts from the world bank provided technical expertise during the sampling and data analysis stages sampling design the sample design used in the 201516 nhies was a stratified twostage cluster sampling where the first stage units were geographical areas designated as the primary sampling units while the second stage units were the households the primary sampling units were based on the 2011 population and housing census enumeration areas and for each primary sampling unit 12 households were systematically selected the primary sample frame was stratified first by region followed by urban and rural areas within region and then the urbanrural strata were further stratified implicitly by constituencies the rural strata were also further stratified implicitly taking into consideration the proclaimed villages settlements communal and commercial farming areas within the rural strata as a result a total of 864 primary sampling units were sampled in the survey the households in the secondary sample frame were identified from the list of all households for each selected primary sampling units while additional information were collected from the primary sampling units in the proclaimed villages settlements communal and commercial farming areas for the purpose of carrying out further stratification before selecting the sample households from there overall the survey had a representative sample size of 10368 households from 864 sampled primary sampling units more detailed information about the sampling design and methods as well as the entire survey can be found in the 201516 nhies report freely available online on the nsa website the inclusion criteria for this study were all households headed by females as captured in the 201516 nhies households with incomplete nonresponse or missing information were excluded from this study the individual households considered in this study were identified from the 201516 nhies as per the inclusion criteria for this study descriptive analysis the household characteristics of the femaleheaded households considered in this study were region age main language spoken main source of income location highest level of education and number of household members as captured in the 201516 nhies data the individual households considered in this study were identified from the 201516 nhies as per the inclusion criteria for this study moreover during the 201516 nhies period each respondent was asked what is the main source of income for this household in order to determine the main source of income of their respective household the obtained response was the households own perception at the time of interview similarly the annual consumption of a household interviewed in the 201516 nhies was described using the total household consumption average household consumption and the consumption per capita indicators for this study in order to determine the respective poverty level of each interviewed household the households average monthly per capita consumption was used in namibia the food poverty line for 20152016 was estimated with a lower and upper bound estimate of n 38930 and n 52080 per month at a rate of us 1n 1323 thus using this poverty line each household considered in this study was classified as follows poverty level more detailed information about the construction of the main source of income annual consumption and the remaining household characteristics considered in this study can be found in the 201516 nhies report freely available online on the nsa website statistical analysis r software was used for the data cleaning variables recoding and data analysis pearsons chisquare test was performed to examine the association between the household characteristics and poverty levels while the effect of the household characteristics on their respective poverty levels was determined using a multivariable ordinal probit regression model considering the ordered nature of the poverty levels an ordinal probit regression model is used to estimate relationships between an ordinal dependent variable and a set of independent variables such that for where is the vector of regression coefficients which needs to be estimated is the error term is the thresholds and is the number of mutually exclusive categories of in this study was the households poverty levels while was the household characteristics significant characteristics from the chisquare tests were used in the fitted multivariable ordinal probit regression model results participants profiles a total of 4451 femaleheaded households were considered in this study as per the inclusion criteria of this study as at 201516 these households had a yearly estimated per capita consumption of n 8302276 and a monthly per capita consumption of n 691856 on average with an estimated median per capita consumption value of n 5201835 and n 433486 respectively as shown in table 1 the highest number of femaleheaded households were recorded in the omusati and ohangwena regions within the rural areas headed by a 60 year old among oshiwambo speakers had salarieswages as their main source of income with a primary education and living with 13 household members as shown in table 2 of the 4451 femaleheaded households considered 4432 were classified as notpoor 11 were poor while 8 were severely poor in 201516 as shown in table 2 majority of the femaleheaded households that were classified as notpoor were in the rural areas in the omusati and ohangwena regions headed by a 60 year old with a primary education spoke oshiwambo as their main language had salarieswages as their main source of income and living with 13 household members of the 11 femaleheaded households that were classified as poor the highest were observed in the rural areas in the omaheke region headed by a 60 year old with no formal education spoke namadamara language with pension and living with 16 household members likewise out of the 8 femaleheaded households that were classified as severely poor the highest were recorded in the rural areas in the kunene region headed by a 3039 and 60 year old with no formal education spoke otjiherero language living with 13 household members and living on a droughtinkind receipts pension remittancesgrants subsistence farming as their main source of income association examinations from table 2 at a 5 level of significance household characteristics such as region main language spoken at home main source of income location and highest level of education can be concluded to have a significant association with the household poverty levels however characteristics such as age and number of household members had no association all the characteristics with significant associations were included in the fitted multivariable ordinal probit regression and the subsequent results shown in table 3 effects on poverty levels notpoor vs severely poor from table 3 while holding other characteristics constant and with a significant pvalue at a 5 level of significance it can be concluded that the femaleheaded households in the karas kavango east kavango west khomas kunene ohangwena omaheke omusati oshana and oshikoto regions were more likely to be severely poor and less likely to be notpoor compared to those in the erongo region however femaleheaded households in the hardap otjozondjupa and zambezi regions were less likely to be severely poor and more likely to be notpoor furthermore femaleheaded households whose main language spoken were english german zambezi and other languages were less likely to be severely poor and more likely to be notpoor compared to those whose language spoken was afrikaans likewise femaleheaded households whose main source of income were from commercial farming and other sources were less likely to be severely poor and more likely to be notpoor compared to those whose main source of income were from business income moreover femaleheaded households in the urban areas were less likely to be severely poor and more likely to be notpoor compared to those in the rural areas while femaleheaded households whose highest level of education were secondary tertiary and did not state their level of education were less likely to be severely poor and more likely to be notpoor compared to those who did not have formal education notpoor vs poor from table 3 it can be concluded that the femaleheaded households in the hardap kavango east omusati oshana oshikoto otjozondjupa and zambezi regions were more likely to be poor and less likely to be notpoor compared to those in the erongo region while those in the karas kavango west khomas kunene ohangwena and omaheke regions were less likely to be poor and more likely to be notpoor furthermore femaleheaded households whose main language spoken were german oshiwambo otjiherero rukavango zambezi and other languages were more likely to be poor and less likely to be notpoor compared to those whose language spoken was afrikaans while those whose language spoken were english khoisan namadamara and setswana were less likely to be poor and more likely to be notpoor moreover femaleheaded households whose main source of income were from commercial farming other sources pensions remittancegrants salarieswages and subsistence farming were more likely to be poor and less likely to be notpoor compared to those whose income were from business income while those whose income were from droughtinkind receipts were less likely to be poor and more likely to be notpoor similarly femaleheaded households in the urban areas were more likely to be poor and less likely to be notpoor compared to those in the rural areas while femaleheaded households whose highest level of education were not stated primary secondary and tertiary were more likely to be poor and less likely to be notpoor compared to those who did not have formal education poor vs severely poor from table 3 it can be concluded that the femaleheaded households in the kavango west khomas ohangwena and otjozondjupa regions were more likely to be severely poor and less likely to be poor compared to those in the erongo region while those in the hardap karas kavango east kunene omusati oshana oshikoto and zambezi regions were less likely to be severely poor and more likely to be poor furthermore femaleheaded households whose main language spoken were english german namadamara oshiwambo rukavango zambezi and other languages were more likely to be severely poor and less likely to be poor compared to those whose language spoken was afrikaans while those whose language spoken was otjiherero were less likely to be severely poor and more likely to be poor moreover femaleheaded households whose main source of income were from commercial farming were more likely to be severely poor and less likely to be poor compared to those whose income were from business income while those whose income were from droughtinkind receipts other sources pensions remittancegrants salarieswages and subsistence farming were less likely to be severely poor and more likely to be poor likewise femaleheaded households in the urban areas were less likely to be severely poor and more likely to be poor compared to those in the rural areas while femaleheaded households whose highest level of education were not stated primary secondary and tertiary were more likely to be severely poor and less likely to be poor compared to those who did not have formal education discussion in this study a multivariable ordinal probit regression model was used to examine the household characteristics that contribute to poverty among femaleheaded households in namibia as well as their effects on the households poverty levels majority of the femaleheaded households in namibia during 201516 were recorded in the omusati and ohangwena regions within the rural areas headed by a 60 year old spoke oshiwambo had salarieswages as their main source of income and had a primary education furthermore household characteristics such as region main language spoken at home main source of income location and highest level of education had significant association with the household poverty levels while characteristics such as age and number of household members did not these findings are similar to those found in biyase zwayne where it was concluded that the levels of education region and location were some of the main characteristics that were associated with poverty levels however the finding on household members contradicts lekobane seleka who concluded that household size was related to the likelihood of falling into poverty since more resources were required to meet the basic needs of larger households moreover femaleheaded households in the urban areas in the hardap otjozondjupa and zambezi regions whose main language spoken were english german zambezi and other languages with tertiary education and main source of income from commercial farming and other sources were less likely to be severely poor and more likely to be notpoor however those in the karas kavango east kavango west khomas kunene ohangwena omaheke omusati oshana and oshikoto regions were more likely to be severely poor and less likely to be notpoor these findings are not surprising as potential employers of government institutions and privately owned companies most often require their new employees and new recruits to be wellspoken in international friendly languages such as english german and other african and european languages while requiring a high class of qualification attainment from them also femaleheaded households in the karas kavango east kavango west khomas kunene ohangwena omaheke omusati oshana and oshikoto regions still experience comparatively high inequality as well as less financial inclusion most often females in these regions tend to engage in jobs that are lesspaying such as domestic works sales and service works while their male counterparts tend to take up jobs that require more skills with high pay such as transportation works mining and construction works likewise majority of the females in the rural areas are left with no options than to engage in lesspaying jobs such as agriculture and farm works domestic works and caregiving works these findings are similar to mwangi who concluded that femaleheaded households face gender discrimination with respect to earnings rights and economic opportunities comparing the poor to the nonpoor femaleheaded households in the urban areas in the hardap kavango east omusati oshana oshikoto otjozondjupa and zambezi regions whose main language spoken were german oshiwambo otjiherero rukavango zambezi and other languages and whose main source of income were from commercial farming other sources pensions remittancegrants salarieswages and subsistence farming with primary secondary and tertiary education as their highest level of education were more likely to be poor and less likely to be notpoor on the other hand households in the karas kavango west khomas kunene ohangwena and omaheke regions whose language spoken were english khoisan namadamara and setswana with droughtinkind receipts as their main source of income were less likely to be poor and more likely to be notpoor this can be due to femaleheaded households in the northern regions struggle to find decent jobs where their main source of income is commercial farming also femaleheaded households may not have collateral to secure loans in financial institutions or own means of production such as land thus most engage in income generating activities such as a blend of small businesses domestic works and lowincome casual jobs these findings are similar to lebni et al who concluded that women have to work in marginal parttime informal and lowincome jobs due to lack of access to highpaying jobs among other factors in addition it is said that free primary and secondary education produces a more literate society which in turn can lower the likelihood of individuals living in severe poverty however most often women do not receive highpaying jobs even though they are highly educated as compared to their male counterparts this further shows how the inequality and power balances pose a great barrier to femaleheaded households in namibia as they serve to justify and maintain socioeconomic inequalities that disproportionately affect women this is similar to mwangi who concluded that femaleheaded households are linked to gender inequality issues as women were more vulnerable to poverty than men individuals from femaleheaded households with droughtinkind receipts as their main source of income most often work on farms that focus on crop farming and occasionally receive donations from government privately owned organizations and generous individuals thus having a better chance of not being poor this in turns marginally improves their household poverty levels although not immensely comparing the severely poor to the poor femaleheaded households in the kavango west khomas ohangwena and otjozondjupa regions whose main language spoken were english german namadamara oshiwambo rukavango zambezi and other languages with commercial farming as their main source of income were more likely to be severely poor and less likely to be poor however households in the hardap karas kavango east kunene omusati oshana oshikoto and zambezi regions in the urban areas whose language spoken was otjiherero with droughtinkind receipts other sources pensions remittancegrants salarieswages and subsistence farming as their main source of income were less likely to be severely poor and more likely to be poor these findings are not surprising as they can be due to the fact that femaleheaded households could have high debt due to hiring cost of agricultural machinery marketing and distribution of produce in addition femaleheaded households in regions who mainly spoke otjiherero depend on agriculture for their livelihood although lack basic necessities such as health care and access to credit facilities and land ownership these findings are similar to findings in mwangi and borchelt with mwangi concluding that women lack access to economic empowerment avenues such as access to credit facilities for business or agriculture expansion and lack access to knowledge and technologies in these industries while borchelt concluded that a womans health affects her households economy where her inability to work due to hospitalization or chronic illness could reduce her income thus increasing the likelihood of falling into poverty conclusion with household characteristics such as region main language spoken location highest level of education and main source of income having a significant impact on the femaleheaded households poverty levels it is therefore recommended that the namibian government and policy makers put more efforts in improving the livelihood of women especially those heading households in the karas kavango east kavango west khomas kunene ohangwena omaheke omusati oshana and oshikoto regions in terms of comprehensive social development of strategy that covers the immediate needs for short term and longterm needs of these women this can be achieve through government ministries as well as relevant poverty eradication organizations continuous strengthening of the national poverty eradication measures put in place in the country introducing programs targeted to benefit women so that they can escape poverty and not be subjected to poverty and incorporation of social services and programs to bring focus on building capacity of women through education life skills and business training to eradicate poverty most especially in the otjiherero rukavango and zambezi speaking femaleheaded households in the karas kavango east kavango west khomas kunene ohangwena omaheke omusati oshana and oshikoto regions also further studies on this topic is recommended with a multidimensional household poverty definition using data from the next nhies pending availability of funds from the sponsors that would be incorporating a multidimensional poverty concept and considering more relevant variables such as place of work duration of employment covid19 effect household indebtedness and a longitudinal study that will examine the same household individuals to detect any changes that might occur over a longer period of time limitations the 201516 nhies key poverty indicators preliminary report contains no sex disaggregated data on poverty which meant that the most recent poverty profile by sex came from the 200910 nhies also being an household based survey people who were homeless and those who usually resided in private households but were in hospital prison and school hostels during the time of data collection of the 201516 nhies were excluded as well as those in institutions such as correctional institutionspolice cells old age homes army and police barrackscampships in harbour child care institutionsorphanages hospital hotels and churchconventmonasteryreligious retreats furthermore there is a possibility that interviewed respondents of the nhies did not give their true annual consumption during the survey seeing as personal income and expenditure are two of the most sensitive information to share with nonhousehold members moreover although the 201516 nhies defined any person who is not able to spend at least n 38930 on essentials needs as severely poor and a person who is not able to spend at least n 52080 as poor these definitions does not necessarily reflect todays economic reality especially with the high cost of living as well as the devastating effect of covid19 on the economy and peoples livelihood likewise even though the most latest nationwide representative data in namibia was used for this study the time between 201516 and today is acknowledged and might have brought about significant changes thus findings about the geographical differences may have changed and interpretations must be made with cautiousness downloadable from the nsa website additionally this study followed all ethical standards for research without direct contact with human or animal subjects as there were no names of persons or household addresses recorded in the nhies data conflict of interest the authors have no competing interests ethics policy and guidelines ethical approval was not sought for this study since the 201516 nhies data used in this study is freely available on a public domain and

poverty incidence in namibia is higher amongst femaleheaded households 46 compared to maleheaded households 41 however this situation is further worsened by females in households increasingly being forced to play multiple conflicting roles after losing their spouses and to work in marginal parttime informal and lowincome jobs due to their lack of access to highpaying jobs while having to take care of children siblings and sometimes parents with no form s of assistance in this study a crosssectional quantitative study design of the 201516 nhies and an ordinal probit model was used to examine the household characteristics that contribute to poverty among femaleheaded households in namibia as well as their effects on the households poverty levels results from this study showed that characteristics such as region p 0001 main language spoken at home p 0001 main source of income p0009 location p0016 and highest level of education p0005 had significant associations with the household poverty levels additionally femaleheaded households in the urban areas in the hardap otjozondjupa and zambezi regions whose main languages spoken were english german zambezi and other languages with tertiary education and main source of income from commercial farming and other sources were less likely to be severely poor and more likely to be notpoor therefore it is recommended that the namibian government and policymakers further improve the livelihood of women especially those heading households in other regions in terms of a comprehensive social development strategy that covers the immediate needs for shortterm and longterm needs of these women

this simulated big data is becoming cheaper analyzing agentbased models outputs over a large parameter space remains a big challenge for researchers in this paper we present a selection of practical exploratory and data mining techniques that might be useful to understand outputs generated from agentbased models we propose a simple schema and demonstrate its application on an evidencedriven agentbased model of interethnic partnerships called ditch the model is available on openabm 1 and reported by meyer et al in the analysis reported in this paper we focus on the dynamics and interplay of the key model parameters and their effect on model output we do not consider the models validation in terms of the case studies on which it is based the next section reviews selected papers that have previously addressed the issue of analyzing agentbased models a proposed schema combining exploratory sensitivity analysis and data mining techniques section present a general schema to analyze outputs generated by agentbased models and gives an overview of the exploratory and data mining techniques that we have used in this paper in illustration implementing the proposed schema on the ditch agentbased model section we present an overview of the ditch agentbased model and discuss its parameters with their default values that have been reported by meyer et al this section also describes the experimental setup and results and finally conclusions and outlook section concludes with next steps in this direction analyzing agentbased models a brief survey agentbased models tend to generate large volumes of simulated data that is dynamic and highdimensional making them difficult to analyze various exploratory data analysis and data mining techniques have been reported to explore and understand a models outcome against different input configurations these techniques include heatmaps box and whisker plots sensitivity classification trees the kmeans clustering algorithm and ranking of model parameters in influencing the models outcomes several papers have proposed and explored data mining techniques to analyze agentbased simulations one such is by remondino and correndo where the authors applied parameter tuning by repeated execution ie a technique in which multiple runs are performed for different parameter values at discrete intervals to find parameters that turn out to be most influential the authors suggested different data mining techniques such as regression cluster analysis analysis of variance and association rules for this purpose for illustration remondino and correndo presented a case study in which a biological phenomenon involving some species of cicadas was analyzed by performing multiple runs of simulations and aggregating the results in another work arroyo et al proposed a methodological approach involving a data mining step to validate and improve the results of an agentbased model they presented a case study in which cluster analysis was applied to validate simulation results of the mentat model their aim was to study the factors influencing the evolution in a spanish society from 1998 to 2000 the clustering results were found to be consistent with the survey data that was used to initially construct the model edmonds et al used clustering and classification techniques to explore the parameter space of a voter behavior model the goal of this study was to understand the social factors influencing voter turnout the authors used machine learning algorithms such kmeans clustering hierarchical clustering and decision trees to evaluate data generated from the simulations recently broeke et al used sensitivity analysis as the technique to study the behavior of agentbased models the authors applied ofat global and regressionbased sensitivity analysis on an agentbased model in which agents harvest a diffusing renewable source each of these methods was used to evaluate the robustness outcome uncertainty and to understand the emergence of patterns in the model the above cited references are by no means exhaustive but provide some interesting examples of the use of data mining techniques in analyzing agentbased models in the next section we give an overview of some of the eda and sensitivity analysis techniques used in this paper illustration implementing the proposed schema on the ditch agentbased model section of this paper further discusses the eda sa and dm techniques visàvis the analysis of simulated outputs of an agentbased model a proposed schema combining exploratory sensitivity analysis and data mining techniques we propose a schematic approach as a step towards combining different analysis techniques that are typically used in the analysis of agentbased models we present a methodological approach to use exploratory statistical and data mining techniques for analyzing the relationships between inputs and output parameters of an agentbased model applying the appropriate technique to analyze a models behavior and parameters sensitivity is the key to validate and predict any real word phenomena in an agentbased model in illustration implementing the proposed schema on the ditch agentbased model section we demonstrate the application of various exploratory data analysis sensitivity analysis and data mining techniques to understand the impact of various input parameters on the model output figure 1 shows a schema that combines exploratory statistical and data mining techniques to analyze outputs of agentbased models we first begin with a broader exploratory analysis of a selected models input variables to understand their effect on the given agentbased models outputs this is a typical way of understanding agentbased models where a wider range of parameters are explored to visually see their relationship with the model outputs performing model sensitivity analysis follows next with many input parameters understanding outputs through eyeballing is difficult hence techniques such as partial rank correlation coefficient help to measure monotonic relationships between model parameters and outputs the use of data mining techniques further allows to find patterns in the generated output across a wider range of a models input parameters next we present an overview of some of the techniques that may be applied for each step in the schema as shown in fig 1 exploratory data analysis data analysis in exploratory data analysis is typically visual eda techniques help in highlighting important characteristics in a given dataset choosing eda as a starting point in our proposed schema provides a simple yet effective way to analyze relationship between our models input and output parameters graphical eda techniques such as box and whisker plots scatter plots and heat maps are often reported in the generated data from an simulation heat maps are often good indicators of patterns in the simulated output when parameter values change whereas the scatter maps are good often indicators to highlight association between two independent variables for a particular dependent variable box and whisker plots on the other hand summarize a data distribution by showing median the interquartile range skewness and presence of outliers in the data other techniques such as histograms and violin plots are used to describe the full distribution of an output variable for a given input parameter configuration and are more descriptive than box and whisker plots in this paper we used the ggplot2 package in r to generate heat maps and box and whisker plots for output variables against the most influential parameters having variations the result as shown in illustration implementing the proposed schema on the ditch agentbased model section highlights the tipping points in heat maps where the percentage of dependent variable changes significantly in order to explore the fig 1 a schema for analyzing outputs generated by agentbased models using a combination of exploratory statistical and data mining techniques variation in output across the varying parameters box plots were plotted for different parameter configurations the results produced while plotting box plots can thus be used to identify the subset of a dataset contributing more in increasing the proportion of a target variable sensitivity analysis the purpose of performing sensitivity analysis is to study the sensitivity of input parameters of our abm in generating the output variables and thus provide a more focused insight than exploratory analysis techniques several techniques may be used to perform sensitivity analysis for instance for the results reported in illustration implementing the proposed schema on the ditch agentbased model section we performed multiple sensitivity analysis techniques such variable importance method recursive elimination method and prcc following step 2 of the proposed schema we identify two useful methods that are used in the analysis in illustration implementing the proposed schema on the ditch agentbased model section variable importance and recursive feature elimination variable importance for a given output variable ranking of each input variable with respect to its importance can be estimated by using model information variable importance thus quantifies the contribution of each input variable for a given output variable the method assumes a linear model whereby the absolute value of each model parameter is used to train the dataset to generate importance of each input variable in our case we used caret package in r which constructs a linear model by targeting a dependent attribute against the number of input attributes and then ranking with respect to their estimated importance recursive feature elimination the recursive feature elimination method builds many models based on the different subsets of attributes using the caret package in r this part of analysis is carried out to explore all possible subsets of the attributes and predicting the accuracy of the different attribute subset sizes giving comparable results using data mining to analyze abm outputs there is a growing interest in the social simulation on the application of data mining techniques to analyze multidimensional outputs that are generated from agentbased simulations across a vast parameter space in this section we present an overview of some of the common datamining techniques that have been used to analyzed agentbased models outputs classification and regression trees a classificationregression tree is based on a supervised learning algorithm which provides visual representation for the classification or regression of a dataset it provides an effective way to generalize and predict output variables for a given dataset in such trees nodes represent the input attributes and edges represent their values one way to construct such a decision tree is by using a divideandconquer approach to reach the desired output by performing a sequence of tests on each attribute node and splitting the node on each of its possible value the process is repeated recursively each time selecting a different attribute node to split on until there are no more nodes left to split and a single output value is obtained kmeans clustering kmeans clustering is one of the widely implemented clustering algorithms and have been used to analyze agentbased models eg edmonds et al it is often used in situations where the input variables are quantitative and a squared euclidean distance is used as a dissimilarity measure to find clusters in a given dataset the accuracy of the kmeans clustering algorithm depends upon the number of clusters that are specified at the initialization depending upon the choice of the initial centers the clustering results could vary significantly illustration implementing the proposed schema on the ditch agentbased model in this section we present an overview of the ditch agentbased model followed by a description of the experimental setup through which the data was generated we then report analysis of the generated output using the techniques introduced in the previous section an overview of the ditch agentbased model we have used the ditch agentbased model by meyer et al for our analysis written in netlogo2 the model simulates interethnic partnerships leading to crossethnic marriages reported in different cities of the uk and is evidencedriven agents in the ditch model are characterized by traits that influence their preferences for choosing suitable partner over the course of a simulation run the model assumes heterosexual partnershipsmarriages within and across different ethnicities agents traits in the ditch model • gender male female agents choose partners of opposite gender • age 1835 preference based on a range with mean 13 years and standard deviation of 634 years • ethnicity agents have a preference for selecting partners of their own ethnicity or a different ethnicity • compatibility agents prefer partners with a compatibility score that is closer to their own • education agents are assigned different levels of education which influences their partner selection environment agents in the ditch model are situated in a social space where they interact with each other and use their preexisting social connections to search for potential partners the choice of a potential partner depends upon an agents aforementioned traits as well as other model parameters which we will discuss later on once a partnership is formed agents then date each other to determine if the partners education and ethnicity satisfy their requirements they continue dating for a specified period after which they reveal their compatibility scores to each other if the scores are within their preferred range they become marriage partners once a marriage link is formed agents remain in the network without searching for any more potential partners there is no divorce or breakup of marriages in the model the model runs on a monthly scale ie a time steptick corresponds to 1 month in the model ditch model parameters following are the model parameters that setup the initial conditions at the start of a simulation run • ethproportion proportions of different ethnicities in the agent population • numagents total number of agents the population remains constant during simulation • loveradar defines the search range by an agent for a potential partner in its network as the social distance • newlinkchance probability that two unconnected agents will form a new link during a simulation run • meandatingsddating mean and standard deviation of an agents dating period • sdeducationpref an agents tolerance for the difference in education level visàvis its romantic partner experimental setup initialization of ethnic proportions the ditch model uses the uk census data of 2001 as a basis for the parameter ethproportion in all of our simulation experiments reported in this paper the following four cases were used based on the four uk cities differentiated with respect to the proportion of different ethnicities the ditch model generates several outputs and a complete description is reported by its developers in meyer et al in the analyses reported in this paper we have focused on one output variable as the primary output crossethnic which is the percentage of crossethnic marriages in the system the values taken for this variable were at the end of a simulation run and averaged over 10 replications per parameter configuration given our resource constraints we performed the experiments in two phases in the first phase we looked into the models sensitivity to scale and the extent to which agents search their potential partners in the network in the second phase we explored the models parameters specific to expanding agents social network and those related to agents compatibility with their potential partners phasei we first explored the model by varying two parameters with 10 repetitions for a total of 600 runs all other parameters remained unchanged each simulation ran for 120 ticks phaseii in the second phase we kept the number of agents fixed to 3000 we then varied the other five model parameters for the four uk cities ethnic configurations for a total of 9720 runs each simulation ran for 120 ticks simulation results and analyses here we present the results of the simulation experiments for box plots and heat maps we used r4 and its ggplot2 package for regressionparameters importance analyses and for cluster analyses we used rs caret and cluster packages respectively for classification trees we used weka3 software5 results from simulation experiments in phasei we varied the number of agents and the three values for the model parameter loveradar for the rest of parameters default values were used as reported in meyer et al the purpose for running experiments in phase i was to gain a broader sense of the models outcomes in particular the outcome of interest which is the percentage of crossethnic marriages happening over a course of 10 years primarily we were interested in testing the models sensitivity to scale and the availability of potential partners once the social distance increases to summarize the results we generated the box and whisker plots and heat maps to explore variation in output across the two varying parameters and within each parameter configuration when repeated 10 times figure 2 clearly indicates that the average percentage of crossethnic marriages across all the four cases is sensitive to the number of agents in the system in particular there is a sharp decrease in the average percentage of crossethnic marriages when the number of agents increases from 1000 to 2500 which is more evident in the case of newham where ethnic diversity was greatest in contrast to the case of dover where 98 of the agent population belonged to the white ethnic group while sensitivity to scale is observed the observed decline goes much slower and levels off as the number of agents reaches to 10000 for a fixed size of agent population the loveradar parameter in the ditch model does influence the percentage of crossethnic marriages for all the four cases this is unsurprising as increasing the value of this parameter enables agents with a wider search space to find potential partners and thus the possibilities for finding a potential partner belonging to a different ethnic group increases as well however the relation with increasing the values of loveradar in the model is nonlinear for the output variable crossethnic for all the four cases in newham which has the greatest ethnic diversity among all the four cities considered the percentage of crossethnic marriages increases as the allowable social distance increases whereas in case of bradford and dover an increase in the loveradar from 1 to 2 results in an increase in the average crossethnic marriages but a further increase from 2 to 3 results otherwise the heat map plot shown in figure s1 in additional file 1 appendix further highlights this effect from an exploratory analysis of simulations from phasei it is clear that the ditch model is sensitive to the number of agents in the system as the effect dampens when the agent population increases further on we fix the number of agents to be 3000 for simulation experiments in phaseii in case of the loveradar the observed nonlinear relation indicates that other model parameters that were kept fixed in phasei also contribute to the output thus a further exploration and a deeper analysis of the four model parameters is presented next results from simulation experiments in phaseii we fixed the agent population at 3000 and ran simulations across different values of the five other model parameters as described in the previous section here we demonstrate the use of several predictive and data mining techniques that might be useful in exploring and analyzing outputs generated from agentbased models first we estimate the importance of parameters by building a predictive model from the simulated data brownlee for instance importance of parameters can be estimated using a linear regression model we used the caret package in r for this purpose the method ranks attributes by importance with respect to a dependent variable here crossethnic as shown in fig 4 as fig 4 shows the model parameters loveradar and the newlinkchange were identified as the most important parameters while the parameter meandating was ranked last figure 4 shows the rmse when identifying the predictive models accuracy in the presence and absence of model parameters through the automated feature selection method again loveradar and newlinkchance were found as most significant having identified loveradar and newlinkchance as two most important parameters we explore variation in the generated dataset for the four cases with respect to these two parameters as shown in the box plots in fig 5 as fig 5 shows increasing the value of loveradar parameter does result in increasing average crossethnic marriages in the ditch model increasing chances of new links formation also contributes albeit less significantly the variations observed in the box and whisker plots also suggest the role of other three parameters which seem to play a role when the values of loveradar and newlinkchance are increased evaluating partial rank correlation coefficients we further explored a subspace of the parameter space to identify the most admissible parameters by evaluating partial rank correlation coefficients for all output variables the rationale behind calculating the prcc is that for a particular output not all input parameters may contribute equally thus to identify the most relevant parameter prcc could be useful one major advantage of identifying the top most relevant parameters based on the prcc is that given a large parameter space if only few input parameters have a significant contribution for a particular output it reduces the dimensionality fig 4 ranking of the five parameters as predictors of the output variable crossethnic left the importance ranking of model parameters right rmse score against different models built using the automatic feature selection algorithm of parameter space significantly for our analysis we calculated the prccs for all output variables using a package in r called knitr 6 table 3 shows the top three contributing inputs for each output variable when the prcc was estimated following our proposed schema we proceed with generating a classification and regressing tree using wekas decision tree builder as shown in fig 6 the decision tree shown in fig 6 was built using wekas reptree algorithm7 it is a fast decision tree learner and builds a decisionregression tree using information gain variance reduction since here we are predicting the crossethnic parameter which is a continuous variable the reptree algorithm uses variance reduction to select the best node to split we used the five varied parameters to build the tree shown in fig 6 in which the ditch model parameters loveradar sdeducationpref meandating newlinkchance sddating were the predictors while the output parameter crossethnic was the target variable we set the minnum property of the classifier to 200 to avoid overfitting the resulting tree had the following accuracyerror metrics on the testunseen data as the constructed tree shows ethnic diversity in the agent population was the strongest determinant of crossethnic marriages once again loveradar was found to be the second most important determinant especially in situations where some ethnic diversity existed when the value of the loveradar was set to 1 it alone determined mean absolute error 09582 root mean squared error 12995 the percentage of crossethnic marriages however for higher values of the loveradar parameter the output was further influenced by newlinkchance and in other instances the parameters related to agents dating in the simulation kmeans clustering on all 13 ditch output variables we now turn towards the kmeans clustering algorithm to find clusters in the generated dataset we performed the cluster analysis on the 13 output variables of the ditch model that were recorded from our simulation experiments we chose the data from phaseii which involved five varied parameters for each sample area with 9720 runs altogether our purpose of applying this technique was to group the output instances that were similar in nature into clusters all output variables were first normalized before proceeding to the next step of finding the optimal number of clusters we then followed the technique used by edmonds et al in which within group sum of squares were calculated against the number of clusters for multiple random initialized runs the optimal value of clusters in the plot could then be identified as the point at which there is a bend or an elbow like curve figure 7 suggests the optimal number of clusters to be around 3 or 4 where a bend is observed the silhouette analysis 8 shown in fig 7 also shows that the optimal value for k is around 3 or 4 in this case here the plot displays a measure of similarity between the instances in each cluster and thus provides a way to assess parameters like the number of optimal clusters the results from this analysis confirms that the optimal number of clusters should be around 4 hence we ran the kmeans clustering algorithm for all the thirteen outputs the centroids of the four kmeans clusters are given in table 3 the partitioning of data into the four clusters gives a good split across parameters explored as table 3 shows the goodness of fit is high indicating that the clusters are distinct with an almost equal number of instances across all the four clusters the mean percentage of crossethnic marriages was highest in cluster 2 and lowest in cluster 4 while clusters 1 and 3 were found to be closer in terms of the average crossethnic marriages these are results we expect as they present quite an accurate picture of the population distribution of ethnicities in the four uk cities we can check the distribution of the input parameter ethproportions across these four clusters and the resulting matrix in table 4 shows that each region is quite accurately labeled in each cluster the dominant ethnicity in which most of the crossethnic marriages occur like in cluster 1 representing the sample area birmingham has ethnicityz which is 564 of the total population showing the most crossethnic marriages while in cluster 2 ethnicityy which is 657 of the total population in cluster 3 ethnicityx which is 179 and in cluster 4 ethnicityx which is 183 of total populations are representing the highest crossethnic marriages figure 8 shows the 2d representation of all the data points of the four clusters as discussed earlier clusters 1 and 3 have some overlapping points while clusters 2 and 4 were distinct and separate finally fig 8 shows the variability in terms of the average crossethnic marriages across the four clusters conclusions and outlook as agentbased models of social phenomenon become more complex with many model parameters and endogenous processes exploring and analyzing the generated data gets even more difficult we need a whole suite of analyses to look into the data that such agentbased models generate incorporating traditional or dynamic social network 8 fig 7 finding the optimal number of clusters for the kmeans clustering algorithm left using the within group sum of squares technique right using the silhouette analysis analysis spatiotemporal analysis machine learning or more recent ones such as deep learning algorithms there is a growing number of social simulation researchers who are employing different data mining and machine learning techniques to explore agentbased simulations the techniques discussed in this paper are by no means exhaustive and the exploration of useful analysis techniques for complex agentbased simulations is an active area of research lee et al for example examined multiple approaches in understanding abm outputs including both statistical and visualization techniques the authors proposed methods to determine a minimum sample size followed by an exploration model parameters using sensitivity analysis finally the authors discussed focused on the transient dynamics by using spatiotemporal methods to gain insights on how the model evolves over a time period in this paper we propose a simple stepbystep approach to combine three different analysis techniques for illustration we selected an existing evidencedriven agentbased model by meyer et al called the ditch model as a starting point we recommend the use of exploratory data analysis techniques for analyzing agentbased models eda provide simple yet an effective set of techniques to analyze relationship between a models input and output variables these techniques are useful to spot patterns and trends in a models output across varying input parameter and to gain insight into the distribution of data that is generated sensitivity analysis techniques follow the exploratory space and are useful eg to rank input parameters in terms of their contribution towards a particular model output sa techniques are not only useful in identifying those parameters but also quantify the variability of the effect these input authors contributions hp ma and sja drafted the manuscript sja and ms designed the study hp and ma generated the data hp ma sja and ms analyzed and interpreted the data all authors read and approved the final manuscript author details ethical approval and consent to participate not applicable competing interests the authors declare that they have no competing interests additional file additional file 1 additional figures and table

agentbased models simulating social reality generate outputs which result from a complex interplay of processes related to agents rules of interaction and models parameters as such agentbased models become more descriptive and driven by evidence they become a useful tool in simulating and understanding social reality however the number of parameters and agents rules of interaction grows rapidly such models often have unvalidated parameters that must be introduced by the modeler in order for the model to be fully functional such unvalidated parameters are often informed by the modelers intuition only and may represent gaps in existing knowledge about the underlying case study hence a rather long list of model parameters is not a limitation but an inherent feature of descriptive evidencedriven models that simulate social complexity theoretical exploration of a models behavior with respect to its parameters in particular those that are not constrained by validation is important but have been until recently limited by the lack of available computation resources and analysis tools to explore the vast parameter space an agentbased model of moderate complexity will when run across different parameters ie the total number of configurations times the number of simulation runs generates output data that could easily be on a scale of gigabytes and more with high performance computing hpc it has become possible for agentbased modelers to explore their models vast parameter space and while generating

introduction the beginning of the process of changing economic political and social in poland was marked by the political transformation begun in 1989 the rejection of the socialist society model and centrally planned economy and the introduction of democracy and a capitalist economy instead was to be the beginning of economic growth it also meant institutional reconstruction privatization transformation of society opening up to new markets new technologies and unlimited access to knowledge however the extent of the changes made and the high speed of implementation of new development directions with the liquidation of subsidies and stateowned enterprises has caused a number of negative effects among these were the rise in unemployment the decline in production in the early 1990s another economic shock was polands admission to european union structures in contrast the impact of the global financial crisis has been felt by most countries around the world however the polish economy has proven to be quite resilient in this regard in turn the pandemic of the coronavirus covid19 outbreak initiated a new era of uncertainty for the sustainable development of economies not only for poland but for the whole world the objective of this study is to review and analyze the factors determining the development of polands socioeconomic situation after 1989 with a special focus on the situation in 20202022 which includes the time of the covid19 pandemic the analysis included indicators illustrating the socioeconomic situation such as the public debt or unemployment rate state spending on the basic areas of the national economy and the digital services sector in terms of the pandemic period the article was based on statistical sources reports and literature changes in polands socioeconomic area after 2000 in 2000 a new stage of polands functioning in europe symbolically began caused by its acceptance as a candidate country to the european union accordingly foreign policy aimed to strengthen its position in the international arena on the other hand internally the country was struggling with many problems the labor market in 2000 was characterized by a high 15 unemployment rate due to the demographic highs low labor mobility high labor costs and labor laws unfavorable to employers high public debt led to the need of reducing budget spending and its growth was related to the resultant of relatively high borrowing needs of the state budget declining privatization income and changes in the zloty exchange rate in 2001 the unemployment rate increased to 175 public debt and state budget expenditures increased the year 2004 was an important year for the polish state due to polands accession to the european union it significantly influenced economic development and the situation in the labor market also improved through the opening of european labor markets and the inflow of foreign direct investment enabling the development of entrepreneurship in the country however the unemployment rate in both 2004 and 2005 remained high the effects of the 2008 global financial crisis reached poland with some delay during this period a decline in business activity could be observed due to declining foreign demand temporary outflow of foreign capital and depreciation of the national currency the negative effects of the crisis were felt only by certain industries that is mainly energy banking finance as well as the construction real estate and transportation sectors the year 20082009 also noted a 16 slowdown in gdp growth a 36 increase in the unemployment rate and a rising public debt another global crisis was caused by the pandemic outbreak of covid19 brought with multidimensional consequences both economically and socially there has been a decline in gdp an increase in inflation an increase in the unemployment rate and negative developments in the labor market the introduction of support programs for the polish economy in the form of anticrisis shields or credit vacations directly affected the state of public finances the covid19 pandemic caused an increase in unemployment and public debt 542 of gdp despite the constant deficit of public funds in almost every sector in the years under review state budget expenditures on higher education and science public administration and culture and national heritage protection gradually increased this trend also continued in the area of social welfare but in 2009 state budget expenditures for this purpose were decreasing in 2000 and 2004 expenditures on public administration accounted for 4 of total expenditures and were realized at 96 a similar situation applied to expenditures of all analyzed areas whose share in total state expenditures did not change in 2000 in the field of culture and national heritage protection 041 of total expenditures were spent and this was related among other things to the modernization of the wroclaw opera house the philharmonic hall in lodz or the construction of the theater and philharmonic hall in lublin in the case of higher education and science material aid for students teaching activities and the construction of the jagiellonian university biological sciences complex in cracow or the expansion of the adam mickiewicz university campus in poznań were financed after polands accession to the european union expenditures on higher education and science increased increasing the mobility of students and academics social assistance which includes family nursing and child care benefits subsidies to the labor fund and the veterans fund accounted for 8 of expenditures from the state budget social policy financed family benefits and contributions to social insurance family nursing and child care benefits the operation of social welfare homes or a subsidy to the alimony fund in the following year 2005 expenditures on public administration amounted to 4 of total state expenditures and were lower than expected due to the lower cost of the elections held for the countrys president and the sejm and senate expenditures on culture and national heritage protection were low accounting for only 049 of total expenditures in contrast 46 in total expenditures was spent on higher education and science nearly 10 of total expenditures were expenditures in the area of social policy the amount of which depended on the amount of payments of family benefits and allowances and lower expenditures on paying health insurance premiums for recipients of family benefits in 2008 expenditures on public administration accounted for 36 of total expenditures while expenditures on culture and national heritage protection did not exceed 05 of total expenditures the year 2008 was also a period of reform of the system of financing and operation of scientific units in order to improve the competitiveness of polish science at that time the research infrastructure of universities was financed as well as the tasks of the program for the development and maintenance of information and computer infrastructure of science and its digital resources for 20062009 or the program for the development of information infrastructure of science for 20072013 in the area of higher education and science tasks related to the universality of education material assistance for equalization of opportunities raising the level and quality of education and support for international cooperation were implemented expenditures in the area of social policy accounted for 46 of total outlays and were related to financing among other things family benefits and allowances care psychological and living services as well as the implementation of government programs such as state food aid in 2009 expenditures on public administration accounted for 3 of total expenditures expenditures from the public budget for culture and national heritage protection accounted for 05 of total expenditures and included activities such as replenishing museum collections and rebuilding library book collections improving the standard of services provided to people with disabilities expenditures on higher education and science accounted for 5 of total expenditures in the period under review 92 of expenditures in this regard were allocated to subsidizing the activities of higher education institutions their teaching activities and increasing the availability of higher education for people in a difficult financial situation and people with disabilities within the amount for statutory activities of scientific units and own research of higher education institutions maintenance of specialized scientific and research equipment was financed as well as ministerial programs and projects in the development of information and information technology infrastructure of science work continued on the creation of the copernicus science center and tasks were carried out within the scope of operational programs innovative economy increasing the competitiveness of enterprises human capital and the norwegian financial mechanism the eea financial mechanism expenditures on social policy accounted for 4 of total state expenditures and focused on financing active ways of assistance eg increasing the availability of specialized services or social work expenditures of the state budget in 2019 amounted to pln 4143 billion and were lower by pln 2 billion than the amount planned in the budget law within the amount indicated pln 219 billion was allocated for the protection and popularization of heritage and national identity at home and abroad the remaining pln 104 billion financed artistic dissemination promotion of culture and intercultural dialogue activities within the framework of this function among other things portals related to archives were developed and popularized or library collections were digitized 67 of state budget expenditures were for higher education and science in this aspect the goal of raising the level of scientific research results the level of quality of education and increasing the level of practical application of research and development work was achieved a significant part of budget expenditures was made in the framework of social policy 35 of total expenditures the indicated amount financed among other things the extension of the family 500 program for the first child or senior 7 of total expenditures were expenditures on public administration in 2020 expenditures on public administration decreased expenditures on culture and national heritage increased 7 of total expenditures were allocated to higher education and science the pan the socioeconomic situation during the crises in poland after 1989 demic situation resulted in the extension of the implementation of research projects that were scheduled for 20192020 for another year and the possibility of spending unspent funds still in 2021 in addition the number of foreigners studying at polish universities decreased significantly and classes at universities were conducted remotely during the period under review the amount of expenditure on social policy increased accounting for 43 of total expenditures within the framework of this function the following were financed in a larger number than expected upbringing benefits family benefits or the maluch program in 2021 expenditures on public administration accounted for 3 of total expenditures expenditures on culture and heritage protection saw a slight increase related among other things to the transfer of activities to the internet or adjustment to the sanitary regime expenditures on higher education and science accounted for 6 of total expenditures among which we can highlight the financing of the nawa project and the transfer of additional funds for competitions within the framework of the intelligent development operational program social policy expenditures accounted for 30 of total expenditures the decrease in expenditures in this area was related among other things to the decrease in the number of people receiving noncash assistance the resignation of seniors from participation in the senior and active programs or changes in the income situation of families with children selected socioeconomic aspects of the covid19 pandemic although we have noticed rapid progress in the digitalization and use of modern technology in recent years it has been further accelerated by the covid19 pandemic by 2020 nearly 60 of the worlds population had access to the network and 43 billion were using mobile internet pandemic restrictions have forced the transfer of education work entertainment and many other aspects of life to the virtual space over the past few years the number of people using the internet has increased noticeably from 588 in 2010 to more than 85 in 2021 the increase was caused by a change in the way people communicate and maintain social contacts as well as perform personal and professional duties as a result of the pandemic the percentage of video conferencing users increased as well as internet users who regularly use social media occupational activity was correlated with internet use among the employed relatively the fewest internet users were in the group of farmers while among managers and specialists technicians and middle staff administrative and office workers service workers and private entrepreneurs all or almost all of them use the internet particular growth has occurred in the ecommerce domain nearly 40 of the public in the 1774 age group searched for information about goods and services in 2010 while by 2021 it was already 656 in 2010 202 of users aged 1674 made purchases of goods and services online with twice as many people in urban areas as in rural areas the number of users did not increase significantly in 2015 but in 2021 compared to 2010 it was more than double significant changes took place in rural areas there the increase in the level of use of online shopping more than tripled according to the cbos survey in 2022 nearly twothirds of poles shopped online and more than one the socioeconomic situation during the crises in poland after 1989 third of all adults made at least a single sale online the number of people using the internet for personal use has grown steadily while the change in 2015 compared to 2010 can be described as quite evolutionary the percentage of total internet users rose from 588 to 68 in 2021 this figure rose to 854 during this period the gap between urban and rural residents narrowed noticeably it was 86 in favor of urban residents according to the cbos survey as of 2021 the largest increase in user groups was among those aged 4554 and over 75 compared to 2021 in 2022 their number increased by 10 and 9 respectively one of the most valuable benefits of using the internet was the ability to administer ones finances remotely by using ebanking services the number of ebanking users which in 2010 in poland amounted to slightly more than ¼ of the population rose to 312 in 2015 as a result of the development of these services successively introduced by banks the crisis caused by the covid19 pandemic caused the number of ebanking customers to exceed half of the population online government services were used by 475 of poles in 2021 as recently as 2010 about ¾ of all polish enterprises could demonstrate access to broadband internet and a website in 2015 nearly 92 of enterprises were connected to broadband internet but only 79 of them had a connection speed of at least 100 mbps their own websites were unchanged from 2010 655 of businesses operating in poland social media profiles were maintained by more than 22 of companies at the time and only slightly more than 7 used cloud services even before the pandemic micro small and mediumsized enterprises were raising the value of using information and communication technologies this was confirmed by the results of a survey conducted by the polish economic institute in the last quarter of 2019 at that time entrepreneurs appreciated the importance of using ict pointing to the following features more efficient communication with suppliers and customers improved brand awareness corporate image and customer relations increased competitiveness of the company and reduced employment which is a direct result of the automation of company processes according to the 2019 pie survey nearly onequarter of the companies surveyed said their enterprises had increased their use of modern technology compared to 2018 the group was dominated by large enterprises in the information and communication section the use of information and communication technologies was seen by the respondents as a competitive advantage and even a condition of the companys operation the pie report indicates that in 2019 47 of polish enterprises highly rated their degree of use of modern technologies in production or services 54 rated their use of modern technologies in communicating with their customers 48 rated their use of multichannel sales of their products or services provided and 73 did not invest in modern technologies the socioeconomic situation during the crises in poland after 1989 business entities during the pandemic sought to support their sales and marketing activities with ecommerce and to transform customer service to remote channels examples of such changes in business models could be seen for example in entities in the automotive industry and businessrelated leasing insurance companies or banks with supporting financial services on offer from these partnerships were born already in the first months of the pandemic sales platforms where one could choose a car and ask the commissionerdealer to bring the chosen vehicle to ones home for a test drive and then after making a choice be guided through the process of obtaining financing and insurance in a completely remote manner entities that failed to implement online sales and customer service for various reasons often lost the battle for survival many industries were affected restaurants or entertainment in the broadest sense however here too there were entrepreneurs who switched to customer service on social media platforms and remote delivery according to the pie report 91 of companies used at least one modern technology during the pandemic 70 used modern forms of communication with customers and 10 of large companies implemented systems to manage remote work during the pandemic the growth of ict usage in polish enterprises can be clearly seen in the 2021 statistics they show increases in the use of broadband internet compared to 2015 by as much as 65 access to a connection with a speed of at least 100 mbps increased by more than 40 which for some msmes companies could be an alternative to having a website meanwhile the use of cloud computing by polish companies more than quadrupled just the socalled cloud which facilitates file sharing or simultaneous work on a document open at the same time on multiple devices became an indispensable technology during the covid19 pandemic the benefits it brought to daytoday work led to an intensification of project implementations which before the pandemic would have reached only the pilot phase in msmes while the market for enterprises and private users of virtual space has seen rapid changes compared to previous years the situation for cultural institutions has been more difficult on this front there have been many barriers related to less adaptability to rapid change a relatively new challenge in increasing the availability of knowledge was the digitalization of library collections this was due not only to the growing needs of the public for easier and wider access to books journals and other publications held in library repositories and lending libraries but also to adapt to operating in a period of tighter sanitation regime the first analysis of the condition of digitization of libraries in poland was carried out in 2002 initiated by the national library of poland among the 55 libraries surveyed at the time 25 had begun digitizing and 14 were forming their own laboratories after nearly two decades this situation has changed significantly and a particular evolution can be seen in the last two years the number of objects digitized by public libraries in 2021 increased by 165 compared to 2020 due to the lack of reader access to library buildings new services were introduced or existing ones were expanded access to online resources the use of emedia and ebooks were promoted in march and april 2020 compared to the previous year statistics on the use of digital platforms related to european library services doubled over the past few years there has been clear progress in the dissemination of digital offerings of libraries especially in the case of booking and ordering library materials compared to 2016 the number of libraries offering these services has increased by almost a third in 2022 an important element significantly improving the use of resources were online catalogs in 2016 more than half of libraries had them however in 2022 it was already more than 80 having an account on social networks was also an interesting activity while in 2016 more than a third of polish libraries had them in 2020 this number exceeded half in 2021 it was also reported that 162 of libraries allow remote registration of new readers interestingly the following year their number increased to only 173 summary each of the considered crises has significantly affected indicators related to economic development the opening of the market as a result first of the political transformation period and later of polands accession to the european union enabled economic and technological development this was associated not only with an infusion of foreign investment and new sources of funds but also with increasing spending from the state budget especially on higher education and science however it has not eliminated problems such as rising unemployment expanding public debt and increasing social welfare expenditures although the 2008 crisis did not have a significant impact on polands economic situation spending on public administration was reduced during this period a similar decrease in this regard also took place in 2020 spending on higher education and social assistance however increased expenditures on culture and national heritage protection in the period under review did not exceed 1 of total budget expenditures the permanent effects of the pandemic on the economy include accelerated digital transformation or for example remote work which was a rather rare benefit before the pandemic while during the pandemic it began to be used for all types of work that could be performed by a worker at home as a result of the pandemic crisis digitization in polish companies has increased more rapidly especially in the financial transportation education and health sectors the use of apps automatons and robots in production and commerce bots in communications ebanking and elearning and teleconferencing platforms have increased work on modernizing the logistics industry has also accelerated driven in part by the explosive growth of ecommerce the demand for online activities has also affected cultural institutions including libraries which have greatly accelerated the implementation of projects to digitize services and resources

the polish economy has been transformed for more than three decades by diverse crises the beginning of the changes was brought by the political transformation which modified the model of the functioning of the state in almost all areas to some extent its continuation was the accession to the european union which opened not only markets for sales labor but also new sources of technological and scientific development economic development did not protect the economy from the negative effects of change which occurred in the form of rising public debt unemployment rates and reduced spending on important public sectors sudden breakdowns in turn forced changes in social needs as exemplified by the explosive demand for eservices during the covid19 pandemic the article analyzed selected indicators that allowed analysis of the degree of differentiation of socioeconomic development in poland against the background of crises

background child maltreatment is a public health problem worldwide 12 and can influence victims mental health from the period of adolescence to adulthood to lifetime there are five types of child maltreatment physical abuse emotional abuse sexual abuse physical neglect and emotional neglect in rural china the estimated prevalence of any child maltreatment has remained at 663 3 boys were more likely to be physically abused than girls and girls were more likely to be neglected because of the parental genderlinked expectations for children 4 a schoolbased study reported that 4309 4165 and 4218 of rural children experienced physical abuse emotional abuse and neglect respectively 5 of the boys 805 suffered abuse or neglect while 751 girls experienced any abuse and neglect in regions with a moderate level of economic growth 6 a systematic review showed that 266 196 and 260 of children suffered physical abuse emotional abuse and neglect 7 we discovered that the prevalence of child maltreatment in rural china was higher than the national norm in china consequently child maltreatment in rural areas is a prevalent and notable issue depression is also a major public health issue and a common disease among adolescents and geriatric patients in china 89 which influences peoples physical and mental health and increases the risks of suicide and morbidity a metaanalysis reported that 227 of geriatric patients had depressive symptoms women were more likely to develop depressive symptoms than men and rural populations developed depressive symptoms more easily than urban populations 10 among the rural elderly in china 547 developed depressive symptoms 11 the prevalence and severity of depression in rural areas were higher than average depressive disorders ranked 19 th up to 13 th as the leading cause of the global burden of disease from 1990 to 2019 and ranked 4 th and 6 th for 1024 years and 2549 years respectively 12 child maltreatment is a potent risk factor for internalizing problems such as depression anxiety and loneliness 13 sufficient studies have shown that females are vulnerable to depression and experience child maltreatment compared with males who experience child maltreatment in china 314 child maltreatment is also a risk factor for developing maladaptive coping skills 15 people who do not have adaptive coping skills may find it difficult to confront stressful events and regulate emotional problems and are prone to depression previous studies have indicated that coping skill was associated with depression symptoms 1617 thus coping skills are a positive factor in the prevention of depression studies have found that child maltreatment was associated with loneliness coping skills and depression 1819 child maltreatment was positively correlated with loneliness and depression and negatively correlated with coping skill several studies examined that loneliness and coping skills mediated the relationship between child maltreatment and depression 2021 however few studies have examined the roles of loneliness and coping skills in child maltreatment and depression based on gender differences exclusive research investigated the mediating effects of different coping styles on the relationship between childhood maltreatment and depressive symptoms among chinese male and female undergraduates 22 but coping styles consisting of six dimensions differed from coping skills in this study other studies have reported the mediating effect of coping skills in young male or female adults 2123 this study aimed to examine the roles of loneliness and coping skills in child maltreatment and depression among rural males and females in china to understand better the cognitiveaffective mechanisms underlying child maltreatment and depression and improve the prevention and intervention processes for depression child maltreatment and depression maltreatment can negatively impact development by altering the developing neural system or disrupting other factors furthermore maltreatment may exacerbate or express neuropsychiatric syndromes in individuals with genetic vulnerabilities 24 people who are exposed to maltreatment in childhood are at risk of having a range of poor mental outcomes such as major depressive disorder posttraumatic stress disorder and substance abuse 25 26 27 specifically numerous studies have suggested that child maltreatment is associated with depression during childhood adulthood and the geriatric period 28 29 30 a retrospective study indicated that patients with depression experienced more severe childhood maltreatment than healthy controls 31 other studies have shown that the number of child maltreatment is associated with increased depressive symptoms 3233 studies found that many elderly people in brazil who reported cumulative maltreatment experiences were more likely to suffer from depression but there was no impact on the severity of depression 34 however it is not clear whether the influences of child maltreatment on depression is similar or different according to sex some studies have indicated that women who experienced child maltreatment were more likely to experience depression than men 1435 few studies have illustrated the reverse results that the men who experienced maltreatment were likely to have depression 36 moreover several studies found a similar effect of child maltreatment on depression for males and females 3738 child maltreatment and loneliness loneliness has been characterized as a feeling of social isolation and separateness 3940 people isolated from society find it difficult to build and maintain social connections and acquire social support thus they become lonely the feeling of loneliness is more intense from middle age onward one study estimated that twentyeight percent of older chinese people reported feeling lonely and approximately seven percent reported often or always feeling lonely 41 a growing body of literature indicates that loneliness is associated with physical and mental health and cognitive functions such as depressive symptoms 42 mortality 41 systolic blood pressure 43 and impaired cognition 43 studies have shown that childhood trauma is positively correlated with loneliness 4445 meaning that individuals who have experienced childhood trauma are easier to lonely than those who have not most importantly previous studies have pointed out a relationship between child maltreatment and loneliness 1346 converging evidence provides empirical support for other studies one study reported that childhood maltreatment is nonnegligible for loneliness in adulthood 47 women who had been maltreated were lonelier and had a more negative network orientation than nonabused women because they tended to isolate themselves socially 48 findings from several studies indicate that children exposed to abuse also experience loneliness and social isolation in their lives preventing the development of developing adequate and efficient social skills 4950 child maltreatment and coping skill coping skills represented the way in which individuals deal with stressful or negative experiences 51 in maltreating families maltreating parents often conceal emotional expressions interact in hostile and aggressive ways and rely on punitive interaction styles based on this due to high levels of unpredictability in parentchild interactions and the home generally maltreated children fail to model appropriate coping skills when they encounter with stress and try to control what happens to them leading to a feeling of helplessness 18 previous studies have reported that child maltreatment is associated with coping skills 5253 people who experienced maltreatment did not cope with stress or regulate emotion and had low coping skills child maltreatment plays a major role in adolescent wellbeing and coping 54 loneliness as a mediator people who have experienced child maltreatment are likely to withdraw from society they are reluctant to contact others due to feelings of inferiority and distress so they are unable to receive social supports or concerns and eventually become lonely the association between loneliness and depressive symptoms appears to be stable across ages 42 a lonely person is more likely to be depressed than a normal person studies have investigated the role of loneliness as a mediator in the relationship between childhood trauma and adult psychopathology and indicated both direct and mediational effects of social resources on adult depression symptoms in women with a history of child multitype maltreatment 32 loneliness mediates the relationship between children abuse and six adult psychiatric disorders depression generalized anxiety disorder mixed anxiety and depression phobia posttraumatic stress disorder and psychosis 20 coping skills as a mediator on the one hand child maltreatment causes poor coping skills making it harder for maltreated children to confront and deal with stress meanwhile the relationship between stress and major depression has been ensured 55 and stress increases the likelihood of depression however a high level of coping skills mediates or decreases the impact of maltreatment on depression compared to nonmaltreated children child maltreatment is associated with a decrease in the usage of coping skills and low coping skills may exacerbate depression studies have shown that coping skills mediated the relationship between child maltreatment and internalizing and externalizing behaviors 15 other studies have also found that coping skills mediate and moderate the impact of maltreatment on depressive symptoms 23 current study this study aims to answer two research questions first we examined the role of loneliness and coping skills in the relationship between child maltreatment and depression second we tested whether the mediation models are differed by gender methods data collection the data for this study were collected in november 2019 all the interviewers were trained postgraduate students who understood the research and questionnaires the participants were voluntary and provided written informed consent for illiterate and semiilliterate participants written informed consent was filled by their legal guardians the interviewers and subjects had facetoface interviews and the interviewers filled the questionnaires according to the subjects responses after the survey was completed at least two trained students checked the contents of the questionnaires and questionnaires with the missing or unclear data were revisited and refilled measures child maltreatment the childhood trauma questionnaireshort form is a 28item selfreport scale rated on a fivepoint likert scale ranging from none 1 to always 5 a sample item was as follows i thought that my parents wished i was never born the final score was the sum of all item scores with higher scores reflecting more frequent and severe of child maltreatment were experiences before the age of 16 the ctqsf includes the coherence and viability of the constructs 58 in this study internal consistency α 087 for both males and females depression the center for epidemiologic studiesdepression is a brief 20item selfreport measure rated on a fourpoint likert from 0 within 1 d to 3 five to seven days the final score was the sum of all items scores with higher scores representing higher frequencies of depression during the past week a scale is a valuable tool for studying the relationships between depression and other variables 59 in this study internal consistency was α 090 for males and females coping skill the simple coping style questionnaire is a 20item scale rated on a fourpoint likert scale ranging from untaken 0 to often 3 in the context of chinese culture the scale reflected that you possibly took actions or exhibited attitudes when you suffered setbacks and encountered difficulties items 112 belong to positive coping and 1320 belong to negative coping 61 the final score is the sum of all item scores with the higher scores representing greater coping skills the internal consistency coefficient of the scale was 090 60 in this study internal consistency was α 061 for males and females loneliness the emotional and social loneliness scale is a 10item rating on a fivepoint likert ranging from 1 to 5 a sample item is as follows i havent special love relationship there are five items which are reverse scores eg someone could accompany me the final score is the sum of all items scores with higher scores reflecting a higher level of loneliness in the past year for this study internal consistency was α 075 for both males and females socialdemographic variables gender was measured as male and female the participants ages were calculated using their date of birth and divided into three groups 1844 years old belong to young people 4564 years old belonging to middleaged people and above 65 years old belonging to old people ethnicity was assessed using the hans and others marital status was assessed as unmarried and married education was assessed by illiteracy and semiilliteracy primary school and middle school and above only child was assessed as yes and no living alone was evaluated using yes or no offspring were evaluated by yes and no income level was assessed as higher average and lower statistical methods statistical analyses were performed by using spss version 230 descriptive analyses were examined as means and standard deviations for continuous variables and numbers and percentages for categorical variables oneway anova or chisquare test was conducted to assess mean differences for variables across the gender bicorrelation analysis was conducted with independent variables mediators and outcome variables linear regression was used to build the relationship between child maltreatment loneliness coping skills and depression while controlling for sociodemographic variables categorical variables are transformed into dummy variables we conducted separate analyses of the data split by sex all significance tests were twotailed and a pvalue of 005 or lower would be considered statistically significant results descriptive statistic and bivariate correlation this study investigated 879 participants from rural communities in shandong province china the sample characteristics and descriptive analyses are revealed in table 1 most males were older while most females were middleaged the percentage of married women was higher than that of married men of the women 449 were illiterate and semiilliterate and 457 males had a middle school education and above most participants werent only child had offspring and lived with at least one person with percentages of 962 969 and 893 respectively the mean cm score of the participants was 4210 females were more depressed and lonelier than males but there was not significant difference more detailed information is provided in table 1 bivariate correlation analysis revealed that cm loneliness coping skills and depression had mutually have significant associations as shown in table 2 greater severity of cm was associated with fewer coping skills and with more depression and more loneliness for males more severe child maltreatment was associated with fewer coping skills and with more depression and loneliness for females mediation analysis for males a mediation model was used to examine the mediating role of loneliness and coping skills on the relationship between cm and depression table 3 demonstrates that males who experienced child maltreatment reported higher levels of loneliness and lower levels of coping skills the effects of loneliness and coping skills on depression were significant a total effect of child maltreatment on depression was observed after controlling for mediative variables the link between maltreatment and depression remained significant tests of the indirect effect of loneliness and coping skills were significant figure 1 presents the mediating role of loneliness and coping skills in child maltreatment and depression among males loneliness and coping skills partially mediated the relationship between child maltreatment and depression among males mediation analysis for females table 3 demonstrates that female participants who experienced child maltreatment reported higher levels of loneliness and lower levels of coping skills the effect of loneliness on depression was significant but the effect of coping skills on depression was not significant a total effect of child maltreatment on depression was observed however after controlling for mediative variables the link between maltreatment and depression was not significant the indirect effects of loneliness and coping skills were significant figure 2 presents the mediating role of loneliness in child maltreatment and depression in females loneliness fully mediates the relationship between child maltreatment and depression in females however coping skills did not mediate the relationship between child maltreatment and depression among females discussion this study used a populationbased sample of rural participants and validated scales to examine the experiences of child maltreatment loneliness coping skills and depression more importantly we aimed to test the association between child maltreatment and depression extend the roles of loneliness and coping skills in the relationship between child maltreatment and depression and compare whether the mediation model for males differed from females in this study males were more likely to be maltreated than females before 16 years of age while the participants were from the rural regions one possible reason may be that rural parents paid attention to boys and they pinned greater hopes for boys so boys were maltreated more than girls the finding that nearly half of the females did not accept education also proved this phenomenon as mentioned in the introduction section we found an association between child maltreatment and depression in rural chinese men and women this study supports the role of loneliness and coping skills in the relationship between child maltreatment and depression which is consistent with previous research 2023 the mediation models of loneliness and coping skills for men and women had similarities and differences a previous study also indicated that sex differences mediated coping styles such as selfblame fantasizing problem avoidance and rationalization on the relationship between childhood maltreatment and depressive symptoms 22 the results proved that child maltreatment was directly predictive of increased loneliness and decreased coping skills loneliness and low coping skills would worsen depressive symptoms loneliness and coping skills partially mediated the relationship between child maltreatment and depression for males loneliness fully mediated the relationship between child maltreatment and depression for females but coping skills did not for males child maltreatment directly influenced depression loneliness and coping skills while maltreatment indirectly caused depression because of loneliness and poor coping skill child maltreatment caused loneliness thereby indirectly influencing depression in females previous studies found that females were more prone to depression 10 and this study also found the average depressive level of females was higher than that of males but there was no significant evidence to investigate this point possibly because research methods measures and participants were different from other studies in this rural population coping skills as a protective factor and higher coping skills may decrease the influence of child maltreatment on depression furthermore loneliness is a positive factor in peoples mental health the findings regarding gender differences revealed loneliness played a more important role in the influence of child maltreatment on depression for females depressive symptoms caused by child maltreatment were fully mediated and led by loneliness and females were more likely to be influenced deeply by child maltreatment than males it is noteworthy that women were shown to be more vulnerable to loneliness and society should provide more support and care for them prevent and intervene in loneliness and improve their coping skills to summarize we recommend that relevant departments promote education to increase individual quality decrease the incidence of child maltreatment and provide more social supports and assistance consequently improving mental health this study has some limitations that must be considered first this was a crosssectional study and we measured independent mediative and dependent factors simultaneously hence the child maltreatment and depression sequence were ambiguous and perhaps child maltreatment influenced depression it is also possible that depressive children were likely to be maltreated second participants may have forgotten the maltreatment experience because of age and some participants were shame to reflect on the experience the study results were lower than expected however the outcomes were statistically significant third we did not explore the different types of child maltreatment or the correlation between loneliness and coping skills lonely people were less likely to develop the skills to cope with difficulties conclusions in conclusion males were more likely to experience child maltreatment than females we also found an association between maltreatment and depression the mediation models are different based on gender the mediative role of loneliness and coping skills for males and the mediative role of loneliness for females the effects of loneliness on females who experienced maltreatment were greater than those of males who experienced maltreatment funding the national natural science foundation of china funded this project but had no role in study design data collection data analyses data interpretation or the writing of the paper competing interests ls is the member of editorial board for bmc psychiatry and the authors declared that they have no other competing interests

background child maltreatment is a prevalent and notable problem in rural china and the prevalence and severity of depression in rural areas are higher than the national norm several studies have found that loneliness and coping skills respectively mediated the relationship between child maltreatment and depression however few studies have examined the roles of loneliness and coping skills in child maltreatment and depression based on gender differences methods all participants were from rural communities aged more than 18 years in shandong province and 879 valid samples female634 ranging in age from 18 to 91 years old were analyzed the childhood trauma questionnaireshort form ctqsf the center for epidemiologic studiesdepression cesd the simple coping style questionnaire scsq and the emotional and social loneliness scale esls were used to evaluate child maltreatment depression coping skills and loneliness results child maltreatment was more common and severe in males than females f 399 p 005 loneliness and coping skills partially mediated the relationship between child maltreatment and depression in males but loneliness fully mediated the relationship between child maltreatment and depression in femalesin this study males were more likely to experience child maltreatment child maltreatment and depression were correlated we also found a mediating role of loneliness and coping skills for males and a mediating role of loneliness in females

introduction as challenging as covid19 has and in many ways continues to be for the worlds population it has taught us a few things as well for instance we have learned that work can take place anywhere the benefits of technology and telemedicine are indisputable selfcare is not selfindulgent and nature matters with the challenges and hardships associated with stayathome orders social isolation and the stress of the pandemic itself many have found a new appreciation for nature and are consequently more motivated to preserve it by most measures the planet did well during covid with limited air travel and consumption movement of people and limited interruption abstract one of the few silver linings in the covid pandemic has been a new appreciation for interest in and engagement with nature as countries open and travel becomes accessible again there is an opportunity to reimagine sustainable naturebased tourism from a therapeutic landscape lens framed within the therapeutic landscape concept this paper provides an autoethnographic account of a visitors experience of three different natural landscapes in iceland shortly after the countrys fourth wave of the pandemic it adds to the understanding of the healing effects of the multicolored natural landscapes of iceland the natural landscapes of interest herein include the southern part of the westfjörd peninsula jökulsárlón glacial lagoon and the central highlands in totality the natural built and symbolic environments worked in synchronicity to produce three thematic results restoration awe and concern all which provided reduced stress renewed attention as well as enhanced physical and psychosocial benefits for the autoethnographic visiting researcher implications of these restorative outcomes for sustainable to wildlife habitat for example the renewed interest in natural areas is likely to create a new boom in naturebased tourism worldwide covid has brought a time of pause for tourism providing the time and attention to better improve the sustainable planning development and management of naturebased tourism in a postcovid era in addition to the impacts caused by the pandemic several other forces are at play in the quest to protect nature these include respite from an increasingly urbanizing and technologically driven world and worry about the loss of nature due to environmental and climate change nature provides an opportunity to slow down offering a timeout from the demands of technology and city life buckley notes that research evidence indicates that both nature and adventure tourism contribute to positive mental health given that enjoyment promotes wellbeing climate change is another force at work in addition to those motivated by last chance tourism tourists are increasingly seeking opportunities to breath fresh air in a world facing a growing number of wildfires every year seeking natural environments through naturebased tourism has been gradually rising in recent decades and is likely to rise more rapidly in the wake of the pandemic this is especially so in iceland a country which has experienced an explosion in tourism since the late turn of the century one of the primary reasons for the burst in icelands tourism sector precovid is due to its natural environment and especially its pristine and wild character which has long formed the backbone of the countrys tourism industry this is reflected in the many marketing slogans for icelandic tourism including all natural unspoiled wilderness pure nature and europes last wilderness as a concept wilderness is however heavily disputed particularly in relation to the uses and management of wilderness areas in the anthropocene still no universally accepted definition of the concept exists wild and untamed nature represents nonetheless an environment that is becoming increasingly rare in our industrialized world and consequently a precious environment which a growing number of tourists are seeking the value of areas where it is possible to get in close contact with nature is increasing and especially so in wilderness settings where it is possible to enjoy solitude and tranquillity in this paper we will generally refer to natural areas given that our sites of concern have varying degrees of wild and untamed nature framed within the therapeutic landscape concept this paper provides an autoethnographic account of a visitors experience of three different natural landscapes in iceland shortly after the countrys fourth wave of the pandemic this paper highlights how health and tourism geographers can work collaboratively to recognize protect and sustain the therapeutic elements of natural landscapes and by so doing inform sustainable naturebased tourism through illuminating the health benefits of natural landscapes this is particularly important within the context of the growing naturebased tourism sector in the fragile arctic and subarctic regions experiencing elevated climate change impacts iceland located just south of the arctic circle is a sparsely populated country with only 376000 inhabitants sharing a land area of 103000 km 2 throughout icelandic history inhabitants have mainly been located along the coastline leaving the interior highlands an uninhabited wilderness over the course of the past few decades tourism has grown rapidly in iceland for example 1950 had approximately 4000 international visitors compared to nearly 24 million in 2018 which is sevenfold the countrys population the same year the number of international visitors dropped somewhat in 2019 and then collapsed in 2020 due to covid in 2021 the number rose to nearly 700 thousand the escalating growth in tourism since the turn of the century triggered overtourism in some of icelands most popular destinations there are many indications that tourism will grow rapidly again as travel restrictions due to the covid epidemic are eased likewise natural destinations like iceland will be highly sought after following a long period of restraint as countries open and travel becomes accessible again there is an opportunity to reimagine sustainable naturebased tourism from a therapeutic landscape lens furthermore using an autoethnographic account of a visitors experience of three diverse natural landscapes in iceland the therapeutic benefits of these natural environments are better understood the three natural sites selected to fulfil the aim of this study include the southern part of the westfjords peninsula the central highlands and the jökulsárlón glacial lagoon both authors travelled together to the westfjords the autoethnographic visiting researcher travelled to the jökulsárlón glacial lagoon on her own and was accompanied by an icelandic super jeep driver in the central highlands the first author is the visiting health geographic autoethnographic researcher with knowledge about therapeutic landscape theory as a tourism geographer and a native of iceland the second author provided important country context while situating the findings within the larger naturebased sustainable tourism literature a short review of the literature pertaining to therapeutic landscapes will provide the background for the paper next the autobiographical approach will be described results are presented via three themes restoration awe and concern implications for naturebased tourism in a postcovid era are discussed the methodology and results are written in first person given that they were experienced by the first author as a visiting researcher to iceland therapeutic landscapes and nature affiliation recognized as significant contribution that health geographers have made to the broad study of health therapeutic landscapes theory is a conceptual framework for the analysis of physical social and symbolic environments as they contribute vol to physical and mental health and wellbeing in places traditionally applications have been realized in the following four areas traditional landscapes natural pristinewild areas landscapes for the marginalized and applications to health care sites a 2018 scoping review of the therapeutic landscape literature noted that as a health geographical concept therapeutic landscapes offer indepth insight into experiential embodied and emotional geographies promote awareness of place as both therapeutic and exclusionary and continues to be a relevant and lively field of inquiry across health geography certainly natural environments have long been shown to be therapeutic landscapes natural pristine and wild places of geographical splendor may also be understood as an important cultural ecosystem service cultural ecosystem services provide a range of varied benefits to humans such as recreational tourism aesthetic and spiritual benefits all which enhance human and physical wellbeing in totality cultural ecosystem services intersect with therapeutic landscapes in the many benefits places have all of which contribute to enhanced mental and physical wellbeing within the ongoing evolution of therapeutic landscapes theory recent focus has been the examination of the coloured elements of landscapes or the palettes of place the colours blue and green have been particularly highlighted as promoting health and wellbeing within the context of iceland the significance of white and black landscapes was discussed by brooke and williams who recognized that many other natural landscapes of various colours have yet to be fully explored with respect to their therapeutic value such as blue green yellow brown and grey azevedo recognizes wilderness as being exemplified by a range of colours including white blue green and gold we introduce a range of colours here within the context of healthenabling places methodology to explore the beneficial impact of icelandic landscapes in relation to tourism an authoethnographical approach was used geographers butz and besio argue that authoethnography enables authors to become part of what they are studying where the research subject becomes reimagined via reflexive narrators of self autoethnography as method is becoming increasingly applied in human geography scarles and sanderson note in their work on tourism studies that …in autoethnography subjectivity becomes constructive rather than destructive accessing hidden spaces stimulating creativity and deepening connection … therefore the researcher is becoming researched and this process can ultimately enable a far richer research engagement and insight a number of health geographers have used autoethnography to capture the experience of place within the context of therapeutic landscapes for example thompson employs autoethnography to reflect on personal encounters with digital health and in so doing illustrates how digital health disrupts existing and creates new therapeutic landscapes liggins et al use autoethnography to reconsider the inpatient unit as a place of healing and in so doing attend to not only the material world but the world within both these papers encourage the further use of autoethnography in therapeutic landscape inquiry the autoethnographic approach used in this study not only allowed reflection on the experience of immersing within the three selected study sites but provided the opportunity to observe others experiencing the sites of concern when selecting the study sites it was considered that the sites reflect different geographical landscapes in terms of nature and accessibility thus the southern westfjords reflects a rural cultural landscape located outside the popular ring road the jökulsárlón glacier lagoon reflects a popular tourist destination located by the ring road on the southeast coast and the icelandic central highlands reflects a wilderness area with limited access especially during the winter months visiting in the fall specifically in the month of october these three sites were targeted in the following order the southern westfjords the jökulsárlón glacial lagoon and the central highlands all three sites were accessed by car or super jeep in keeping with autoethnographic method the i pronoun will be used from hereon in to describe the first authors experience of the icelandic landscape as a visitor data collection was similar across each site and included observation and documentation of the landscape and the associated activities and feelings experienced which was facilitated through copious field notes poetry writing picture taking and videorecording this was complimented by observing and documenting the various activities that others at each of the sites concerned were engaged in therapeutic mobilities were limited to driving walking hiking and boating at times during this project i did feel like an interloper as i was not only a visitor but also a researcher autoethnographic data captured the lived experience of these places through observing hiking and being fully immersed in these sites i used the power of observation in each of these sites being cognisant of all senses and the thoughts and feelings that were experienced the primary field data were my field notes and poems which were entered into my electronic field book multiple times each day the other data types supported these field notes analysis of data followed thematic analysis which systematically organized and identified data into meaningful themes thematic analysis procedures included creating preliminary codes which were assigned to the data in order to describe the content themes were organized across the data from these preliminary codes the themes were then reviewed defined and named following qualitative guidelines for assuring reliability and validity research findings came to be transferable dependable credible and confirmable in totality the natural built social and symbolic environments worked in synchronicity to produce three themes the thematic results are presented using descriptive realist narrative and imaginativecreative poetry descriptive realist narrative portrays places and experiences as accurately as possible while imaginativecreative writing allows the use of creative energy to express the autoethnographic experience in a range of genres such fiction poetry and drama when combined descriptive realist narrative and imaginativecreative writing create autobiographical poetry that depicts places and experiences in prose given the importance of situating the ethnographic researcher the positionality and reflexivity of the first author is now briefly described i was introduced to the therapeutic landscape concept via wil geslers writings when studying as a doctoral student in social and health geography although not my central area of study i became quickly captivated by the concept and engaged with the health geography community in developing it further i published my first edited collection on therapeutic landscapes in 1999 this laid the groundwork for a second collection published in 2007 i was particularly interested in increasing engagement with the lesserknown spiritual aspects of therapeutic landscapes engaging in pilgrimage sites both in real time and virtually i had the privilege of supervising numerous graduate students on the topic ranging from green spaces for university student mental health through to housing for both families with autistic children and immigrant careremployees working from home a large part of my engagement with the therapeutic landscape concept was due to my interest in health geography quality of life and wellbeing as well as my own welldeveloped nature affiliation my affiliation with nature began as a child where i spent copious amounts of time outside engaging in a wide range of natural spaces usually in an active way whether gardening cycling swimming crosscountry skiing playing a range of games such as badminton softball golf and hideandseek my parents had the foresight of purchasing a cottage near canadas longest freshwater beach when they started their family here my siblings and i spent every summer and most weekends as the majority of our outofschool time was spent at the cottage and much of it outdoors as one of my former graduate students revealed in his work with university students nature affiliation positive experiences growing up in natural places have longterm mental health benefits given that they nurture connectedness with nature throughout the life trajectory in this work it was found that nature connectedness had a positive and significant correlation with students selfrecalled positive childhood nature experiences such as proximity to expansive accessible natural places and shared family engagement and valuing of these places my love of nature was nurtured further in high school where i received summer employment as a junior conservationist spending time hiking in nature was a favorite pastime and i jumped at the opportunity to go hiking elsewhere whether outside my own community in the city or at my familys cottage in addition to hiking longdistance cycling throughout north america was another therapeutic mobility that provided nature affiliation while in university having my own family provided the opportunity to raise my kids with many of these same activities who now have high nature affiliation as i move into my middleage years i am fortunate to have the opportunity to engage in work to conserve and protect natural places for future generations this provides purpose and meaning while continuing to nurture my love of nature having had the opportunity to visit iceland in 2018 driving the famous ring road around the island in search for coloured therapeutic landscapes i was familiar with the white landscapes of the glaciers and ice geothermal steam and thousands of grazing sheepall which contrasted with the black sand and basalt evident throughout the island the inconceivably peculiar but wild mountainscapes of iceland quite consistently reflect this colour palette of white and dark colours going back to iceland in 2021 i had the opportunity to spend an extended amount of time visiting what i had perceived in 2018 as three of the comparatively more wild and pristine areas of iceland each of the selected sites will now be briefly described in turn icelands westfjords are often described as untapped nature given that the famous ring road that circles the island does not include the many fjords making up the larger three fingers of the westjords many would say that the lack of ringroad access has protected this part of iceland and particularly the northern tip of the westfjords which is primarily made up of the hornstrandir nature reserve this northern finger also contains drangajökull one of the many glaciers in iceland my visit was focused on the southern finger and specifically the area around the largest populated village in this area patreksfjörður an early snowstorm postponed the trip twice but once there provided a white snowscape to experience i accompanied two icelandic researchers on this 3day excursion both of whom were interested in landuse conflict between industry tourism and other purposes i too engaged in this work while visiting as it provided a deep understanding of the villages we visited we drove a rental vehicle with fourwheel drive in order to manage the snowy conditions of the roads one of these researchers is a tourism geography researcher and coauthor of this paper the second site jökulsárlón glacial lagoon became one of icelands most popular tourist site in the years before the pandemic many travel books on iceland describe the jökulsárlón glacial lagoon as bewitching given the sense of awe it engenders amongst visitors the glacial lagoon is located south of vatnajökull which is europes largest ice cap its current size is approximately 18 square kilometers it is attached to the atlantic ocean by a short waterway less than a kilometer in length the lagoon has a very short history both geologically and historically it began to form around 1930 as a result of the retreat of the glaciers south of vatnajökull ice cap following the end of the little ice age the lagoon has been expanding rapidly since along with the growth in tourism in iceland the popularity of the site as a tourist destination has steadily increased at this timeless site the glacial water and glacial chunks flow into the atlantic ocean leaving pieces of ice on the black coastal atlantic beach this beach affectionately called diamond beach is almost as popular as the lagoon the lagoon shapes breiðamerkursandur the glacifluvial sand plain south and west of it the glacial lagoon has characteristically cold blue glacial waters dotted with icebergs from the surrounding breiðamerkurjökull glacier an outlet glacier from the vatnajökull ice cap seals visit the fishfilled lagoon the lagoon is often described as one of the many natural wonders of iceland not to be missed i spent 3 days at this site on my own while hiking along the lagoon up to the boundaries of the glacier i spent hours observing the site at many different angles and altitudes i took a zodiac boat tour to get a fulsome understanding and experience of the expansive deep lagoon as well as the glacier tongue the third site visited the icelandic central highlands was the most anticipated given that it is perceived to be the comparatively most wild the central highlands are primarily located in the center of the country and make up a vast area of wilderness as the countrys population are primarily found in settlements near the coast with nearly 70 living in the capital area the highlands are primarily visited for outdoor recreation such as hiking hunting jeep touring and crosscountry ski touring part of the highlands is accessible to all kind of cars in the summertime in the wintertime the area is less accessible as there are no road maintenance services consequently the highlands are only accessible by super jeep in winter given that they are equipped with 4 wheeldrive and have balloon tires that can be deflated for better traction in the snow grazing of animals especially in the highlands has been greatly shortened in recent decades in order to protect the fragile vegetation grazing is only allowed during the summer months icelands central highlands is often described as the largest span of wilderness in europe in years past many in iceland have tried to establish it as a national park and continue to advocate for its legislation i was accompanied by an icelandic super jeep driver who was very knowledgeable about the highlands given that he had been a former member of icelands search and rescue team and consequently able to manage the worst weather and storm conditions thematic results in keeping with the therapeutic landscape concept the natural characteristics of the three sites studied were vibrantly clear being augmented by built elements the therapeutic social and symbolic characteristics of these environments were less apparent at first only showing themselves as time was invested in experiencing the sites given the centrality of mountains as a key component of the landscape across all three sites i was reminded and often felt their symbolic meaning throughout my visit as with other mountainous regions across the world icelandic mountains not only symbolize strength greatness and permanence but also proximity to a heavenly existence and good health although perceived as claustrophobic by some the general perception is that mountainous environments are healthful a proponent of highaltitude medicine auer wrote that the stimulating powers of sun and snow in high altitudes exerts an influence on physical health noting that a stay in high altitudes has been a longstanding medical prescription remaining valid today with doctors recommending stays in high altitudes as good preventative medicine he also summarized the spiritual rewards of an alpine environment he who knows how to open his mind and his heart in the mountains and to the mountains will be richly rewarded there is no question that the mountains made me feel a sense of awe in their size and beauty especially when painted with the various colours of white grey black and green climbing mountains often symbolizes overcoming obstacles and making progress as it did for me described below as restoring my attention reducing my stress and enhancing a more positive outlook the primary colours in the visited sites were white black and green although yellows greys and browns were also evident in certain locales providing bursts of colour in totality the natural built and symbolic environments worked in synchronicity to produce three thematic results restoration awe and concern overall the thematic results written below using descriptive realist narrative and imaginativecreative poetry provided reduced stress renewed attention as well as enhanced physical and psychological benefits for the researcher as discussed in the first and dominant theme restoration awe fed into feeling restored while feeling more restored allowed me to experience greater awe feeling both restoration and awe engendered a sense of concern for the future of these natural landscapes restoration having been the glue that held my fourperson nuclear family together safely and in good healthy throughout the first 15 years of the pandemic i was ready for an adventure the monotony of virtual teaching and working under lock down coupled with the ongoing tasks of domestic management and kids learning online due to stay at home orders took their toll on my wellbeing further as a caregiver to my closest uncle aged 88 years who was living in longterm care and had experienced numerous outbreaks and subsequent lockdowns i felt a great deal of worry and concern as a university professor and parent i was experiencing many of the symptoms of burnout characteristic of human service professionals poor physical health cynicism and negativity all of which were reflected in a lack of energy and motivation a change in sleep quality and appetite and a loss of satisfaction from activities that previously were enjoyable in addition to needing a change and break from the everyday mundane activities of the pandemic i was starving for wide open natural spaces in addition to feeling burnt out i experienced a serious knee injury 5 weeks before travelling and had only 3 weeks of physiotherapy to heal and strengthen it luckily i was able to purchase a knee brace for the trip throughout the trip i continued my regular daily exercises to ensure my knee was strong enough to endure the arduous hiking i was planning for i did manage to complete all the hikes and walking tours i set out to do but it was painful at times the limited hiking i did in the westfjords and central highlands was primarily done with others accompanying me on these trips these trips primarily include 12 h hikes often on challenging terrain having my hiking poles close by at all times assisted both my balance and confidence as a consequence of having company on these hikes there was a strong social component conversation often focused on the geological history culture or the people that characterized the place in which we were hiking or in the case of the westfjords the research we were involved in there specific to the forces of globalization causing landuse conflict between industry and tourism as a result of this project which included collecting data via stakeholder interviews and focus groups i was fortunate to speak to a number of icelanders both native and newly settled consequently i was able to more fully understand the forces at play that made the place work i felt fortunate to be part of the research project as it allowed me to gather an insiders understanding of the community and brought to life the physical geography of the fjords and surrounding geography the central highlands experience also contained a strong social component in that i was accompanied by a native icelander who had a great depth of knowledge specific to the geography culture and history of iceland he was generous in sharing his knowledge which was often shared in the form of stories he also knew the highlands intimately sharing the special places rarely written in tourist guides we did quite a few hikes together and he provided two opportunities to do two shorter solo hikes similar to the hiking in the westfjords conversation focused on the geography culture and history of the places we were visiting the solo hikes felt comfortable and safe given the safety net of knowing he was waiting at the end point although the social element in both the westfjords and central highlands provided a more intimate understanding of both places and even though i am still in touch with the folks who i travelled with i still felt very much like a visitor an outsider looking in the hiking i did around the jökulsárlón glacial lagoon spanned both east and west of the main artery leading to the atlantic ocean the eastern hike was shorter following the lagoons beach the western hike was more variable crossing flood plains and hills the western hike reminded me of the weeklong tour de mont blanc that i did in the european alps as a university student the scenic views of the mountains were ever changing as i was alone in this site i felt a strong sense of adventure but also vulnerable given the vast and expansive landscape into the second day of my stay i was yearning for social connection what follows is a poem i wrote describing the vulnerability of being alone and injured on these hikes trails of the jökulsárlón lagoon so many trails to choose from will my body hold up climbing and climbing knees and hips jarring with every step can i do it am i fit enough where is my balance use the hiking poles are my hiking boots sturdy enough pace yourself this is not a race both hikes gave me a sense of the size of the lagoon as well as the ecological processes at work on both hikes i experienced the loud sound of glacier pieces calving breaking into smaller pieces and hitting the water on each occasion a loud crack was heard followed by the sound of the waves produced by the smaller pieces falling into the water these calving processes are unplanned as the glacier pieces calve at all hours and times of the day i felt lucky to have experienced this being present to and observant of the natural ecological processes at work otherwise the soundscape is dependent on where you are located in the lagoon there is the either silence accompanied by birds singing or the gurgling of water under and around the glacier pieces the cold arctic wind blowing down from the highlands was constant being extremely strong at times and literally blowing me forward or backward on the trail depending on which way i was travelling i stopped to rest about every 20 min or so finding a rock to sit on while observing the landscape here i listened watched and felt each time i was struck with the beauty and serenity of the experience artic terns flew above me while water streamed out of rocks flowing into the lagoon the glacial ice floating in the lagoon melted before my eyes provided a sense of timelessness like i was in a backwards time warp the experience of watching the ice melt as it floated toward the atlantic ocean felt like a spedup movie reel century old ice melting in a matter of minutes therapeutic mobilities were limited to walkinghiking and boating in the lagoon both the westfjords and central highlands with their majestic wild scenery extent and wideopen spaces provided not only relief from stress but renewed attention reflected in the goal setting i did in both these environments given the rugged terrain in all three places hiking provided enhanced physical benefits while nature provided psychological benefits awe similar to the work of pearce et al who explored tourists views of a natural part of tasmania australia a range of aweinspiring experiences were felt when visiting the three chosen sites including vast geological landscapes aesthetics and fauna ecological phenomena and reflectiveperspective moments each of these will be discussed in turn vast geological landscapes iceland is made up of vast geological landscapes which are characteristic of all the three sites of concern herein the southern westfjords have majestic mountains surrounding every fjord the drive to and from the southern finger of the westfjords was exceptionally scenic as the road follows the coast of each uniquely beautiful fjord although the size of the mountainscapes made me feel miniscule the beauty of each fjord made me feel and that i was in a perfectly wild place with the greens blues whites and blacks working so beautifully in combination i felt a great deal of gratitude for having experienced such beauty the central highlands are made of what appears to be a neverending range of white glaciertopped mountains with great extent and much folklore in snowcovered hveravellir where we stopped for the first night i received a tour of the many hot springs and spent some time in the geothermal pool here the awesome story of the legendary fjalla eyvindur which translates as eyvindur of the mountains was shared eyvindur is the most wellknown icelandic outlaw in history being the source of numerous myths and stories eyvindur fled into the highlands in the mid1700s being accused of stealing he lived there for 20 years evading the state that were consistently on the hunt for his whereabouts the westfjörds also has folklore about him as fjallaeyvindur lived there for a few years these stories are taught in icelandic elementary schools as the tail of the outlaw is a story of resilience determination strength of body spirit and mind how he could live for so long in such a vast sparse and wild environment was bewildering to imagine the jökulsárlón glacial lagoon is known as the jewel of iceland for the tourism industry having a backdrop of the massive white vatnajökull glacier and the white and grey mountain ranges making up the vatnajökull national park as with the mountains in the central highlands westfjörds and in all parts of the world there is a feeling of majesty and magnificence when looking at them the mountain ranges and glaciers contribute to the aesthetics of these natural landscapes as do the waterscapes skies and landform shapes all reflect the naturebased colours of blue white green brown red grey and black i felt beauty surrounding me in each of these sites often having trouble deciding in which direction to look aesthetics fauna the large spaces extent and uninterrupted spectacular natural views made me feel remarkably small and insignificant the many fjords that make up the southern westfjords were an icy blue surrounded by steep mountains of grey red and black all of which were spotted with cascading rivers and green meadows sea birds were abundant in the fjords making it an international birding destination the many hues of blue and white within the jökulsárlón glacial lagoon provided great contrast to the grey and black seals sunning themselves on the glacial ice the large white glaciers atop the grey and black mountains in the central highlands were stunning given the vast brown and black rock deserts that stretched out on either side of the singlelane twodirection dirt road such multicoloured natural wilderness gave me a strong feeling of being alive reflected in a experiencing a sense of excitement adventure and hope for my lifes future ecological phenomenon a wide range of ecological phenomena most related to climate change and glacial melt take place in each of the sites of concern but the visual effect is most rapid in the jökulsárlón glacial lagoon as referred to earlier the lagoon experiences the calving of glaciers as well as the movement and melting of the resulting icebergs out to the atlantic ocean various wildlife habitats are also evident including a range of birdlife fish and harbor seals the latter which congregate near the mouth of the lagoon to catch fish one of the most fascinating processes is the melting of the many 1000yearold glacial ice melting into the atlantic ocean within a 6month window the lagoon vol is perpetually growing being formed naturally from melted glacial water big blocks of ice calve off the evershrinking glacier the rapidity of this ecological process is not only awe inspiring but astonishing the lagoon grows approximately 300 m each year as the glaciers tongue recedes with a greater degree of calving and a greater volume of meltwater reflectiveperspective moments the reflective moments in each of the natural sites were many the westfjords provided the first geothermal bath of the trip located high in the mountains it was a sight to watch the sky turn from blue to orange then pink as the sun set over the fjord geothermal baths recognized by others as socially and culturally responsive therapeutic landscapes were a common occurrence in the central highlands as well given the abundance of geothermal activity all over the island time in a natural geothermal bath provided time to reflect on the day while providing restoration to sore muscles and a full but tired mind the timelessness of the jökulsárlón glacial lagoon was where i simultaneously felt my mortality and brevity of life together with gratitude for the beauty of the place the expansiveness of the central highlands with its many glaciertopped mountains and miles of moraine desert had great extent provided perspective on the importance of sustainable development as beautiful as the land was it was the sky that seemed to come alive given its everchanging nature whether in the many hues of blue white orange and pink the following poem was written about the sky in the central highlands highland sky constant change like a symphony of sound rain or snow falls clouds move in and over mountain tops mist falls in waves wetting my face the sun peaks out to join the orchestra playing hide and seek with the other elements before succumbing to mastering the sky a rainbow presents itself as the climax of the concerto together with a backdrop of blue grey and white were these the same skies of eyvindur of the mountains concern concern was felt in all three sites due to the effects of overtourism climate change impacts and the anthropocene this was evident and symbolized by the litter at the jökulsárlón glacial lagoon land conflicts with tourism in the westfjords and a growing network of roads in the icelandic central highlands the expanding road network in the highlands unlocks these wild landscapes for infrastructure development and resource exploitation primarily in the areas of tourism and energy harnessing all three sites and particularly the glacial lagoon and central highlands showed clear signs of being impacted by climate change as with elsewhere in the world the icelandic glaciers are melting at an alarming rate having clear impacts on naturebased tourism especially in the southeast of the country the breiðamerkurjökull glacier started to retreat due to rising temperatures and between 1930 and 1940 the first signs of what now is known as jökulsárlón glacier lagoon became evident the lagoon has been growing in size ever since due to a warming climate rising temperatures continue to shape the lagoon which is currently the deepest lake in iceland and growing four times larger since the 1970s in addition to receding glaciers the warming climate is evident in the slow creep of the tree line evident in the new growth of native birch trees albeit stunted tourism ballooned in iceland at the turn of the century following the countrys economic collapse the central government initiated a highly successful marketing campaign to boost tourism in iceland consequently many of the most popular hiking trails are over trodden this is for example the case for the longdistance hiking trail between landmannalaugar and þórsmörk in the southern part of the central highlands of iceland to illustrate the rapidity of the growth of the tourism sector the second author recalls setting this trail with direction markers back in the 1980s and in 2021 the trail is recognized as one of the most popular in europe over trodden trails are not the only concern as congestion of both people vehicles and buses at the jökulsárlón glacial lagoon and diamond beach has initiated the building of two additional paved parking lots on the diamond beach side of the ring road tourism people and people bring pollution both in the jökulsárlón glacial lagoon and in the central highlands i found myself picking up garbage and specifically plastic bottles bags and rope of various kinds tourism has brought garbage and plastic specifically over what was formerly known as pristine wilderness many tourists appeared to be visiting the jökulsárlón glacial lagoon to check the site off their list of places to see while visiting iceland this idea of a tourist site checklist was brought up in discussion with community stakeholders in the westfjords as well i felt concern and worry over the changes that tourism has brought to these natural environments in the form of building road construction sign pollution and all other forms of pollution garbage sound and plastic the developing road network in the central highlands is a sign of potential infrastructure development visiting one of the oldest and most remote hiking huts in the central highlands demonstrated the very basic accommodations once available bunk beds and an outhouse further up the main dirt road is hveravellir a reconstructed hiking hut located beside a natural hot spring area the newer hotel beside it is equipped with intranet flush toilets hot water showers and sophisticated kitchen facilities all of which have become available yearround since a power and intranet line was dug across miles and miles of the central highlands a few years ago road access allows such infrastructure to be built providing the foundation for further development although there are many protected areas within the central highlands the whole area is not currently protected the increased interest in experiencing this last bastion of wilderness in europe continues to grow this is evident in the large busses equipped with allwheel drive and balloon tires taking tourists into the highlands for day trips through to winter when accessibility becomes more limited i felt concern over the need to protect the whole area given the growing popularity of the central highlands as a naturebased tourist destination driving along the snowy road toward hveravellir we rescued two tourists whose vehicle had gotten stuck in the snow they had been stranded for some time although they had rented a 4wheel drive vehicle they wrongly assumed they were able to transverse the highlands once out of the snow it was suggested they head down to the coast and to not veer from the ring road according to my driverguide such an incident is commonplace in the highlands happening far too often sheep farming is one of the largest agricultural sectors in iceland with thousands of sheep freely roaming during the summer months in most areas outside of the capital area of reykavik given that rural areas make up 90 of the island there is much opportunity for sheep to freely roam sheep are very much a part of the natural landscape whether in farmyards fenced off fields or grazing near the roadside or up in the highlands gorman discusses the need to incorporate animals in the study and understanding of therapeutic landscapes suggesting the need for them to be understood as coconstituents and coparticipants of therapeutic spaces using examples of how animals are agents in the therapeutic encounter for children with learning challenges such as dyslexia and adhd gorman highlights the needs to bring the animals back in certainly the sheep give life to the landscape not only with their movement but with the pleasant singing sounds they make hiking past the yews and lambs was a real treat allowing close proximity and observation of the beautiful animals although there are black sheep amongst the many white sheep most of the icelandic sheep are white farmers keep the yew and lambs together on the farm early in the spring once the lambs are established and firmly bonded with the yew the sheep are let out to freely roam the pasture all summer long colouring the landscape with various intensities of white depending on the number they are collected in the fall using dogs horses and various mechanized vehicles sheep were still roaming free when i visited the westfjords in october when i wrote the following poem although all three sites had unique therapeutic characteristics which contributed to healing burnout the westfjords were comparatively most healing followed by the central highlands and the lagoon this order was primarily due to the influence of the extent of the social component in the first two most healing sites complimenting the natural and symbolic components the results of this study speak to one of the most immediate discussion points that being the need to act to encourage sustainable tourism development especially in the subarctic and arctic where changes due to climate warming are happening at a faster rate than elsewhere the concern over how natural environments are being impacted by climate change motivates action whether via micro or macroscale changes this certainly occurred for me with respect to my everyday life posttravel as i consequently swapped my clothes drier with a drying rack purchased an electric car and accepted an invitation to join the board of directors for a community food garden that i volunteer for in the summer this transformative impact provides promise that the same will be experienced by the thousands of millions of travelers seeking naturebased tourism further building awareness of our environmental impact and building agency around sustainability and sustainable living more broadly discussion using an autoethnographic approach to the experience of icelandic natural areas through the lens of therapeutic landscapes provides four discussion points first as with earlier work on wilderness as therapeutic landscape the first thematic finding provides further evidence that nature provides cognitive restoration the autoethnographic researchers experience of the icelandic natural landscape via the three study sites was restorative this feeling of being restored was evident when returning back home feeling refreshed reenergized and ready to engage in both academic work and family home managementcare work once again given that therapeutic landscapes theory understands place as a key element in engendering health and wellbeing through physical social and symbolic environments the three sites of concern herein highlight the healing power of the natural environment employing autoethnography this paper has emphasized the experiential embodied and emotional geographies from the researchers perspective via three thematic findings awe feeds into feeling restored while feeling more restored allowed one to experience greater awe feeling both restoration and awe engendered a sense of concern for the future of these natural landscapes related to this is the variable of coloured landscapes or palettes of place the healing blues and greens were found across all three sites complimented by the awesome yellows browns and greys given the presence of water recognized by environmental psychologists and health geographers as the most healing natural component of landscape the various colours of water in iceland whether blue grey bubbling white or mineral rich green was apparent across the three sites blue was the dominant colour of the ocean surrounding the many fjords in the northwest and the coastline surrounding the lagoon in the south building on earlier work white was also dominant given the vast amount of moving water whether found in the many rivers and falls of the westfjords central highlands or lagoon site mineralrich green water was evident in the central highlands and the westfjords specifically in areas rich in geothermal baths and geysers in addition to white water white landscapes dominated each of the sites given the presence of thousands of sheep and ice and snow via the substantial numerous glaciers the colour white often contrasts with other colours such as the black sand on diamond beach adjacent to the glacier lagoon the green fields and pastures of the westfjords and the grey rock and brown soil of the central highlands a third discussion point addresses the possible exclusionary attributes of these sites with respect to the exclusionary nature of the identified sites of concern two points are most evident cost and accessibility costs of travel in iceland like most of europe is expected to exclude many potential visitors those who visit and travel in iceland are generally welloff given the high costs of services when compared to many other equatorial tourist destinations surprisingly access to the three sites of concern herein as with most natural places in iceland is free still having no entrance fee in place free access seems however to be slowly changing as a parking fee is now in place in a few popular tourist destinations such as in vatnajökull national park and in þingvellir national park increasing a number of other sites especially private ones are requiring an admission fee andor payment for using the restrooms increased tourism in iceland has furthermore changed accessibility demands both with respect to volume of access to all popular tourist destinations and with increased accessibility for those in wheelchairs andor who use mobility aids one development noted by the autoethnographic researcher since the earlier 2018 trip to the glacial lagoon was the addition of four parking spots allocated to those with disabilities these spots were strategically placed to allow access to the waterway trail between the atlantic ocean and glacial lagoon this improved accessibility brings nature closer to more people allowing greater inclusivity and therefore a greater number of visitors to reap the positive health benefits that nature provides however many researchers have shown that increasing accessibility to a greater number of tourists leads to landscape change transforming wilderness to developed and often populated areas and subsequently also changing visitors experience of it it is therefore a great challenge to manage naturebased tourism in wilderness settings like the icelandic central highlands implications for naturebased tourism in a postcovid era this study has many implications for naturebased tourism given that therapeutic landscape theory intersects with cultural ecosystem services there are many benefits that natural places provide one of which is the contribution they make to enhanced mental and physical wellbeing this benefit provides considerable opportunities for naturebased tourism in a postcovid era after 2 years of isolation and stayathome orders at various levels covid has opened our eyes to the therapeutic values of nature as confirmed by the results of this study research evidence notes that spending time outdoors in nature has been a critical factor enabling people to cope with the stress in and following the pandemic further with the growing number and intensity of natural disasters brought on by climate change across the world crisis such as the covid pandemic has alerted us to how quickly our world can change the experience of the pandemic amplified concern for climate change while increasing public support for a green recovery suggesting bolder climate policies and greater interest in sustainability as outlined by the united nations sustainability development goals sustainability is a key dimension in our planets wellbeing which in turn impacts societys wellbeing sustainable development has been a key theme in icelands government tourism strategy for the past 30 years and in so doing acknowledges its importance for icelandic tourism in 2019 the icelandic government set out an ambitious vision for icelandic tourism through to 2030 where the goal was to become a leader in sustainable development worldwide although sustainable development is the goal the economic dimension of sustainability has consistently been a leading force in icelandic tourism somewhat reflecting the laissezfaire approach largely guiding the tourism sector ólafsdóttir points out that with increased knowledge of sustainable development there is greater acceptance that the three pillars of sustainability defined as economy society and nature are part of a closed system nature sets limits for societal growth and society sets limits for economic growth it is therefore necessary to understand the behavior of the system in order to know where the boundaries between these pillars are and consequently manage development so that it remains within a sustainable system a holistic vision of all the influencing factors and an understanding of how they interrelate is therefore fundamental to the development of sustainable tourism as noted earlier covid has brought a time of pause for tourism thus providing an opportunity to critically reconsider tourism challenges such as overtourism and impacts of climate change moreover this pause has given precious time to better improve the planning and management of tourism in meeting the goal of the sustainable development for therapeutic naturebased wellbeing for example this time of respite allowed iceland to renovate sites experiencing overtourism such as the jökulsárlón glacial lagoon in addition to extending the number of parking spots signed accessible parking spots have been allocated for disabled folks making use of the space adjacent to the jökulsárlón glacial lagoon on the diamond beach site in addition achieving ecological sustainability natural tourist destinations should involve interpretation education and enjoyment of nature while bringing benefits to both visitors and local communities related to this is the issue of safety in each of the three sites of concern many of the features are viewed at the tourists risk with limited signage direction or rules trained as a national lifeguard in canada the autoethnographic researcher often caught themselves worrying about the lack of safeguards such as fences and other such barriers at the sites of concern the limited safety protection translates into somewhat of a hazard for some such as those with young children shaky on their feet or overly zealous photographers exploring whether this was a concern for others would be a useful followup study hence when developing naturebased tourism it is critical to develop sitespecific zoning for the different market groups using focal points as a management tool in this way it is possible to protect the most pristine wilderness icelands naturebased tourism sites exist on a continuum from minimally developed to fully commercialized in the most remote and wild places such as the central highlands visitors must often rely on their own gps navigation systems to find the many natural treasures in the most popular highland areas there is a volunteer search and rescue team stationed during the summer high season and so far they have been very quick to respond when they receive a call for help further mobile phone connection is now available across a large part of the highlands whether this means that the therapeutic value of the place improves or declines is important to explore in a followup study although limited in number iceland has commercialized some of its natural sites near one of the entrances to the central highlands two geological attractions are found gullfoss waterfall and geysir geothermal area in both these sites we find a large food court gift shop and multiple hotels in fact unlike many of the natural sites throughout the country these natural sites have built paths meant to steer the crowds although these commercialized sites are accessible to those with mobility aides the autoethnographic researcher much preferred the sites which were not commercialized as their natural quality and consequently their therapeutic value remained much more intact exploring the therapeutic benefits of limited development versus commercialization as seen with mass tourism provides yet another topic for further studying this realm conclusion framed within the therapeutic landscape concept this autoethnographic study of three of icelands natural sites adds to the understanding of the healing effects of the multicolour natural landscapes of iceland in a covid era in sum the natural sites of the southern westfjords jökulsárlón glacial lagoon and the central highlands worked in synchronicity to produce three thematic results the three themes of restoration awe and concern provided renewed attention reduced stress as well as enhanced physical and psychological benefits for the autoethnographer researcher further this paper has highlighted how health and tourism geographers are well positioned to work collaboratively to sustain the therapeutic elements of natural landscapes recognized as a cultural ecosystem service in so doing they can influence sustainable development and consumption through proper and appropriate planning and development of such tourism destinations open access this article is licensed under a creative commons attribution 40 international license which permits use sharing adaptation distribution and reproduction in any medium or format as long as you give appropriate credit to the original author and the source provide a link to the creative commons licence and indicate if changes were made the images or other third party material in this article are included in the articles creative commons licence unless indicated otherwise in a credit line to the material if material is not included in the articles creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use you will need to obtain permission directly from the copyright holder to view a copy of this licence visit creat iveco mmons org licen ses by4 0 publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

naturebased tourism in a postcovid era are discussed this paper highlights how health and tourism geographers can work collaboratively to recognize protect and sustain the therapeutic elements of natural landscapes recognized as a cultural ecosystem service in so doing such collaborations can positively influence sustainable naturebased tourism development and consumption through proper and appropriate planning and development of such tourism destinations

countries and segments of the population except in msm gay and bisexual men in the us are 4486 times more likely to be diagnosed with hiv compared to heterosexual men more than half of hivpositive young msm are unaware of their hiv status further only one quarter of the 11 million americans living with hiv have appropriate access to care and a suppressed viral load these data highlight the need to develop effective strategies to improve testing and healthcare utilization among msm one possible strategy for interventions among msm is the use of social networking technologies social networking technologies social networking technologies are tools that allow users to create connections communicate and share interests online social networking technologies encompass all technological tools used for communication within networks including websites mobile applications video and other media the rapid expansion of smartphones has resulted in increased use of social networking technologies the msm population has disproportionately embraced smartphone ownership over the past few years with 91 of gay males versus 63 of heterosexual males currently owning a smartphone device likewise membership to social networking sites has increased more rapidly in lesbian gay bisexual and transgender populations in recent years than in the general public in 2013 67 of gay men reported having visited an msmthemed websiteblog demonstrating an increase of 34 across one year this increased use provides an opportunity for social and behavioral researchers to disseminate health messages and implement interventions to curb behavior change using these new technologies soon after its conception and dissemination the internet has been a tool used by msm to find sexual partners a practice that has continued to increase in popularity and complexity over the years a survey in 2012 found that 46 of gay men used the internet to meet new sexual partners mostly through the use of mobile applications the most prominent mobile application described in the literature is grindr in 2009 this mobile app geared toward msm introduced the use of geolocation features to communicate with nearby individuals and facilitate finding romantic or sexual partners ever since similar mobile apps targeting subsegments of the msm population have also gained popularity among msm worldwide social networking prevention technologies for msm earlier studies show that a high percentage of msm use the internet and snts to seek health information making snts ideal for dissemination of information to this high risk group snts also provide the perfect routes for behavioral interventions because they represent the primary mode of socializing and sexualizing for many young msm further interventions using social technologies are advantageous for msm because they bypass the need for facetoface interventions providing privacy confidentiality convenience and reach that can increase the willingness of young msm to participate in prevention and care services social technologies for hiv prevention represent an emerging phenomenon in critical need of efficient study while platforms are so popular and useful for health interventions among msm to date several interventions have targeted msm using new social technologies a systematic review found that technologybased interventions for people living with hiv show promise for encouraging medication adherence sexual risk reduction decreased drug use increase health literacy and improvements in depressive symptoms earlier studies have shown that hivpositive individuals seldom discuss their hiv status with potential partners online prior to engaging in highrisk sexual encounters the lack of communication of sexual risk is mostly attributed to hiv stigma risk reduction interventions delivered via social media technologies have demonstrated low to moderate success in most populations one randomized controlled trial found that interventions using social networking sites such as facebook are acceptable and can be both effective in changing behaviors and increasing testing rates among participants however a different randomized trial using facebook showed that behavioral change was present in the short term but returned to baseline in the long run similar to the short term effects often found in nontechnology interventions other studies looked into the way in which theoretical online interventions should look like to make them more appealing to msm they identified high interest in sexual health topics and sexually explicit content we need a better understanding of the way in which msm use social networking technologies in order to customize them to achieve maximum effect within prevention programs the objectives of this study are to explore how msm and their social networks interact using social networking technologies uncover the perceived barriers to prevention programs using social networking technologies and explore ways in which a behavioral hiv intervention can be successfully implemented among msm using social networking technologies materials and methods a convenience sample was recruited from a small urban area of new england from september 2013 to march 2014 by posting flyers at a health clinic that serves a predominant msm patient population local lgbt bars and establishments and by posting a facebook event on a msm dance clubs facebook page interested participants contacted staff members for further information about the study and enrollment eligibility criteria included selfidentifying as gay bisexual or a man who has sex with men 18 years of age or older and englishspeaking further we stratified our recruitment approach according to hiv status such that half our sample was hivpositive while half was hivnegative or unknown status hivpositive status was confirmed because all hivpositive participants were recruited from a participating hiv clinic the focus groups were coled by two members of the research team one who led the group facilitation and the other who took notes and asked probes when applicable interview guide a semistructured interview contained four main themes participants social networks technology practices hiv knowledge and communication and prevention as it relates to all three previous categories the guide consisted of 24 questions with 8 pertaining to social networks 7 pertaining to technology use and 9 pertaining to hiv knowledge and communication most questions were open ended and meant to encourage open and honest participation by focus group members and allowed for probe and followup questions all sessions were audio recorded using a digital recorder the focus groups lasted approximately 90 minutes each the participants received a 30 incentive for their participation at the end of the group procedures for the focus groups were approved by the university institutional review board participants for this study we conducted five focus groups for one of the focus groups all but one participant cancelled a scheduled appointment turning that session into an individual interview this individual was hivnegative the other four focus groups two for hivpositive msm and two for hivnegative msm each included 8 to 10 participants for a total of 34 participants participants were organized by hiv status in order to provide insight into how hiv status influenced testing and engagement in care all participants were informed during recruitment of the type of group that they would join and we develop group rules that stressed privacy and confidentiality to build trust and rapport given the potential sensitivity of disclosing ones status data analysis all transcripts were transcribed by a member of the research team we used grounded theory and the constant comparative method as our main analysis frameworks the entire research team read each focus group transcript and the individual interview to identify main themes and to create a preliminary coding tree the coding scheme was developed using an inductive approach we modified the coding tree to add any new relevant themes and codes before transcript coding began two research team members independently coded the transcripts using the finalized coding tree and used qsr internationals nvivo 10 qualitative data analysis software we established an a priori coder agreement of 90 and had multiple coders code one transcript to establish coder calibration and agreement coding discrepancies were discussed and reconciled between coders if coding agreement was less than 90 we would retrain and recalibrate coders in an iterative process until 90 or higher agreement was reached we achieved greater than 90 agreement on all themes from the initial coding and therefore did not need to retrain or recalibrate coders all focus group and the individual interview data were coded and analyzed using matrix coding queries to determine the most salient themes finally we compared themes between hivnegative and hivpositive groups using matrix coding queries to assess whether themes differed between our two main groups results the demographic characteristics of the participants are displayed in table 1 of the 34 participants almost all were caucasian hivpositive participants ranged in age from 28 to 55 years old whereas hivnegative participants ranged in age from 18 to 41 years old overall 44 of our participants were hivpositive and 56 were hivnegative several themes emerged in response to our social networking technology questions including meeting new people demographic differences in use social media etiquette disclosure privacy concerns and the use of technology in prevention meeting new people social networking technologies were the main way by which participants met new people and kept in touch with current members of their social networks in terms of meeting new people even though the use of certain sites was meant for sexual encounters many participants revealed how interactions that were initially sexual in nature turned into friendships i made a couple of friends through those hook up sites people i only met with the intention of hooking up with but turned into a friendship another participant from the same group also acknowledged this unintended consequence ive used it for both purposes friends and looking for sex … and the line gets very blurred sometimes i just want to chat … and get into these deep conversations and they will go on for a couple of days and then theyll tell me … do you want to f k so i kind of just stay away from all that stuff even though many of the participants showed some contempt towards these platforms the potential of finding longlasting friendships through them was often acknowledged i have a sort of cyclical or undulating relationship with these gadgets but the thing is i met some really nice people in the likes of manhunt and facebook and some of them turned into great friendships so i think its important not to discount them the use of social networking technology for friendships and sex was especially useful for some participants when traveling and in areas with inactive gay scenes and infrastructure when we moved here it was a big deal because we didnt know people and it was like where do you go because theres really no bars here … demographic differences in use another theme that emerged was differences in social networking technology use based on age location and hiv status younger participants described their use of new social networking technologies and the trends they see regarding older and more established ones like facebook this participant implied that among the individuals who used this app to engage in bareback sex the nondisclosure button was an invitation to assume an hiv positive status further this quote emphasized that some social networking sites are used primarily for social purposes whereas others are used primarily for sexual purposes this distinction between social and sexual purposes often led participants to discuss issues related to social media etiquette social media etiquette the idea of media etiquette is a concept that was raised in several groups this concept describes the ways in which people should behave when using social networking platforms and also how an initial interaction can lead to a transition from one social networking platform to another which eventually leads to a facetoface encounter the way in which people first introduce themselves in social networking technologies was explored in one of the hivnegative groups everyone does that oh im just looking for friends and im like really be cause youre a headless torso or youre shirtless showing your body and youre just like yeah looking for friends but you wont respond to everyone youll just respond to attractive men … so you arent just looking for friends youre looking for attractive men that you are eventually going to f k so stop saying youre looking for friends a sexual undertone is commonly assumed when meeting someone in a gay forum or app even if the person explicitly states he is not looking for a sexual encounter this creates a problem for participants looking for long term partnerships or friendships i remember there would be a lot of people who would reply to me when i said whoa what are you looking for and i would say friends or chatting they would get pissed and they would say you know this is for hooking up and what are you doing out here the participants describe the process of transitioning from one social technology platform to another in one of the hivnegative groups theres a hierarchy like youll start off on grindr and then text and then you get to know them and then heres my facebook…id like to learn more about you participants also discussed that what people talked with each other about and how they communicated with each other was influenced by the type of social media platform and that certain types of communication was more appropriate for some platforms than for others participant m thats probably like my biggest pet peeve when someone comes at me really directly and sexually on any kind of social media its like hey heres a picture of my d k and im like cool i could have found a much better one online … participant n even in text messaging its like that its like awful oh my gd get over yourself participant o thats why i stopped using grindr people start conversations with pictures of their penises participant p or guys that have a picture of their abs as their profile picture most groups agreed that apps and websites which granted a greater degree of anonymity allowed for people to be more sexual and direct when contacting others participants identified a similar direct approach to conversations regarding risk taking behaviors i think that conversation escalates a lot quicker as far as … hi how are you what are you looking for what are you into then it goes right into condoms or no condoms this also applies to uses of prevention as one participant summarizes … its a place for people to meet other people its not a place for you to be an activist about hiv or gay rights … etiquette and appropriateness of such messages were cited as barriers for possible prevention interventions using social technologies disclosure the topic of hiv status and disclosure when meeting new potential sex partners was a prevalent theme in both the hivpositive and negative groups some participants expressed frustration when sites asked them for their status in their profile that bothers me in those sites where you have to put your status i put negative because i dont want everybody to know because its not their business at that point the hivpositive participants expressed conflict in whether to be forthright by disclosing their status on social networking hook up sites and the potential consequences of men being uninterested in them i mean when this is what you get … and it was hard people were uninterested if you disclosed people would not hook up with you negative participants expect the status question to be part of the social networking technology platform they are using and tend to readily believe what they read i have never asked if youre disease free it will be on their little blurb in the phone app … still for negative participants the conversation was avoided mainly because it was considered to be something that would turn off a potential sexual partner i wouldnt ask because its just awkward i feel like it would ruin the conversation if you are trying to just meet someone with the goal of hooking up with them i feel like asking them being up front with him would be a turn off and they would look for other options on grindr in addition to disclosure of status some social networking sites encourage the disclosure of ones viral load people in those websites now have the option of saying instead of positive undetectable…and that bothers me because i know a lot of people that say they are undetectable and … they could be … but ive also spent 3 to 4 days with them and the only drugs that ive seen them put into their bodies are done recreationally … several participants stated that this new type of status gives a false sense of security to hivpositive individuals who in turn transmit this information to potential sexual partners i know someone who was going around saying that because he was undetectable he couldnt pass the virus around … so he wasnt disclosing his status with anyone this may represent a strategy to manage potential stigma situations caused from their hivpositive status privacy concerns privacy of social media postings was a frequentlycited concern for participants say you are head of a company and youre hiring and ive been with people that go to facebook to check the person out and when you post something whether you are positive or not its … you know … i wonder about this person this concern for privacy was related to people within their social networks best expressed in one of the hivpositive groups earlier in my life … i was very open and honest i was ok with having that conversation about my status but im in a relationship with someone who tries to be very anonymous and doesnt want his business out there so i keep my s t on lockdown … i try not to have my facebook and twitter … i mean i wont even do a four square app checkin when im at the gay and lesbian center because i dont need people knowing why im there or asking why the concern for privacy was mentioned by both hivnegative and hivpositive participants but was more prevalent in the hivpositive groups hivpositive participants expressed concerns that posting messages about hiv prevention within social network sites would lead to negative consequences for themselves and their loved ones because of stigma toward hiv and how quickly information can spread within a social network using these platforms participants in both groups often described their social networks as separate or compartmentalized there was some overlap between their networks but generally they were kept separate often along the lines of sexual orientation for some participants this compartmentalization was due to perceived lack of empathy specifically from heterosexual members of different social networks such as work andor school for hivpositive participants this compartmentalization also included the fear of discrimination and stigma which influenced what they put out there on social technologies i used to have a blog right after i first got sober and it was just about like trying to date and dealing with my status … now my partner works in the medical field and … there are restrictions about going into medicine if youre already positive … so that creates a problem and he doesnt want his family all over the place knowing that i have a blog this hyper vigilance in social networking technologies regarding sexual orientation and hiv messages is a limiting factor affecting the dissemination of prevention messages within important msm networks use of technology in prevention the link between technology use and prevention strategies was carefully explored during the group discussions and several possible prevention strategies using technology emerged first participants stressed that current prevention messaging through popular gay websites do not have the farreaching effect they intend one hivnegative participant commented on a mass email about hiv testing sent by one of these websites ill be honest ive never read that email and im pretty sure that unless youve had a recent risky behavior you probably have not looked at those emails they are easy to delete participants felt similarly towards group messages sent via mobile apps describing them as poorly orchestrated many participants stated that an individualized message within a given social network would be the most effective way to change behaviors within that network the more personal the message the better texting is more effective than emailing calling is more effective than texting the only way that we really get through to people is by talking with them face to face i think this is generally applicable and that by far the most effective way would be to talk to somebody participants understood that personal messages had a more profound effect than any behavior campaign out there one of my friends just recently became hivpositive and hes a close friend of mine … and im like oh crap it can happen to anyone so thats when it lit a fire under my ass be more safe go get tested it has to hit you at home because if it doesnt no one is going to care these little 1718 year olds that are going to a club … theyre not going to care several other participants related similar ideas expressing the power of message communication within their social networks as greater influencers in shaping their behaviors however many participants showed hesitation to reach out to others directly because of as previously explored privacy concerns and social network compartmentalization for example this is what a participant said about making his facebook posts private for me personally im too lazy to do that im just going to be blunt id rather go through my phone list and message those rather than create a group thats my own personal preference if someone put me in one of those groups and i felt comfortable with everybody in there i would but when i have different people from various walks of life family and what not i wouldnt feel comfortable doing that piece of my personal life the overlap of social networks and possible breach of privacy through technology appeared daunting for some participants however participants suggested that masking prevention messages would allow participants to maintain privacy while still receiving important information participants suggested embedding prevention messages in something that would not only be more appealing but also more attractive to the intended audience if you were to do something that is masked … that somehow can engage others in the education of different topics like transmission and risk activities and mask it like some kind of survey where like … oh your friend took this survey and failed why dont you see if you pass it … and it can kind of go viral using this subtle engagement strategy would open the doors for people to more widely share hivprevention content within their networks participants also mentioned the need for wide broadcasting of the message through multiple types of media saturation and variety would increase the likelihood of reaching the target audience and increasing the messages impact on behavior participants also felt messages should come from both external sources such as clinicians and prevention experts as well as from within social networks through peer deliveredmessages discussion consistent with the literature our results suggest that msm are frequent users of social networking technologies using them to maintain current relationships and to meet new people including for friendships and sex use was particularly prevalent and important for young msm young peoples preference for newer technologies has been previously described in the literature and aligns well with our study that highlighted that younger msm are early adopters and frequent users of technologies several important themes emerged which provided insight into how msm use social technologies as well as the best strategies for using social technologies in hiv prevention an important theme that came out of discussions with our participants was social compartmentalization which has been previously observed in the literature compartmentalization suggests that certain behavior and conversations over social media depended on the target audience and perceived privacy of the technology participants were reluctant to discuss hiv or gayrelated themes on social media sites particularly ones with large groups of heterosexuals for concerns of privacy and fear of potential social consequences for themselves and romantic partners accruing from stigma this compartmentalization due to issues of privacy may limit the usefulness of mainstream social networking sites for hiv prevention where msm may not feel comfortable to discuss their sexual orientation or topics that may make people think they have hiv participants expressed discomfort discussing hiv prevention topics using the public functions of general social networking sites like twitter and facebook and were more comfortable using technologies that allowed for more intimate and private conversations such as small online groups of friends mobile apps with greater privacy settings or even more preferably oneonone text or instant messaging this is consistent with a recent study of young heterosexual men and women that showed that people did not feel comfortable posting hiv and sti prevention messages on relatively public social networking sites like facebook and preferred face to face communication of hivsti prevention messages or more private technologies like oneonone textingmessaging this suggests that a deep concern for privacy is a primary obstacle for any intervention employing social networking technologies the issue of privacy with online interventions has been raised in several studies each providing creative solutions or strong precautions to protect privacy while utilizing those technologies protection of confidentiality was recognized as the single biggest obstacle against prevention efforts within social networking technologies without assurances about anonymity most of our participants expressed great reluctance in transmitting messages related to hiv awareness and prevention these results suggest the need to create private options within social networking sites or social networking technologies that allow for people to engage in more intimate and sensitive conversations without fear of violations of their confidentiality or privacy technologies like snapchat slingshot and crumble messenger messaging apps that allow one to post messages and pictures with the premise that they will permanently disappear may be a step in the right direction for providing msm with more privacy in posting and receiving prevention messages without threat of breaking confidentiality in addition to the compartmentalization found in general social networking sites like facebook and twitter we uncovered compartmentalization on gay websites and apps in terms of content and behavior many of the gay themed apps like grindr and manhunt were perceived by many of the users as primarily sexual attempts to develop platonic friendships on these were often perceived as unwelcome or unsuccessful further discussions of prevention on many of the gaythemed apps were often perceived as out of place participants were quick to note the poor reception to mass produced messages found in many gaythemed sites this extended to even disclosure issues disclosure of hiv status in social networking platforms is precluded by fear and stigma associated with the disease a theme which also emerged in the present interviews participants noted that there are only a few gay apps that allow for hiv status disclosure in online profiles mostly participants avoided the disclosure conversation altogether which is consistent with studies showing high rates of nondisclosure to new sexual partners by hivpositive individuals lack of etiquette of disclosure on social networking sites may facilitate hiv transmission and risk increasing social norms around disclosure on social networking sites particularly ones used for meeting sex partners is an important avenue for future prevention interventions a few limitations should be noted from our study first our sample was primarily white and therefore the application of these findings to largely minority msm populations still needs to be explored second the use of focus groups to discuss sensitive topics such as sexual behavior and hiv may have limited some people to speak up compared to individual interviews particularly given the concern our participants had about privacy however focus groups can also facilitate conversations and add richness that would not be obtained with individual interviews considerations for future interventions our results suggest that broad hiv prevention approaches such as mass texts or the creation of prevention facebook pages or twitter accounts are unlikely to be successful implying that the field needs to devise strategies that allow msm to maintain network compartmentalization and address concerns for privacy while receiving hiv prevention interventions using social networking technologies this is consistent with results from trials using social networking sites like facebook which have faced problems with retention and decreased efficacy longitudinally techniques that embed prevention messages in clever ways may be more effective such as integrating hiv prevention and testing messages in social networking games quizzes or larger themes of health and wellness of msm further our results suggest that participants are not opposed to engaging their peers and friends about hiv prevention but prefer to choose the best social media platforms to have these discussions based on who they are communicating with and the nature of the message this suggests that strategies such as diffusion of innovation which suggests intervening with key members of social networks who will subsequently spread the messages to relevant members of their social networks might be an appropriate way to spread hiv prevention messages throughout msm populations diffusion of innovation employs early adopters with wide access to a given social network in disseminating messages about hiv testing and prevention and allows for spread using oneonone conversations within social network technologies focusing on key individuals within networks and providing them training in hiv prevention and how to tailor messaging for different social technologies may be an effective strategy that provides msm with agency and choice when intervening with members of their own social network

social networking technologies are influential among men who have sex with men msm and may be an important strategy for hiv prevention we conducted focus groups with hiv positive and negative participants almost all participants used social networking sites to meet new friends and sexual partners the main obstacle to effective hiv prevention campaigns in social networking platforms was stigmatization based on homosexuality as well as hiv status persistent stigma associated with hiv status and disclosure was cited as a top reason for avoiding hivrelated conversations while meeting new partners using social technologies further social networking sites have different social etiquettes and rules that may increase hiv risk by discouraging hiv status disclosure overall successful interventions for msm using social networking technologies must consider aspects of privacy stigma and social norms in order to enact hiv reduction among msm although men who have sex with men msm make up only about 2 of the us population purcell et al 2012 in 2010 msm accounted for 78 of new hiv infections among males and 63 of new infections in all populations combined hiv is reemerging as a serious epidemic among msm beyrer et al 2012

1 introduction background and motivation the audience member has often been just a spectator in public art not a participant or creator 1 2 3 digital technologies allow audience members to help build a citys scenery by their own action 45 it is possible to change the citys landscape using audience members activities mediated by digital technologies through interaction this public experience put audience members in cooperation and competition to change a citys landscape digital art is avantgarde because it makes use of digital media which prompt interactive participatory art whichfor its partprompts participatory democratic society 6 values of public artwork make public participation an unforgettable experience not just a private experience of artwork these experiences could lead to direct audience action mediated by digital technologies in the viewpoint of the audience participation claire bishop proposed participatory aesthetics these aesthetics were different from bourriauds relationship aesthetics 78 according to bishop the artists practice and his behavior as producer determines the relationship that will be struck up with his work in other words what he produces first and foremost is relations between people and the world by way of aesthetic objects the work of art has a social and historical context but its role is not to engage directly with society art is disengaged and it has its own space bishop asserted that the relationship aesthetics concept is the ideal form of audience collaboration and cooperation through the public interactive artwork for media façade by audience interaction audience members actively participate in and change contents producing a landscape of the city the main motivation of this paper is to produce a digital interactive artwork building on a cultural archetype cultural heritage directly supports public interactive artworks in audience action and in the embodiment of contents this audience action not only involves body movements from passive observers and performers for choosing the scene it also involves generating energy for changing social views of politics this aesthetic values public artwork based on cultural heritage through the archetypes it was possible to extract original emotion and activity from the human universal model and derive artworks contentsnarrative visualization sonification and embodiment of artworks objective 910 audience members participated in the public artwork and saw their shadows changing due to other audiences action on video cultural heritage have seen use in digital games especially narrative ones to extract a main characters action for their features and graphic images cultural heritage can also support artwork to enhance the aesthetics values through the audiences universal activity patterns this is because audience members have situations with mythical or traditional experiences and return to the origin model of humanity through the culture heritage related work public digital artwork has been produced in various ways these public digital artworks gave new artistic values for collaborated or competed experience to participating audience lozanohemmer rafael has made a public interactive artwork installation based on digital technologies the city as interface lozanohemmer showed that an alternative interface design is possible which stimulates brief encounters as part of everyday urban life 11 emily et al proposed the videomob an interactive video platform and artwork that enables strangers visiting different installation locations to interact across time and space through a computer interface that detects their presence videorecords their actions while automatically removing the video background through computer vision and cosituates visitors as part of the same digital environment 12 beyer et al proposed the puppeteer display a wide interactive banner display installed at a city sidewalk and two longterm field studies investigated the opportunities of public displays to actively shape the audience 13 however these artworks or research works have not used audience archetypes to make new artwork contents audience members just had an experience of real life with much the same patterns audience members did not know various meanings of their own actions and so duplicated their usual actions this was because this artwork and research did not consider human psychology and cognitionin view of objective and result from their own actions these audience actions effected on temporarily and not expanded public experience for making new societynew rules communities and role of humans applied archetypes will create new expanded experiences making various layers generate audience actionbeyond space and time age and gender 2 artwork overall design artwork concept the basic artwork concept is to make new artwork form audience members wholebody action the audience action will influence social values mediated by public media the meanings of the title deballution are as follows first it means a digital revolution by throwing balls a symbolic revolution mediated by digital artwork a change from tradition to digital technologies second it means devolution by throwing balls devolution is the transfer of some authority or power from a central organization or government to smaller organizations or government departments the audience here performs symbolic devolution audience members threw the pseudoballs for media façade and caused symbolic digital revolution devolution 14 this paper chose the throwing action to make audience resistance and destruction activities for competition and antagonism generating a new worldnot passive media or society why did we focus on the throwing action in the artwork the throwing action is related to disruptive aesthetics concerning disruptive aesthetics our motive was overthrowing a society in summation the term overthrowing means beyond throwing which regards the accomplishment of objective through the throwing activities 15 overhand throwing is a basic throwing action used in war hunting and sports it is a direct fast and accurate throw by moving the hand over the shoulder this throw is a symbol for a strong motivation to hit a target and change a target condition this artwork referred three throwing games that are part of different cultural heritages greek hyakintos myth throwing discus myth content is about the origin of the flower hyakintos from a relationship between a god and ordinary people in terms of friendship love and jealousy however this myth told a story about the origin of throwing action sports which in greece involved the discus unlike other sports games throwing discus is not war game it is a pure competition game for records 16 ① main objective throwing a discus for a long distance singlehandedly ② activities throwing discus with threequarters movement according to the rules ③ values a thrown discus will come back just like a boomerang as will friendship and create entertainment in a group 2 stone war from korean traditional play a war of throwing stones is a traditional korean game 17 two communities separated and began throwing stones each other this game came from real war but had been developed as a traditional folk game in the festival the game enhanced a group relationship through competition in each community ① main objective competing and winning by throwing stones for communities ② activities throwing real stones and avoiding or defending against stones from opponents ③ values establishing cooperation within the community and competition with opponent communities the ultimate value was to strengthen both for future real battles battle of the oranges from ivrea in italy the battle of the oranges is a festival at ivrea in italy it involves some thousands of towns people divided into nine combat ontheground teams who throw oranges at tens of cardbased teamswith considerable violenceduring the last three carnival deballution a prototype of interactive artwork days 18 people wearing a red hat will not be considered part of the revolutionaries and therefore will not have oranges thrown at them these traditional games were based on participators throwing the participators enjoyed the game like they were playing at war and felt the pleasure of rebellion and victory ① main objective throwing real oranges to opponents and win the official guards as traditional carnival ② activities throwing real oranges and avoid flying oranges ③ values revolution for ordinary people in carnival game and visualization pleasure by crushed oranges these archetypes have features for throwing action by individual or group and are beyond making festival play making a new world scenario design we created deballutions scenario design based on the previous artwork concept and applied by narrative forms 19 audience members watched video contents about citys landscape on a media façade or a large display audience members threw pseudoballs onto the media façade or the large display video contents in the media façade or the large display broke or generated pseudoballs audience members disrupted the video content when they filled the media façade or the large display with broken or generative images the new content that played in the media façade or the large display symbolized a new world graphic design the main concept of graphic design is to visualize audience throwing action to generate new images on the throwing point the contents express visually that participants desire to overthrow reality by throwing the first screen images are realistic and fanciless reflecting everyday life after participants throw a festival starts on the screen but the screen begins to be damaged at any point where a participant throws a kaleidoscope image expands just like images of crushed oranges the throwing action has usually happened at festival in the past the throwing action in this project means that participants gather and they set off firecrackers by making a festival the kaleidoscope images are like firecrackers and reminiscent of festivals the many points of the action signify the many participants ernest edmund used kaleidoscope images in basic interactive research to generate various pattern images from audience action 2021 these repeated throwing actions of participants creates recurring but diverse patterns of firecrackers these lead participants into a rhythmic fireworks festival the various images of firecrackers depend on the motion of the participants this is intended to emphasize the diversity of individuals after festival ends soon strange images like errors appear on the screen these little errors lead to big changes and damages finally participants overthrow the screen image the glitch effect is used for the damage effect as it is similar to the principle of a glitch unintended simple errors by participant generate the new screen this gives a positive meaning to errors failure and the participants ultimate conquest of the screen applied by aesthetics for artwork audience members could put their emotions in the artwork and change their emotions through participation in the artwork this artwork is based on technical implementation and graphic design however these technical factors of the interactive installation would not lead to interactive artwork without aesthetic values this project did not serve designs or technical devices but two aesthetic valuespleasure framework and disruptive aesthetics pleasure framework the concept of pleasure framework proposes thirteen pleasurescreation exploration discovery difficulty competition danger captivation sensation sympathy simulation fantasy camaraderie and subversion by participation in an interactive artwork these are only possible categories that a participant might feel pleasure in during an interactive art experience 22 audience members could experience the following emotions typically by participating in deballution through a pleasure framework ① creation audience members felt they were part of the creation when they drew a new painting by making a circle making a new world through their own actions ② discovery audience members discovered new unfamiliar scenery of the city particular actions may provoke different images and transformed contents ③ difficulty audience members had difficulty making circles on the screen precisely where they wanted to draw them this difficulty gamified the experience focusing them on achieving a goal ④ competition audience members participated in deballution in collaboration they tried to achieve a defined goal together completing the goal fig 4 examples of graphic design 14 could involve working with or against another human participant when making a new world ⑤ subversion audience members could destroy the background image on the screen and create the new world through their own action disruptive aesthetics artworks each have their own artistic values disruptive aesthetics placed artistic value on social meanings 23 especially they lead audience members to break down traditional social values the audience overthrows the social order and proposes a new world ① audience audience threw pseudoballs ② interactive installation the installation represented a screen video and covered circle images influenced by audience action ③ artwork contents the previous background video broke down after the audience filled it with generative circle images a new futuristic video ensued ④ breaking a rulecommunityrole audience members disrupted the city landscape in the screen by their own activities such disruptive aesthetics in deballution broke down the rule of maintaining community and created a new world these aesthetics will influence the artwork creating a new artistic value and experience independent of design values or technical implementation issues prototype and evaluation prototype implementation the prototype focused on audience throwing action and reflecting on the screen circle images deballution a prototype of interactive artwork these audience activities could be possible to two or three participants those images filled the screen and disrupted background images this distorted content is a new world the audience itself created by changing city scenery the prototype made by openframeworks used c programming connected by kinect this is because in the prototype test video about scenery of the city played on a small screen instead of a media façade and focused on audience activities not on video contents audience members made throwing gestures in front of the screen which generated circle images at the positions of the audiences throwing by calculating virtual location through kinect connected by openframeworks programming audience members continued throwing and circle images at the position of the previous images and new images expanded on the screen progressively until the screen filled with images covering up the scenery of the city at that time the screen was full of various circle images the origin video was a reversal of the screen and the audiences throwing play was completed video cuts from prototype exhibition are as follows evaluation factors after the prototype exhibition we evaluated the user test and group interview ten participants performed in the prototype test their ages ranged from 22 to 38 years old eight were righthanded and 2 were lefthanded participants could throw pseudo balls as much as they wanted without a restriction on time or throwing numbers after a survey we interviewed the participants in the participant interviews we focused on two questions involving social group play experimentation and development ideation for increasing the artwork value results and discussion main objective the highest factor concerning the main objective of the participants was making circles in the content this means that participants wanted to know the results of their own activities and just the throwing action would be possible to influence content participants were interested in the throwing action for making circles and developing next stages the participants objectives influenced content development because they wanted to change the media through interaction this objective is different in regards to observation or appreciation from bishops viewpoint of participatory aesthetics however participants had different objectives and desires in the developing artwork we focused on participant activities of adjusting different images by throwing actions reflecting their own desire and creating antagonism and competition between the participant groups the average number of throwing actions was 37 continued throwing activities by the audience meant that the participants were immersed in the deballution because the test did not ask how many throwing activities were performed participants performed voluntary throwing actions in the prototype test this was because participants wanted to watch the deballution content of their own actions and were interested in participation by making circles then participants acted on the artwork with various throwing actions and poses just like game play for example participants jumped for powerup throwing shotput throwing and throwing with both hands the original throw for this artwork was the overhand throw which means overthrowing the rule community and role by participants however participants made various throwing actions sidearm underhand threequarters twisted throwing and jump throwing trials of a throwing action with a whole body movement especially influenced audience emotion through participation this result means that the audience wanted to act on various selfobjectives and were not controlled by installation limitations this is because the deballution installation fit the audience overhand throwing action however it could be perceived with other throwing actions as well participants preferred group play over single play this means that participants wanted to play in collaboration competition or conflict for selfmotivation values participants had various artistic values in the prototype of deballution the highest factor of the pleasure framework was the creation pleasure subversion and simulation were the second highest factors in this framework the highest factor of disruptive aesthetics was the overthrowing rules the highest factor of content developing the artwork was the circle image changing to other images narrative development background image modifying and competition among participants were the highest factors in the developing elements in the interview participants proposed various background images and videos the participants also wanted to perform by stage level developing like storytelling or gamification in general participants interests and immersion were increased by group performance this is because competition influenced participants throwing objectives and enhanced their throwing action skills in short participants wanted to experience dramatic visualization by their own activities and changing of artwork values these elements were our intended objective we found the pleasure framework and disruptive aesthetics in the artwork the interactive artwork outcome generated intended or unintended audience participation 24 participants were absorbed with the deballution merely by the throwing activities participants drew their own images of their own throwing actions they wanted to draw circle images where they drewjust like the abstract drawings of kandinsky or jackson pollock participants wanted to draw the same size and location image as the previous throwing points due to their reflection desire this means that they wanted to draw an indepth layered visualization of the circle image and background participants had a duplication desire for their own creatures and developed the next stages these participantdesired actions will adjust the realization of public interactive artwork deballution they will generate more active unintended actions and create a new image relation between the background image and the participants generating images these artwork values were values of participatory artwork by claire bishop influencing a new world by direct participant activities 7 these results mean that the throwing action autonomously influenced various participant activities using these activities it was possible to make developing contents and artistic values in the prototype test audience members threw imaginary objects and generated extended circle images those images filled the screen and disrupted background images this distorted content is a new world the audience itself created by changing city scenery the original objective for the deballution was seeing a display for a media façade or a large display through the discussion we revised the contents with the prototype test results the follow table is a summary of the changing contents in the artwork for increased audience participation we applied these audience action patterns in the prototype to generate random kaleidoscope images realization deballution the system was designed to recognize the users throwing actions and patterns the 6 main parameters included the elbows x y and z positions and the hands x y and z positions these were observed and analyzed to make a decision as to whether or not throwing actions happened the patterns of the audiences throwing experiences were used to describe interactivity in levels the high level of interactivity concerns a meaningful interaction between the system and the participants the audiences become active authors or creators the diversity of interactivity levels comes in different shapes sizes and colors of 3d generative kaleidoscopes for instance highlevel interactions make bigger sizes dynamic shape changes in animation and vibrant shades of red based on color theory this is associated with different meanings energy strength power and celebration medium levels of interaction are possible to make a middle range of sizes animation and comfort shades of green that create feelings of relaxation balance and soothing emotions low levels of interaction create small sizes changes and sophisticated shades of blue that are associated with emotions of calmness spirituality and futurism 14 conclusion in this paper we proposed the basic prototype of interactive artwork deballution based on cultural heritages audience members threw pseudo balls on a screen and could make a new world by their own activities in the interactive artwork based on cultural heritage

based on cultural heritage plays about throwing action we made a public interactive artwork by throwing pseudoballs deballution audience members participated in interactive artwork not only for pleasure but also as part of their cultural heritage maintaining and also disrupting social orders and structures first of all this research extracted the audiences basic activities from cultural archetypes then it applied audience activities to a basic model of public interactive artwork for playing on a media façade to participating in collective performance for disruptive social structures the interactive artwork concept is to catch audience members throwing movements on a virtual screen and drawing various generated kaleidoscope images to predict points from the audience throwing on the screen we made prototype deballution and then exhibited it and evaluated user tests through evaluation results for the prototype we revised deballution artwork contents for developing artistic values and produced overall interactive artwork

weight 34 infants exposed to tobacco smoke are at greater risk for sudden infant death syndrome 1 childhood obesity 67 and ear infections and upper respiratory infections 8 these risks can be reduced by helping pregnant women quit smoking and helping them reduce exposure to tobacco smoke 9 pregnancy is an opportunity for pregnant women and people in their social circle to change their health behavior such as quitting smoking 1011 however not all women quit smoking during their pregnancy in europe the estimated prevalence of smoking during pregnancy is around 8 12 30 of women who smoked before pregnancy continued to smoke daily during pregnancy 12 in 2018 7 of pregnant women in the netherlands smoked at some point during pregnancy 23 of the women who smoked before pregnancy continued smoking during the entire pregnancy 13 a pregnant womans partner friends and family were found to be a major determinant for maternal smoking cessation during pregnancy 14 research shows that a pregnant womans social circle directly influences her smoking through the support they give and by changing their own smoking behavior 15 16 17 18 however if a pregnant woman lives with people who smoke and if smoking is common within her social circle her chances of succeeding in quitting smoking have been shown to be reduced 19 in addition exposure to second and third hand smoke is associated with adverse health effects for mothers and children 42021 healthcare providers can be effective at assisting members of a pregnant womans social circle in quitting or encouraging them not to smoke near a pregnant woman 22 due to the harms and risks to maternal and fetal health associated with tobacco use and tobacco smoke exposure 42021 it is important that obstetriciangynecologists and midwives address tobacco use and tobacco smoke exposure with the pregnant womens social circle pregnancy can serve as a teachable moment for smoking cessation for a pregnant womans social circle particularly partners and an opportunity for birth care providers to help the pregnant woman and members of her social circle to quit smoking 23 24 25 engaging the social circle has the potential to increase the effectiveness of smoking cessation programs for pregnant women 8 and can improve the public health impact of these programs by increasing the number of people who quit smoking however the members of pregnant womens social circle often receive little to no smoking cessation advice or assistance from birth care providers 26 in the netherlands midwives are the primary birth care providers for the majority of pregnant women in accordance with the netherlands healthcare inspectorate regulations midwives should counsel pregnant women and their partners about quitting smoking using the vmis protocol 2728 the protocol consists of asking pregnant women and their partners about smoking working to increase motivation to quit addressing barriers to cessation setting a quit date discussing cessation tools and techniques offering help after the quit date and working to prevent relapse 27 research on the use of the protocol also showed that 81 of midwives almost always learn the smoking status of pregnant womens partners yet midwives lacked skills in motivational interviewing 29 and didnt follow all of the steps of the vmis protocol 30 further research is needed on the provision of smoking cessation support by birth care providers to the social circle of pregnant women aims the aim of this study is to explore through interviews experiences of birth care providers in the netherlands with providing smoking cessation support to members of pregnant womens social circle the results of this study provide insight into the ways in which birth care providers assist members of pregnant womens social circle with smoking cessation as well as into the barriers that birth care providers have faced when working with a pregnant womans social circle data from this study can be used by health policy developers birth care educators and birth care providers to further develop improve and implement smoking cessation care guidelines for midwives especially guidelines in the netherlands or in healthcare systems with a similar structure of midwifedelivered care for pregnant women methods birth care in the netherlands in the netherlands midwives are trained in prenatal care birth care and postnatal care through a 4 year directentry bachelor of science in midwifery program 31 after completing their education midwives register as healthcare professionals with the netherlands ministry of health welfare and sport in 2016 3221 midwives were registered healthcare professionals in the netherlands with the majority working in primary care midwifery practices 32 midwifery care for pregnant women begins in the eighth week of pregnancy and continues until a few weeks after birth 31 most pregnancies in the netherlands are at least at first cared for by primary care midwives who practice in independent midwifery practices if complications arise during pregnancy midwifes refer women to hospitalbased care where care is provided by an obgyn or secondary care midwife for as long as necessary design of data collection in order to understand birth care providers experiences with providing smoking cessation support to the social circle of pregnant women semistructured interviews were conducted with fourteen birth care providers in the netherlands the interviews were conducted using an interview guide the interview guide included an introduction to the interview a description of the goals of the interview and questions about birth care providers experiences with addressing tobacco use and exposure with the social circle of pregnant women barriers in discussing cessation with the social circle and the role of birth care providers in cessation support to the social circle an english version of the interview guide is provided in additional file 1 ethical approval the research was approved by the trimbos ethics committee in october 2017 and was carried out in accordance with the 1964 helsinki declaration and its later amendments the data presented in this article comes solely from the interviews with birth care providers and does not include any data from patients or any identifiable data about patients or members of patients social circles prior to interviews all participants signed a consent form stating that they were informed that participation was voluntary that they could withdraw at any time that they were willing for the interview to be recorded and that the data would be analyzed anonymously no incentives for participation in the interviews were offered the audio files and transcripts were saved on a secured drive and were only accessible to those analyzing the data all data from the interviews has been presented anonymously participant selection and recruitment the study team aimed to conduct at least twelve interviews with birth care providers this number is in line with guidance on interviews and saturation which notes that 1012 interviews are often sufficient for reaching data saturation 3334 the interviews and the data analysis were conducted simultaneously we reached saturation at interview 11 however two additional interviews were conducted to ensure no new information emerged a mix of purposeful sampling and convenience sampling was used to recruit birth care providers for interviews first purposeful sampling was used to engage with birth care providers working often with people who smoke birth care providers were recruited from four large cities in the netherlands which have relatively high smoking rates 35 the research team used public data to select eligible midwifery practices within or near socially disadvantaged city districts 36 a list of eligible midwifery practices was made these practices were contacted by telephone to invite one birth care provider employed in the practice to participate in an interview potential participants were invited to be interviewed at a time and location of their choice of the 28 eligible midwifery practices 13 practices did not respond to our request of the 15 practices that did respond 8 practices declined participation as they had other priorities were participating in other studies or had a lack of experience with smokers seven practices from the 28 eligible midwifery practices responded positively to the request to have a birth care provider participate in an interview simultaneously convenience sampling was used to recruit birth care providers to participate in interviews the study team invited 7 birth care providers with whom they had had previous contact because they participated in an exploratory research for a smoking cessation intervention for pregnant women 37 in this exploratory research birth care providers shared their experiences on smoking cessation care for pregnant women in focus groups results are not published the study team only invited birth care providers to participate in this study who were not involved in the intervention study the birth care providers were contacted by telephone or by email all 7 birth care providers agreed to participate and were interviewed at a time and location of their choice these birth care providers were located in the hague utrecht zeist gouda leiden and zwolle data collection and setting thirteen interviews were conducted with 14 birth care providers the interviews were conducted by two female researchers working in the field of smoking cessation and trained in qualitative research methods facetoface interviews were conducted between november 2017 and february 2018 the interviews took place at midwifery practices or at the participants home one interview was conducted with two midwives simultaneously both working at different midwifery practices all interviews were conducted in dutch the interviews took 3060 minutes and were recorded the interviews were transcribed verbatim coding all interviews were coded 38 using maxqda18 ew and ls familiarized themselves with the data by reading the transcripts an inductive coding approach was applied where datadriven codes on the influence of the social circle on pregnant women and the barriers birth care providers perceive in discussing smoking cessation with the social circle of pregnant women were generated after coding five interviews individually ew and ls discussed their findings and developed a preliminary list of codes after coding the following four interviews individually ew and ls reviewed the codes and discussed the definitions of codes to determine agreement the final list of codes was developed ew went back to the previously coded interviews to include the new codes ew coded the remaining four interviews with the final list of codes data analysis data were analyzed according to the principles of thematic analysis by braun and clarke who define a theme as a theme captures something important about the data in relation to the research question and represents some level of patterned response or meaning within the data set 39 after data familiarization and agreement between ew and ls on the initial coding process codes were grouped in preliminary themes by ew comparison between coded data was used to identify new patterns from qualitative data and ensuring that the themes reflected these patterns ew then summarized these preliminary themes into paragraphs for a dutchlanguage report 40 ls reviewed the preliminary themes for the dutchlanguage report through discussion between ew and ls consensus was reached on the definitions and names of the themes the paper was produced including only the themes related to the aim of this paper see additional file 3 for more information on the themes translation quotes were translated from dutch to english by ew a native english speaker assisted with translation of a selection of quotes results participant details fourteen birth care providers were interviewed twelve primary care midwives one primary and secondary care midwife and one obgyn the birth care providers were all women and had at least 1 year experience working in prenatal care the results were primarily derived from interviews with midwives the term midwives will be used hereafter unless the data was from the interview with the obgyn results of the analysis three main themes were identified during data analysis these themes were midwives experiences with assisting members of the social circle with cessation perceived barriers to discussing cessation with members of the social circle and midwives role in assisting the social circle with cessation experiences with assisting members of the social circle with cessation midwives believed that a pregnant womens social circle has a considerable influence on her smoking status they the social circle play an important role what you often see is that if women smoke their partners and their mothers smoke too you rarely come across a woman who is the only one who smokes in a smokefree social circle when it concerns the social circle of pregnant women midwives come across partners of pregnant women more often during antenatal appointments than family members or friends partners often attend the first consultation with the midwife but their attendance later in pregnancy varies some partners we never see and others come along every time on average they come along 3 or 4 times … sometimes a grand mother comes along but not very often we even less often see a friend while midwives acknowledge that pregnant women who smoke are usually part of a social circle in which smoking is common midwives noted that they do not commonly ask members of the pregnant womans social circle if they smoke when i ask a pregnant woman about smoking it could be that her mother also spontaneously says something about smoking but i am not going to ask mothers sisters or friends about their smoking when midwives reported when they talk about smoking with partners this usually happens only once with limited or no followup i always mention in the first consultation that quitting smoking together is easier if i am being honest after that i let go of the partner a little bit and i focus on the pregnant woman i mention it smoking cessation again to pregnant women but i wont mention it again to the partner further when midwives do talk about smoking with partners or members of the pregnant womans social circle the focus may be limited to harm reduction as the quote below reveals the midwife views smoking cessation as not necessarily feasible well smoking outside is often the highest attainable goal because they have complicated lives and it smoking is just hard to deal with this view may influence how midwives address the smoking behavior of pregnant womens partners barriers to addressing smoking with members of the social circle midwives faced barriers to provide cessation support to the social circle of pregnant women one barrier midwives perceived is the lack of a trusting relationship with the social circle of pregnant women i wouldnt proactively ask a mother of a pregnant woman during a consultation if she smokes even though i know it would be good to do … i feel less connected to the pregnant womans mother than to her partner moreover midwives expressed that they do not want to risk their relationship with the pregnant woman by discussing smoking with her social circle the trusting relationship can be damaged by involving her mother thats why its such a big problem all around concerns about raising the topic with members of the social circle of pregnant women were expressed by the interviewed midwives sometimes it feels a little … how can i explain that … it feels a little like im interfering too much with them according to some midwives partners do not want to talk about smoking or smoking cessation with them i think that partners are less open to smoking cessation support than pregnant women because they dont really see why a midwife should discuss this with them midwives were concerned about giving unwanted smoking cessation advice to the members of the social circle they were also concerned that the social circle do not think that midwives are the right professionals to receive cessation advice from another barrier many midwives perceived is a lack of opportunity to discuss smoking we only see them pregnant women and partners for about seven months or so and after that it stops that is a short amount of time im in a practice with four midwives so how many times do you see someone personally when a pregnant woman receives care at a group practice she may see different midwives during her pregnancy as partners andor other members of a womans social circle do not attend every visit the midwife has limited interactions with a pregnant womans friends family and partners and limited opportunities to address smoking midwives stated that most partners had already made changes to their smoking you know in general of course that quitting smoking is discussed at some point during the pregnant womans care in 9 out of 10 cases a partner has already made changes and goes to the balcony or outside to smoke if the pregnant woman is okay with that who are we to say that it is not okay according to midwives most partners believe that they are already doing enough by smoking outside a belief which is echoed by the pregnant women themselves as a result some midwives did not encourage partners to make further changes by quitting smoking midwives role in assisting the social circle with cessation the midwives described being ambivalent about their responsibility to provide smoking cessation support to a pregnant womans social circle when asked about the midwifes role with regard to assisting the social circle with smoking cessation one midwife stated yes and no i think our role as midwife is to take care of the health of the mother and child the social circle can help but i think it is their own responsibility too … i am not sure if i am really responsible for that smoking cessation support of the social circle however other midwives noted that cessation advice to the social circle would be important to do as part of care for pregnant women on the one side it is the role of a midwife because i think that if the social circle is engaged more pregnant women will successfully quit smoking this is eventually our goal on the other side we must draw a line somewhere also from a timeresources point of view some midwives saw a limited role in engaging the social circle i think that it is the role of a midwife to get a picture of the smoking behavior of the social circle i dont think it is our role to mobilize the social circle in smoking cessation i find it hard to tell if that fits our role midwives stated that other healthcare professionals such as general practitioners and youth health care providers could play an important role in smoking cessation counselling to both partners and the extended social circle of pregnant women gps have a more equal treatment relationship with both the partner and the pregnant woman than a midwife i have a better relationship with the pregnant woman of course this makes the gp more suitable to provide smoking cessation counselling to the social circle than a midwife while midwives indicated that a gp could help pregnant women and her social circle with smoking cessation actively referring smokers to smoking cessation services is often not done in part due to a lack of knowledge for us it was a problem that we didnt have a guide of social services where we refer someone if we want to refer them pregnant woman and social circle what are the costs what is useful and what is not in general most midwives agree that they have to play some kind of role in smoking cessation counselling for the social circle albeit a very limited one as a midwife my initial focus is on my important task of taking care of the baby and the mother of course this the social circle is also included in this but still i find it more important to focus on the pregnant woman than on her social circle discussion the interview data shows that midwives acknowledged the importance of a pregnant womens social circle when it comes to smoking cessation however while they found it important the interviewed midwives noted that they dont commonly provide smoking cessation support to members in the social circle in the netherlands primary care midwives are required by the healthcare inspectorate to counsel pregnant women and their partners to quit or reduce smoking by using the vmis protocol 28 while partners are specifically mentioned in this protocol other members of pregnant womens social circle are not included absence of clear guidelines and protocols could influence the provision of effective smoking cessation advice to the pregnant womens social circle 41 the interviews showed that midwives were often ambivalent about their responsibility to provide smoking cessation support to a pregnant womans social circle this ambivalence may have influenced the midwives interactions with the social circle midwives encountered a variety of barriers when addressing smoking with members of a pregnant womans social circle one such barrier was the fear of jeopardizing their relationship with the pregnant woman when they discuss smoking with her social circle having a trusting relationship with pregnant women was seen as needed for addressing tobacco use and exposure previous studies found that midwives were concerned about adversely affecting the relationship they have with pregnant women by asking about smoking 1942 in addition the interviewed midwives found it challenging to discuss smoking cessation with members of the social circle as they felt less connected to them than to pregnant women research conducted in the netherlands on nurses working within a preventive care program for disadvantaged young women during and after pregnancy 43 found that the ability to build on a trusting relationship with pregnant women was seen as useful for discussing smoking as seen in our data and in the literature addressing smoking and discussing smoking cessation is affected by having and keeping a trusting relationship with the pregnant woman and her social circle midwives found it challenging to motivate partners to quit smoking when they had already taken steps to prevent exposing pregnant women to tobacco smoke a study by gage et al 44 found that partners of pregnant women would rather reduce their smoking or smoke outside than quit smoking completely our data collection showed that according to midwives pregnant women and their partners believed that smoking outside was a legitimate way to reduce the risk and harms from exposure to second and thirdhand smoke with complete smoking cessation by the partner seen as unnecessary some midwives in this study also believed that harm reduction mainly smoking outside is the highest attainable achievement a pregnant womens social circle could reach this may have influenced why and how midwives didnt discuss quitting smoking completely with partners however it is important that partners quit smoking completely because women are less likely to quit themselves if their partner smokes 45 and smoking outside does not completely prevent second and thirdhand smoke exposure 46 a study on the role of midwives and gynecologists in smoking cessation care of pregnant women in belgium found that healthcare professionals saw their role as limited to asking about smoking providing brief advice determining the readiness to quit and referring clients to specialized cessation counseling 41 the interviewed midwives in the current study also saw a role for other healthcare professionals especially gps in helping the social circle of pregnant women quit in the netherlands health insurance is compulsory in 2016 less than 02 of the population was uninsured 47 since 2020 health insurance covers one primary care smoking cessation program per year 48 referring to other healthcare professionals for smoking cessation counselling is part of the vmis protocol 27 however findings from the current study show that referring smokers for more intensive cessation counselling is often not done and referral options were not well known by midwives limitations this study has a few limitations birth care providers were selfselected which could indicate an interest in smoking cessation a more representative group of birth care providers may have different insights and experiences our study only took into account the perspectives of dutch birth care professionals in providing smoking cessation advice to the social circle future research should explore the views of the social circle in receiving smoking cessation from birth care providers conclusions this study provides insights in why midwives in the netherlands may be reluctant to actively provide smoking cessation advice to the social circle of pregnant women the interviews showed that midwives can be ambivalent about their responsibility to provide smoking cessation support to a pregnant womans social circle which may influence the interaction they have with the social circle in addition midwives may have barriers to discussing smoking cessation with the social circle of pregnant women such as a lack of a trusting relationship with the social circle concerns about raising the topic and giving unwanted advice on cessation to members of the social circle and a lack of opportunity to discuss smoking practical implications pregnancy can be a teachable moment for smoking cessation for members of pregnant womens social circle 23 24 25 partners of pregnant women can be engaged in smoking cessation efforts by advising them on the risks of secondhand smoke and on quitting smoking 8 to overcome barriers such as damaging their trusting relationship with pregnant women educational programs or new modules for existing program could be used to improve skills related to discussing smoking with the social circle of pregnant women 1937 clear guidelines and protocols on the role of birth care providers in providing smoking cessation support to the social circle could help midwives overcome ambivalence that they might have while midwives have a unique role in providing smoking cessation advice and support to pregnant women and members of pregnant womens social circle the smoking cessation advice support and care that they can provide is limited by time and opportunities to interact with the social circle and by their role and skills which may not be the best suited for intensive smoking cessation support for members of the social circle to that end it is crucial that midwives know where and how to refer smokers to other healthcare professionals for more intensive smoking cessation care 41 the development and implementation of care pathways in primary care midwifery practices could contribute to a better referral to other healthcare professionals 49 abbreviations additional file 1 interview guide for birth care providers additional file 2 coding scheme additional file 3 identification of themes authors contributions ew and ls were involved in the design of the study data collection and the analysis of the interviews jb was involved in the recruitment of the participants bjhw reviewed and revised the manuscript and contributed to the discussion section ls jb and mcw were involved in the revision of the manuscript all authors read and approved the final version of the manuscript competing interests the authors declare that they have 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 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background if smoking is common within a pregnant womans social circle she is more likely to smoke and her chances of succeeding in quitting smoking are reduced it is therefore important to encourage smoking cessation in a pregnant womans social circle midwives are ideally positioned to help pregnant women and members of their social circle quit smoking but there is currently little knowledge about if and how midwives approach smoking cessation with pregnant womens social circlesin 2017 and 2018 semistructured interviews were conducted with 14 birth care providers in the netherlands interviews were inductively coded data were analyzed thematicallyin the interviews midwives reported that they dont commonly provide smoking cessation support to members of pregnant womens social circles the respondents noted that they primarily focused on mothers and werent always convinced that advising the partners family and friends of pregnant women to quit smoking was their responsibility data from the interviews revealed that barriers to giving advice to the social circle included a lack of a trusting relationship with the social circle concerns about raising the topic and giving unwanted advice on cessation to members of the social circle and a lack of opportunity to discuss smokingmidwives in the netherlands were reluctant to actively provide smoking cessation advice to the social circle of pregnant women to overcome barriers to addressing cessation to the social circle educational programs or new modules for existing programs could be used to improve skills related to discussing smoking clear guidelines and protocols on the role of midwives in providing cessation support to the social circle could help midwives overcome ambivalence that they might have

background although centenarians still represent a small proportion of the total world population their number is projected to increase rapidly from approximately 441000 in 2013 to 34 million in 2050 and 201 million in 2100 1 the rise in the number of centenarians has attracted research interest all over the world particularly for the last two decades in which several centenarian studies have been conducted in europe following the examples of longterm centenarian studies conducted in the us and japan 2 collectively international studies have presented wideranging information about centenarians sociodemographic characteristics 3 longevity patterns from a psychosocial and health perspective 4 and need for and use of health care services 56 to name a few of the research focus areas in portugal although the number of centenarians has almost tripled over the last 10 years from 589 in 2001 7 to 1526 in 2011 8 and the first populationbased study has been recently established the pt100 oporto centenarian study 9 no largescale information has been made available on this age group particularly on their overall health status this study aims to present the main sociodemographic characteristics of portuguese centenarians based on data from last national census and to provide a first overview of their elementary health profile in terms of sensory functions functional status cognition and communication this set of questions has been developed by the washington group on disability statistics and is consistent with the international classification of functioning disability and health 10 sex differences are also investigated methods the present study is based on information provided by statistics portugal and collected within the framework of the 2011 census 1112 it considers information about people aged 100 years or more at the moment of census data collection gender marital status number of years of education completed income religion and selfreported disability which was assessed by a general question about having difficulties doing certain activities due to health problems or aging difficulty seeing even with glasses difficulty hearing even if using a hearing aid difficulty walking or climbing steps difficulty remembering or concentrating difficulty with selfcare such as washing all over or dressing difficulty communicating each of these questions had three response categories no difficulty or some difficulty a lot of difficulty cannot do it at all information about type of residence and geographical mobility was also collected an exploratory analysis was performed in order to characterize portuguese centenarians differences between men and women were examined using chisquare test or fishers exact test a significance level of α 005 was considered results in 2011 the number of centenarians in portugal mainland and madeira and azores islands was 1526 of which 1253 were females women outnumber men by a ratio of 46 the majority of the population was widowed followed by singles married and divorced as for educational level 940 centenarians were illiterate 436 had completed up to four years of school and 121 had completed between 6 and 9 years of school about half of them never attended school and only a small minority had higher education the great majority lived in private households and 29 lived in institutions most centenarians were born in the place they currently live monthly income came mostly from their own pension with a minority relying on their family as the main source of economic support the majority was catholic with regard to the centenarians sensory functions functional status cognition and communication most reported having great difficulties in seeing and hearing understanding othersbeing understood was the dimension with a higher percentage of individuals presenting nomild difficulties and walkingclimbing stairs was the dimension with a lower percentage on the other hand almost half of the 1526 centenarians mentioned being totally unable to take a bathdress by themselves vision and hearing were the dimensions with a lower percentage of total limitation with 140 and 136 centenarians respectively gender analysis is presented in table 1 with the exception of income source all other sociodemographic characteristics of centenarians vary according to gender marital status and gender were associated standing out a high percentage of married males compared to married females analyzing education level also associated with gender there was a higher percentage of illiterate females when compared to males in both sexes the majority of centenarians lived in the community however an association between sex and type of residence was also observed with a higher percentage of males living in the community although the 425 religious profile was similar for males and females sex and religion were associated with a slightly higher percentage of males without religion the comparison of sexes according to sensory functions functional status cognition and communication revealed statistically significant differences for all the dimensions under analysis overall females recurrently present greater difficulties in performing activities due to health problem or aging 105 could not see at all whereas only 29 of the males were in this situation being totally unable to hear was reported by 96 of the females and by only 59 of the males 411 of the females could not walkclimb stairs a situation reported by 212 of the males being unable to memorizeconcentrate was mentioned by 248 of females and only 88 of males half of females reported being totally unable to bathe dress by themselves whereas this happened in 311 of the male population in the communication dimension 201 and 73 of females and males respectively mentioned being totally unable to understand othersbeing understood when combined only 38 centenarians showed no capacity in all considered dimensions of these most were women on the contrary 91 centenarians were at the top level of functioning ie presented nomild difficulties in all considered dimensions concurrently most were females but within the group of male centenarians there were up to 29 discussion this is the first descriptive largescale health profile of portuguese centenarians ever conducted overall along with the expected constraints in sensory functions and the presence of great difficulties in basic daily living activities and cognition a significant proportion of centenarians was found to have nomild difficulty in understanding others and being understood although subjectively measured these healthrelated dimensions provide an important basic health profile with implications for service programming first it reveals that most centenarians do not generally present a positive outlook and may potentially be in a frail condition second it discloses the need to pay attention to this populations careprovision needs namely to the maintenance of their capacity to express their wills regardless of the reported sensory constraints and functional difficulties in being able to understand othersbeing understood the capacity of centenarians to express personal resolutions about their own lives according to personal rules and preferences must be acknowledged this is a crucial aspect of mental health in advanced ages considering that centenarians often present high prevalence of diseases and chronic conditions that put them at risk of experiencing limited or restricted participation in society being able to communicate with nomild difficulties ought to be of crucial importance and must therefore be incentivized by care providers particularly when difficulties in other domains may limit independent living or social integration if appropriate accommodations are not made in addition to centenarians care provision needs equal attention must be given to their living arrangements housing conditions and provision of informal care considering that the great majority of centenarians live in private households most probably with their immediate family having a deeper insight into the flows of care provision in multigenerational households is imperative encouraging and sustaining familyand communitybased care for the elderly is likely to be more costeffective than residential and nursing care placements and it is certainly a traditional scenario for portugal due to the strong tradition of familism that characterizes southern european countries 13 but it raises important questions on the circumstances in which the care is provided how to care for a very old relative while the caring family members themselves are in advanced age and how to organize affordable care and medical services that meet the needs of the very old and their families are just two of the currently recognized challenges within centenarian studies 14 that must be taken into account when further analyzing the health circumstances of this population as for the second goal of this paper identifying sex differences our findings are globally in line with previous studies suggesting that very old men are a minority and tend to present better outcomes than women females live longer but suffer a higher level of morbidity and this has been shown in several studies with the most elderly and particularly within centenarian studies from around the world for instance in a recent populationbased cohort study of centenarians using electronic health records conducted in the uk authors found that fewer men than women reached the age of 100 and that women had greater multiple morbidity than men as well as greater likelihood of having multiple geriatric syndromes 18 in portugal we found that centenarian women substantially outnumber men and present an overall worse health status but we also found that examining the data for women reveals a more vulnerable social condition significant differences were found for marital status educational level and living arrangements indicating that on these domains men present a more favorable situation these findings are easily understood within sociocultural and historical circumstances and can be framed within a gender lens that characterizes this cohorts life men and women differ in their life expectancy and health condition along life and considering the observed differences in the current cohort of centenarians genderspecific and gendersensitive approaches to the understanding of health care service needs in very advanced age is to be cautioned the feminization of aging is thought to have impact on health outcomes and services and several authors have argued for a greater focus on the unique needs of women a gendered approach to policy and intervention development and the promotion of health across the life span 19 it is our conviction that such focus ought to include the most elderly population particularly in the portuguese scenario there is strong evidence of inequity in health against women and also of the existence of a gender effect in health care use 20 on average portuguese women report a worse health condition than men a higher number of disability days and are more likely to suffer from longstanding illness the way these conditions link to their socioeconomic status and access to treatment in very old age deserves further attention following the trends observed in recent research with centenarians in the mediterranean that focus on both quantitative and qualitative measures in order to explore perspectives on longevity 21 the study of gender differences and its determinants and consequences should also be conveniently addressed in further studies with this population finally it is important to highlight a specific sociodemographic aspect of the obtained profile of portuguese centenariansthe percent of illiteracyvery low educational level regardless of the observed differences between men and women on this aspect most centenarians never attended school which is due to sociohistorical reasons bearing in mind further research with the portuguese most elderly population namely those grouped as near centenarians the use of complex assessment protocols is to be used with caution the analysis of the current study relied on a dataset limited to the information available for centenarians which did not allow for analysis on the trajectory of prevalence and the sex pattern of disability in the most elderly this is a weakness of this paper that would be important to overcome in future studies such analysis of disability separately for males and females should be done to place the analysis of centenarians health in perspective conclusions this study provides important information about the current sociodemographic profile of portuguese centenarians and describes their elementary subjective health profile as given by national census data the high proportion of centenarians presenting great difficulties in sensory domains basic daily living activities and to a lesser extent in cognitive and communication capacities reveal the need for more information regarding this populations specific care needs their current arrangements of both formal and informal care and how this may differ from those of younger cohorts of older people the washington group on disability statistics questions considered in the portuguese census were designed to provide comparable data crossnationally and outline a set of domains that were selected using the criteria of simplicity brevity universality and comparability 10 in being able to capture persons with similar problems across countries relevant further research will be to compare data on this population at an international level considering that the wg short set of questions has already been used in a few censuses another step will be to analyze the prevalence trajectory of difficulties by age nationally and crossnationally this would provide important information on the population at higher risk for limitations in the ability to fully participate in society due to functional limitations in core domains as for the fact that most portuguese centenarians are living in the community this finding brings attention to informal caregiving dynamics that might be present in multigenerational households finally the predominance of women among the centenarians and the observed sex differences reaffirm the importance of recognizing gender as a crosscutting determinant for personal healthy aging trajectories 22 differences in health outcomes by sex are common throughout the lifecourse but large populationbased studies reporting trends in incidence and the health of centenarians are still scarce and should be conducted due to their pivotal role for planning adequate care competing interests the authors declare that they have no competing interests

the number of centenarians is rapidly increasing in europe in portugal it has almost tripled over the last 10 years and constitutes one of the fastestgrowing segments of the population this paper aims to describe the health and sociodemographic characteristics of portuguese centenarians as given in the 2011 census and to identify sex differences methods all persons living in portugal mainland and madeira and azores islands aged 100 years old at the time of the 2011 census n 1526 were considered measures include sociodemographic characteristics and perceived difficulties in six functional domains of basic actions seeing hearing walking cognition selfcare and communication as assessed by the portuguese census official questionnaires results most centenarians are women 821 widowed 82 never attended school 51 and live in private households 71 the majority show major constraints in seeing 674 hearing 723 and particularly in their mobility 837 cannothave great difficulties in walkingclimbing stairs and 807 in bathingdressing in general a better outcome was found for reported memoryconcentration and understanding with 391 and 425 presenting no or mild difficulty respectively toplevel functioning nomild difficulties in all dimensions concurrently was observed in a minority of cases 596 women outnumber men by a ratio of 46 and statistically significant differences were found between men and women for all healthrelated variables with women presenting a higher percentage of difficulties conclusion portuguese centenarians experience great difficulties in sensory domains and basic daily living activities and to a lesser extent in cognition and communication the obtained profile though selfreported is important in considering the potential of social and family participation of this population regardless of their functional and sensory limitations based on the observed differences between men and women genderspecific and gendersensitive interventions are recommended in order to acknowledge womens worse overall condition

introduction in december 2019 the world saw the first case of covid19 in wuhan a city of hubei province china and the who declared a pandemic on march 11 2020 1 the symptoms of this novel and rapidly spreading disease were largely unknown but were shown to impact physical mental and cognitive health 2 the pandemic had caused enormous disruption to human life and the world economy presenting an extraordinary challenge to global health 3 with the rise in the number of cases and covid19related deaths vaccine development was accelerated and several pharmaceutical companies began largescale clinical trials to test new vaccines including those that were in the early stages of development 3 there was a rapid development of vaccines to tackle the sarscov2 virus particularly by biotech moderna and johnson johnson 3 in india three vaccines covishield developed by the serum institute of india covaxin developed by bharat biotech and sputnik v developed by the gameleya research institute of epidemiology and microbiology also gained approval from the central drugs standard control organisation 4 the covid19 outbreak in india began in thrissur kerala after a few students returned from wuhan china 5 the first wave of the covid19 pandemic in india began in march 2020 with thousands of daily infections but by february 2021 the curve of covid19 cases had flattened however the spiralling cases during the second wave of the pandemic in march 2021 led to devastating conditions of an overworked health care system a limited supply of hospital beds oxygen medications ventilators and rapidly increasing mortality rates 6 india saw the worst of the pandemic during this period as a result of the high infection rate of the new mutants of the sarscov2 virus especially the doublemutant strain of the alpha and delta variant 7 the phenomenal speed of infection and the rise in reproduction number during the second wave of the pandemic can be attributed to the confluence of numerous factors lack of preparedness of the health care system noncompliance with socialdistancing norms increased testing political elections poorly implemented precautions during festivals and weddings sporting events and largescale religious gatherings like the haridwar kumbh mela and the tablighi jamaat 689 the indian health care system cracked under pressure and was unable to keep up with the volume of covid19 cases 10 during this time india was recording more than 400000 daily infections and the highest number of deaths over 4000 in a single day 10 this was indias worst battle against the virus as graveyards ran out of space roundtheclock mass cremations were conducted and hospitals turned away patients due to the lack of beds and medical supplies 10 as per the indian constitution health care is the responsibility of the individual states and not the central government 11 the national health care organization the union ministry of health family welfare is the organization responsible for any nationallevel health care programs and health policy and planning 11 despite the continued efforts of the state governments to control the spread of covid19 their health care system was crippled under pressure and required leadership from the central government 9 in this situation the constitutional limits were crossed and the central government stepped in to take charge of the situation 9 owing to indias population density differences in health literacy and administrative barriers vaccinating the entire population was going to be a massive undertaking 11 the vaccination drive in india began on january 16 2020 4 the central government also launched a mobile application called cowin for selfregistration of vaccination slots along with monitoring and surveillance of the number of doses administered 4 in india a certain level of vaccine hesitancy was expected with the novel coronavirus disease 4 several challenges to achieve high vaccination rates had already sprung up and undermined efforts to control the pandemic 4 a limited number of vaccine slots on the cowin app vaccine shortage and cost of vaccines had posed challenges in the early phases of the vaccine drive 4 initially they were not offered free of charge and the price of the vaccine steadily increased and varied from one hospital to another 12 furthermore barriers to registering on the government website which was initially available only in english intensified inequalities deepening the technological divide in the country 13 however the government has modified the program by waiving preregistration on the portal and making vaccines free for all 4 affordability availability and access to vaccines due to the severe demand and supply mismatch were major concerns 4 despite the extensive measures to provide information about the precautions and vaccination plans through telecommunication platforms the rampant spread of covid19 misinformation has been posing major threats to vaccine uptake 14 for example myths about vaccines causing infertility and disrupting the menstrual cycle consuming alcohol to treat covid19 previous bacillus calmetteguérin immunization as an effective measure to prevent covid19 infection and a previous infection of malaria making a person immune to covid19 have been leading to vaccine hesitancy especially in rural areas 4 misleading information spread in hindu and muslim communities relating to the vaccines containing pork and aborted fetal tissue also proved detrimental to the vaccine drive 14 the existing literature does a fair job of assessing the concerns about the covid19 vaccine including in india 1516 but there is a paucity of research on the perceptions regarding covid19 vaccinations among middleaged and older adults in india a narrative review by troiano et al looked at vaccine hesitancy in students and the general population in india 17 additionally a study by umakanthan et al also documented the results of a national survey demonstrating the importance of vaccination coverage within the country 18 however none of the studies focused on middleaged and older adults in india in many indian families the elders in the family are the primary decisionmakers that influence overall behaviours and practices 19 due to these cultural beliefs and the importance of elders in the family it is fundamental to understand the vaccination perceptions of this age group since they are largely responsible for healthrelated decisionmaking in the family the goal of this paper is to address this gap and examine what are the major factors that affect covid19 vaccine hesitancy in middleaged and older adults in india drawing on a small convenience sample of middle age and older adults residing in india this paper aims to offer initial insights about attitudes towards vaccinations and covid19 vaccines in this population group materials and methods this exploratory pilot study utilized a sequential mixedmethods design where online quantitative surveys were followed by qualitative individual interviews after receiving ethics clearance from an invitation for an online anonymous survey was distributed to a small sample of people utilizing convenience sampling whatsapp social media platform was used to recruit participants the recruitment message contained a link to the online survey data collection and analysis quantitative online survey the survey containing 34 items on vaccine hesitancy was distributed in september 2021 when the delta strain initiated the second wave of the pandemic in india survey development was based on a validated scale from a study by wong et al 20 and the questions were modified to be compatible with the context of the covid19 pandemic in india the questionnaire consisted of several sections that covered demographics vaccine acceptability perceived severity susceptibility benefits barriers level of trust in the government and individual behaviour to assess their level of agreement concern severity and likelihood with respect to covid19 the variables were measured on a 5point likert scale for example to assess the level of concern participants were asked how concerned are you about the following with the following subquestions the survey was housed on the qualtrics platform and opened up with information about the study participants consented to the survey by clicking the i agree button to indicate their willingness to participate at the end of the survey the participants were asked if they would be willing to be contacted for the oneonone interview and those who consented were prompted to provide their email addresses for future contact through the anonymous online survey the quantitative data collected on qualtrics was exported to excel where descriptive analysis and summary statistics were used for data analysis descriptive statistics were used to highlight any relationships and patterns between the data obtained using histograms and pie charts 21 the data were organized and coded by converting the responses into a numeric format to extract themes and correlations qualitative oneonone interview for phase two of the study 10 oneonone interviews were conducted with individuals who agreed to be contacted for a followup interview these interviews were conducted during the third wave of the pandemic in february and march 2022 when the omicron strain was prominent questions were openended and included short demographic probes about age gender family composition and decisionmaking powers as well as more indepth questions about participants overall response to the covid19 pandemic as well as about their perceptions about covid19 vaccines safety and efficacy post transcription and removal of identifiers from the openended interviews a thematic analysis framework was used to analyze qualitative or textual data to generate codes and identify themes 22 braun and clarkes sixstep repetitious method was utilized for coding and generating themes to interpret and report the findings 22 this involved familiarization with the data initial coding from related comments generating preliminary thematic groups reviewing themes final data analysis once quantitative and qualitative data analyses were completed a convergent parallel design was utilized for the final interpretation this concurrent methodology enabled the independent collection of diverse yet complementary data during a similar timeframe and helped merge the results to obtain a comprehensive evaluation 23 the themes and patterns identified during quantitative and qualitative data analysis were used for a sidebyside comparison jointly displaying both forms of data 23 for this purpose tables and figures were used to summarize the findings and concisely present them by the major themes identified figure 1 demonstrates the steps involved in the data collection and analysis process figure 1 steps involved in data collection and data analysis respondent profile a total of 65 people participated in the survey six responses were discarded because the surveys were incomplete or the age criteria were not met thus the final number of responses for the survey was 59 table 2 summarizes the demographic profile of the survey respondents the average age of the participants was 53 years among the participants 61 selfidentified as women and 39 as men in this participant group 67 of them held an undergraduate degree most of the respondents were married and lived with foursix people in their households table 2 sociodemographic profile of survey participants at the time they completed the survey 80 of the participants had received a vaccine for covid19 and most of them had received both doses of the people who got the vaccine 24 waited for others to get the vaccine before scheduling a shot results from the quantitative survey also showed that women were more likely to receive the covid19 vaccines when compared to men as seen in figure 2 figure 2 proportion of men and women who received and did not receive a vaccine for covid19 results after analyzing the quantitative and qualitative data collected three key themes were identified during the analysis perceptions about covid19 disease and covid19 vaccine in india as seen in table 3 more than half of the respondents strongly and somewhat agreed that their friends and family were at risk of getting covid19 and most believed that they were at risk of contracting covid19 evidently while participant 6 like many others was unsure about the impact of new variants he still perceived the government policies to be good for fighting covid19 however not all participants trusted the government or saw covid19 as a real threat some like participant 8 a 45yearold woman had a different perspective i have not been scared at all we have to live this way there is nothing to fear its its like the flu its like a common cold it comes and goes away there is no reason to be scared my daughter works in a lab but im not worried because we all are very healthy and we eat very good food so there is no reason to be scared during the pandemic i think the best way to avoid covid19 is by taking homeopathic medicines im drinking warm haldi milk and chyawanprash every single day you see here these antiseptics will cure everything and they will make your body stronger just rely on home remedies and focus on eating well comparing covid19 to a common cold participant 8 normalized the disease presenting it as insignificant and not particularly scary this can be attributed to the period in which the interviews were conducted where india saw the emergence of the highly transmissible but less deadly omicron variant which led to fewer hospitalizations despite the rising number of infections the participant also referred to the use of alternative medicine to prevent the onset of covid a conviction that made her not fearful of contracting covid when the concerns about covid were minimized it also affected individuals decisions to get a vaccine for instance participant 9 a 45yearold man discussed the shift towards working from home and having less contact with people as a primary reason for not getting the vaccine he said i really dont think i need it because i have been working from home since the start of the pandemic i havent really been going out so i cannot get infected we get our groceries online we get food delivered we get clothes online we dont attend weddings or any functions close to half of the respondents strongly and somewhat disagreed that the covid19 vaccine will protect them from getting and spreading the infection as seen in table 5 below however a large group ie 80 also strongly and somewhat believed that taking the vaccine can decrease the severity of illness and the chances of complications during a covid19 infection additionally a majority of the participants also strongly and somewhat agreed that the covid19 vaccine will provide their family members with protection against the virus table 5 perception of covid19 vaccines in the interviews some participants expressed their belief that vaccines help to reduce the severity of covid19 symptoms suggesting that with vaccines people are having milder infections and are not getting hospitalized as seen in the second wave while the survey results suggested that participants considered themselves and their families at risk for covid19 infection results from the interviews showed complexity in the perceptions regarding the disease the low levels of perceived risk and a decline in trust in the government seemed to be important drivers for lower acceptance of the covid19 vaccines the shift to working from home especially during lockdowns also led to dismissing the pandemic as mild which in turn altered the perceived risk of getting the disease safety efficacy and availability of covid19 vaccines in the survey participants were also asked whether they thought that getting the covid19 vaccine was the best way to avoid complications postinfection and as seen in table 6 the majority of the participants agreed with this statement indicating their trust in the covid19 vaccines to minimize hospitalizations and prevent future complications table 6 level of agreement about postcovid19 infection complications the interviews however showed the nuances in the level of trust in the covid19 vaccines while most participants believed that the vaccines were effective in protecting against severe illness they also pointed out that the covid19 vaccine did not offer complete protection against infection and reinfection with newer variants of the virus participants were also concerned about transmitting the virus to family and friends even after getting two shots of the vaccine several participants also raised concerns about covid19 vaccines effectiveness referring to some of the information on their ingredients delivery and safety as seen in the quotes below participant 7 a 70yearold man for instance was questioning the effectiveness of the vaccine and was also concerned about the vaccine changing fertility patterns and causing more harm than good he said a lot of people say that there are several side effects of the vaccine some people say that you cannot have a child if you get the vaccine… like you get infertile some people say that you will get a heart attack if you take the vaccine some people say that there will be blood clots with the vaccine and you could even die so this should be a personal choice and not forced i dont want it his fear of serious adverse side effects led to the downright rejection of the covid19 vaccine an important event that got a lot of media attention was the death of a wellknown tamil actor vivekh just two days after taking the covid19 vaccine during the second wave of the pandemic participant 5 a 50yearoldwoman highlighted this important event noting that many people were afraid to take the vaccine after this and thought that it had to do with the government vaccines after vivekhs death the increased fear of death among the people led to a change in public attitudes regarding vaccines this was reiterated by participant 6 who discussed how rumors and misinformation around the indian covid19 vaccines affected peoples intent to get vaccinated he said there are rumours and the word is floating around that covishield and covaxin vaccines will give you a lot of side effects and the rumours about the vaccine being not correct or not good or being harmful and stuff like that so that plays havoc in the minds of people people who are gullible or people who dont have their own mindset it really you know gives them a lot of trauma and that they do it for their own political or political or their personal gains so that is rampant here displaying concern around misinformation he suggested that false information for political or personal gains affected vaccine uptake similarly this issue regarding the lack of transparency was also seen in participant 10 a 51yearoldwoman who said yeah i dont trust the government ive heard cases where they are substituting water substituting the vaccine with water or even giving saline solution instead of the vaccine some places ive heard that they are just injecting air i feel like the government does not give a lot of attention to villages in small towns it is only focused on big cities so i dont trust the government very much calling attention to the vulnerabilities of the rural population she condemned the governments response to covid19 vaccinations highlighting the issues faced by the neglected rural areas when compared to larger metropolitan cities this was also intensified by the inconsistencies in the governments pricing structure for covid19 vaccines participant 3 a 54yearoldwomen said some places they were charging rs 500 rs 600 and some places they were charging rs 1500 due to this some people were substituting it with water for money they were incentivizing people to pay more to get the vaccine faster and can save their families now it is free so it is proper there is no reason for the government to give fake vaccines trust has increased free vaccination has helped everyone trust the government while most participants believed in vaccines some felt that they were not effective by suggesting that todays situation if we see we are not happy about vaccination that even after taking two doses people are getting infected for the second and third time demonstrating uncertainty in the effectiveness of the vaccines this was confirmed by the survey results where the majority of the participants were concerned about the effectiveness and the safety of the vaccine although only 12 expressed extreme concern about the ingredients of the vaccine to further understand the challenges faced with covid19 vaccinations the survey asked questions regarding individuals experiences with the cowin application to book slots for vaccine shots and table 7 level of agreement about vaccine drive several other concerns were also raised around the covid19 vaccines during the surveys table 8 displays the responses of the participants on a likert scale where the 10 statements captured their concerns surrounding covid19 vaccines overall the primary barriers that came up were the chances of reinfection as well as unclear and insufficient information regarding the vaccines a majority of the participants strongly agreed that they needed the vaccine despite previous covid19 infection and did not have religious reasons to question the vaccine fear of needles was also not found to be a major reason for concern for most of the participants table 8 level of concern regarding the covid19 vaccine as seen in table 9 an additional concern was related to the lack of covid19 information however 3559 of the participants reported that they were not at all concerned about vaccine availability the participants who reported their concern about the lack of covid19 information relied on social media and their social circle as their most common source of information about the pandemic additionally only 2203 reported their reliance on public health websites for their information survey results suggested that the majority of respondents displayed trust in the government to control the covid19 pandemic deliver timely care during the pandemic and seemed to be supportive of their measures to control the virulent spread however participants reported challenges with the cowin application to book vaccine slots and a lack of covid19 information overall the comments from the interviews seemed to indicate that the participants had several concerns with the government and the health care system concerns regarding reinfection safety and efficacy of the vaccines were prominent however the shift from charging vaccines to making them free nationwide seemed to have a positive impression on the participants in this study public health promotion and education when asked about the strategies to further promote the vaccine interview participants offered several approaches to strengthen the current vaccine drive participant 6 with a focus on using media to spread the message suggested increasing health promotion activities to improve awareness of covid19 vaccination he said i was saying youve got to educate people youve got to instil confidence in them that this is not a bad thing this is not going to harm them in any way you do it through by way of advertisements or by way of word of mouth you know educating through mass media through papers through newspapers through electronic media through the internet or whichever way but the message has to be reached to the people that this is good and that maybe somebody would be doing but all this you know maybe ask a bollywood person or hollywood personalities to post on instagram if they get into this mode of promoting the vaccine it should definitely help focusing on further publicizing the vaccines safety and benefits as a public health intervention is especially important for educating those who might be living in rural and remote areas as was noted by participant 4 who said mouth to mouthmobilewhatsapp forwards in villages education is important if there is a gathering of people you should let everyone know that vaccine is important or we can even do doortodoor as we did during polio but that is very laborious doortodoor could be a potential strategy when they go they can educate the people at their homes and give the vaccine there itself keeping in mind the enormous size of the indian population participant 4 suggested that medical teams go doortodoor especially in rural areas due to the technological divide to ensure that everyone has received the covid19 vaccine moreover to focus on the use of vernacular language for health education participant 3 said education is the most important telling them about the results and showing them statistics will help people understand that they are good telling people in the local language is also important so they trust the information more the stats will show them that people are not dying with the shot and improve immunity regionspecific transparent messaging in rural areas could help motivate people to get the covid19 vaccine suggesting that if paid close attention to the needs of rural india vaccine messaging could be more effective and impactful similarly with a focus on education and building awareness for covid19 vaccines participant 9 highlighted the importance of targeting educational campaigns for people living in economically weaker areas specifically the largest slum in asia dharavi he stresses the importance of educating this traditionally excluded group to improve health literacy when he said if you look at dharavi in mumbai the largest slum there is so much superstition and ignorance in those areas its such a big slum area and there has to be more awareness at least for the people who are not educated many people think that the vaccine kills people i do not think it kills people but i think they are very scared of the side effects i feel like theres a lot of ignorance i do not think that vaccines will 1000 protect you from the disease but if people do want to take it then they should look at the pros and cons he also brought up an important issue about dailywage workers and how they are left out of the vaccination programme due to insufficient support available to help them deal with any potential side effects he said why it should be mandatory also you have to think about slums and poor people and daily wage workers there are so many here in india you cannot make it mandatory because if they do fall sick after getting the vaccine then the government should pay for their daily wages they should not be losing out on their days meal just because theyve gotten the vaccine there has to be some provision for people to take the vaccine and then if they are not well then they should be taken care of overall results from the survey and interviews suggested the use of multipronged strategies for targeted public health messaging to promote covid19 vaccine uptake inclusive educational tools especially for the most vulnerable and marginalized need to be employed participants suggested that targeting these groups of people is critical to combating misinformation and ignorance regarding the pandemic to support their wellbeing additionally the specific focus needs to be given to economically weaker areas to instil trust in the covid19 vaccines and promote their uptake discussion the goal of this study was to identify the factors that affect covid19 vaccine hesitancy identify barriers that affect vaccination attitudes and understand how to improve vaccine uptake overall more participants displayed provaccine attitudes than antivaccine attitudes the main reasons for expressing vaccine hesitancy included uncertainty and concerns regarding the effectiveness of the vaccine fear of side effects unclear and insufficient information about the vaccines insufficient financial support postvaccination for daily wage workers altered risk perception and the reliance on home remedies for protection against the virus in contrast to the western counties a higher level of public trust and confidence in the modi government in this participant sample certainly helped india in its fight against the covid19 pandemic 24 while a study conducted in the united kingdom suggested that people were concerned about the ingredients of the covid19 vaccines 25 this study with older adults shows that these concerns were not important in the indian context the tide of vaccinerelated misinformation is a critical barrier that needs to be addressed to increase vaccine uptake in india especially for middleaged and older adults 4 false and misleading claims about the covid19 vaccine being dangerous and harmful have cast doubt preventing people from getting vaccinated 4 during the interviews several rumours about vaccines leading to infertility blood clots disruption of menstrual cycles the risk for pregnant women and the fear of death emerged as some of the key reasons for vaccine refusal and vaccinehesitant attitudes speculations about side effects combined with perceived lower severity of the virus were shown to reduce trust in the covid19 vaccines notably the primary source of information for the majority of the participants was social media platforms like whatsapp facebook instagram and twitter this is important as the participants in this study were older adults who are often assumed to have low literacy levels when it comes to digital technology studies reveal that people who rely on social media for news are more likely to have misconceptions about the covid19 vaccine 26 this study confirms this finding but also shows that older adults in india might also be exposed to messages on social media and be influenced by misinformation among the interview participants three out of four people who displayed vaccinehesitant attitudes lived in rural communities concerns about infertility blood clots breast cancer heart attacks and the reliance on ayurveda and homeopathic treatment were common among this group there is a rising inequity for covid19 vaccinations between urban and rural india with unequal access to vaccines along with the differences in vaccine procurement and allocation policy between the state and central governments 27 the liberalized vaccine policy has enabled people with access to the internet to book vaccination slots but excluded those without access from getting vaccinated this is an important consideration for middleaged and older adults who may not be technologically literate to access online services this study shows that in addition to the challenges with physical access to the vaccine rural residents might also have less access to reliable information about the vaccine a challenge that can be addressed only with an increase in educational campaigns targeting this specific demographic group an important finding of this study was that greater vaccinehesitant attitudes were found in men when compared to women this is not consistent with findings in the literature where women were found to be more vaccinehesitant than men 28 29 however this can be attributed to the findings from other studies that reported that women were more adherent to medical recommendations and are more cautious about their health 30 this positive trend is likely to benefit the indian population as women are more commonly the caretakers at home and having provaccine attitudes can potentially benefit their families however given that the participants in this study had higher educational qualifications and greater awareness about health when compared to the overall population in india this finding should be interpreted with caution the perceptions about covid19 in india have changed since the second wave of the pandemic in 2021 the delta variant led to millions of hospitalizations and deaths and left several people without medical treatment 4 the omicron variant which became the predominant stain afterwards was relatively mild and thus caused fewer hospitalizations and deaths the interviews for this study were conducted during the third wave of the covid19 pandemic when a large number of adults were already doublevaccinated and some had even received their third shot of the vaccine findings from the study show that although there were some individuals who challenged the efficacy of covid19 vaccines the majority still agreed that they were effective enough to reduce complications postinfection the participants also provided interesting insights on increasing covid19 vaccine uptake doortodoor and mass information campaigns were offered as useful strategies to promote vaccines and stop the spread of misinformation specifically the harghardastak campaign for doortodoor vaccination needs to become more widespread and according to the participants might have the most positive impact in rural areas it would also help to offer some targeted messaging regarding covid19 vaccines misinformation such as the fears of disruption of menstrual cycles and breast cancer in women and infertility in men by relying on the voices of celebrities and famous personalities that evoke a high level of trust in population moreover there is a need to establish support for dailywage earners and migrant workers who might be reluctant to get a vaccine because of a temporary inability to work postvaccination holding support camps for these groups is essential for maximum vaccination coverage this study has several limitations first given the pilot nature of this study and the use of a small convenience sample the findings presented here cannot be generalized to the larger population of india another limitation embedded in the research design was the timing of data collection for logistic reasons the survey was conducted during the time india struggled with a more deadly delta variant whereas the interviews were conducted during the spread of the omicron variant the timing of the survey and the interview could have impacted the responses provided by the participants and their attitudes towards vaccinations finally since the survey was offered on the whatsapp platform it was not accessible to those individuals who may have had limited access to the internet notwithstanding these limitations this study offered some interesting insights about the views on covid19 among middleaged and older adults in india which can be utilized to develop a largerscale studies to learn more about vaccine attitudes in this demographic overall this exploratory pilot study identified key drivers for vaccine acceptance which included the perceived health benefits of the covid19 vaccine offering it free of charge maintaining trust in the government and health care system and facilitating access to reliable information regarding the covid19 vaccination this study also offered some insights on how to address the gap in the knowledge about covid19 vaccines among older adults in india which hopefully can impact the decisionmaking of their families conclusions covid19 vaccines are an important public health intervention in the fight against the pandemic the findings of this study suggest that the majority of older adults who took part in this pilot study are vaccinated against covid19 andor have positive attitudes towards covid19 vaccines however vaccine hesitancy is still a concern especially among those residing in rural and remote areas it is important to note that the contributions from this paper are only applicable to the sample in this study and more research is required to understand the diverse perceptions of middleaged and older adults in india findings from this sample showed that improved health communication including nondigitalized information about covid19 vaccines can improve the uptake of vaccines focusing on middleaged and older adults is critical for ensuring that the health promotion messages are an effective way of reaching out to families and reducing vaccinehesitancy attitudes among this population additional information disclosures human subjects consent was obtained or waived by all participants in this study university of waterloo research ethics committee issued approval ore 43498 animal subjects all authors have confirmed that this study did not involve animal subjects or tissue conflicts of interest in compliance with the icmje uniform disclosure form all authors declare the following paymentservices info all authors have declared that no financial support was received from any organization for the submitted work financial relationships all authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work other relationships all authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work

introduction vaccine hesitancy is a significant threat to public health efforts to stop the negative impacts of the covid19 pandemic in india it is critical to attain high vaccination rates to prevent overload in the healthcare system older adults play a central role in families decisionmaking but there is a lack of research on middleaged and older adults vaccine perceptions in india in general and about their concerns about covid19 vaccinations research question this study aimed to explore which factors affect covid19 vaccine hesitancy in middleaged and older adults in india and what factors can reduce their vaccine hesitancy and increase its uptake materials and methods a mixedmethod sequential design was employed to conduct the study convenience sampling was used to recruit participants by sending an online invitation for phase one of the study a quantitative survey with 34 questions was distributed through whatsapp for phase two of the study qualitative oneonone interviews were conducted with those participants who completed the survey and agreed to participate in this next phase results in total 65 individuals responded to the online survey and 10 participated in semistructured interviews the participants were residing in india and their age range was from 40 to 89 years analysis of the data identified that although the majority of participants supported the vaccine the main reasons for vaccine hesitancy included uncertainty about the effectiveness of the vaccine fear of side effects unclear and insufficient information about the vaccines and altered risk perception this study also showed that those who felt that the consequences of covid19 were mild were also more likely to be vaccinehesitantwhile the results of the study showed that most of the participants supported the covid19 vaccines they expressed uncertainty regarding their effectiveness the safety and effectiveness of the vaccines were found to be prime contributing factors to vaccine hesitancy in this sample the findings from this pilot study can be used to develop a larger more comprehensive study on vaccine hesitancy among middleaged and older adults in india which would provide more insights into strategies that can be employed to promote vaccinations

background australia has a workforce shortage of general practitioners particularly in rural and regional areas 12 this phenomenon is reflected globally in countries including england canada usa india israel and south africa 3 4 5 6 7 8 as gps are responsible for providing primary care services 9 any deficit in their numbers has a significant potential impact on access to basic medical services and followup care 10 in areas of workforce shortages gps are required to work longer hours often on their own or in a small practice and at the extremes of their scope of practice 11 one of the most commonly noted issues for rural and regional doctors is the difficulty in accessing locum support that is timely affordable or of an adequate quality 11 additionally access to continuing professional development including procedural upskilling or specialising can be also difficult to obtain in areas outside major towns and cities 11 this is a barrier to sustained interest and challenge for gps and can together with issues of unsustainable work demands lead to burnout and early retirement 12 a further issue is the ageing of the existing gp workforce approximately 30 of the gp population in nsw is aged over 55 years and approximately 25 australiawide 13 with the average age being 53 years 14 not only are rural and regional gps on average older than their urban counterparts as a population they also retire at a younger age 12 increasing workforce supply is inherently a multifactorial challenge necessarily entailing both increased recruitment and training of new gps of which experienced gps are an integral part as well as strategies aimed at minimising early retirement from general practice it is an important aspect to keep experienced gps in practice in order to continue to provide healthcare to rural communities as well as to facilitate the training of future generations of doctors gp recruitment migration and retention in rural and regional areas are important national matters if shortages are to be addressed 15 this should necessarily involve the identification of appropriate and effective incentives as well as strategic efforts directed at addressing barriers and facilitators identified through consultation with gps the work ability model has historically been used to explain and explore retirement and longterm employability the wa model was developed in the 1980s at the finnish institute of occupational health as an instrument to predict retirement age by analysing the interactions of various factors that affect work ability 16 the model encompasses the resources of the individual the external factors related to their work the environment outside of their work and how these factors relate to an individuals workability the model has been visually depicted as a house with four interconnected floors and a surrounding environment to illustrate the interactions of all of these elements the work ability concept blends well with the sustainability movement people organisations and governments are increasingly aware that employment goes beyond having a job at one point in time but rather that we need to think about sustainable employment 17 van der klink and colleagues have defined se as follows sustainable employability means that throughout their working lives workers can achieve tangible opportunities in the form of a set of capabilities they also enjoy the necessary conditions that allow them to make a valuable contribution through their work now and in the future while safeguarding their health and welfare this requires on the one hand a work context that facilitates this for them and on the other the attitude and motivation to exploit these opportunities 18 while the capability approach is not synonymous with workability it is important to note the definition here to place the se concept into a wider context while the wa model has historically been used to explain and explore retirement and longterm employability this may not be the same as sustainable employability the international standards organisation has recently released a guideline on sustainable employability for organisations 19 in this guideline se for the individual is defined as the longterm capability to acquire create and maintain employment through adaptation to changing employment economic and personal conditions throughout different life stages workability can be seen as an element of sustainable employability at one point in time and can also be used as a proxy measure to measure sustainable employability 20 in a recent study amongst 49 content experts 97 of participants agreed that workability can be used as a proxy measure to measure sustainable employability 20 based on the above we propose the following definition of sustainable employability in order for it to be more measurable in practice sustainable employability refers to a persons ability to gain or maintain quality work throughout their working lives while having the motivation to conduct quality work maintaining good health and wellbeing and having the opportunity and the right work context cocreating value on personal organisational and community level being able to transfer skills knowledge and competencies to another job company or other future roles the wa model does not necessarily have a future component in the model itself but it may lend itself to categorising and exploring factors influencing sustainable employability demonstrating this in the case of general practice it can help us explore how gps can recycle current knowledge skills and abilities for use in future roles such as teaching or gp advocacy work it can also help us understand how gps maintain a worklife balance to sustain a busy demanding career in general practice more evidence is needed to demonstrate the effectiveness of se interventions for ageing workers 2122 the purpose of this study was to ascertain whether the wa model can provide a useful explanatory framework to understand sustainable employability amongst gps methods the current investigation is based on a qualitative analysis of data that was previously collected as part of a larger mixedmethod study described in further detail elsewhere 11 participants were recruited via the northern rivers general practice network which is a local body representing gps in the region the region is a coastal area comprising the far northeast corner of the state the region depends economically mainly on tourism with a large number of small towns and comprises localities classified as small regional to medium large regional according to the modified monash index 23 gps received a study package from the nrgpn containing a covering letter from the nrgpn a participant information sheet consent form a replypaid envelope and an anonymous quantitative survey about early retirement healthy lifestyle occupational health and workrelated factors 10 all eligible participants received two reminders 2 and 4 weeks after the initial invitation gps who returned a completed consent form for participation in the interview component were contacted to arrange a time and a preferred venue for the interview consenting gps who were unable to participate in a facetoface interview were interviewed by phone two interviews were conducted by an occupational health physician while the remainder of the semistructured interviews were conducted by author sp who is an experienced academic researcher who was personally known to some of the participants due to her familiarity with the medical professional networks in this geographical area there were no other people present at the interviews interviews lasted approximately 60 min and were mainly undertaken in general practice clinics a few gps preferred the interviews to be conducted at a café their own home phone or a university location the semistructured interview schedule was developed by the authors and pilot tested with two gps specifically the questions were asked to explore gps perceptions of the factors which hinder and encourage healthy workforce participation reasons for choosing to work or not until and beyond traditional retirement age and to explore current retirement pathways amongst gps the interviewer showed and briefly explained the wa model to the participants at the beginning of the interview interviews were audiotaped and transcribed verbatim and identifying information was removed data analysis nvivo 10 was utilised to assist with the organisational aspects of the data analysis a hybrid deductiveinductive thematic analysis approach was used similar to that described by fereday and muircochrane 24 initially two authors independently coded three transcripts and developed a draft coding hierarchy this was both deductively derived from the wa model 25 as well as inductively generated based on categories arising from in vivo coding discrepancies were discussed and the revised coding structure was applied during a first cycle coding of the full data set this structure was further discussed refined and expanded by all the authors throughout the coding fig 1 work ability model 17 process allowing the development of a final coding scheme which was applied the data set during a second cycle coding a thematic map was developed based on the coded data with the wa model as the organising framework the alignment with this and the identification of aspects which were not explained within this model were discussed amongst the authors and formed the development of a revised model thematic narratives were generated results of the 19 gps participating 14 were male the average age was 57 years all participants were actively engaged in gprelated employment two were in solo practice the analyses supported the general applicability of the wa model in understanding se amongst gps in finding that all the elements of the original model were strongly represented in the data themes aligned with the model and embodied the fluid and dynamic relationships between the various model components from a general practice perspective however in order to provide a more comprehensive reflection on the factors and dynamics found to underpin work ability in this group of gps a modification of the wa model was required which entailed the creation of additional subcategories within the model additionally new themes relevant to general practice also emerged from the data which were not reflected in the original model hence the current data set revealed a set of important new factors and relationships that required additions and refinements to the original model in order to fully explain sustainable employability in this gp sample these factors included worklife balance and lifestyle which both were found to connect to the external and internal environments the addition of an extended social community to reflect the influence of the wider community within which a gp resides and the impact of gender worklife balance and lifestyle a desire for worklife balance or to pursue a particular lifestyle was a significant influence on where many gps chose to reside and work intrinsically linked to this theme was family these themes were dynamically interactive and uniquely functioned as a connection between the external environment and the interior of the wa house and all of its floors personality and personal characteristics determined the gps desire to pursue a particular lifestyle and the ability to work in a particular manner drove their education and upskilling a balance between lifestyle and work meant improved physical and mental health and consequently improved their attitude to work and the perception of intrinsic benefits such as personal fulfilment the influence of lifestyle and worklife balance also affected workload …weve tried to make the job fit the lifestyle rather than the other way round distance and travelling gps identified that pursuing the lifestyle or worklife balance they desired had a significant impact on the time they were required to spend travelling to work education or social events gps described living close to schools for families near the beach on a farm or in a different town to maintain anonymity which often lead to increased distance and consequent time spent travelling when i stopped working at a clinic it was because i was spending two hours driving there as with the theme of worklife balance this subtheme interweaved all of the floors of the wa house as too much travel was found to negatively impact mental and physical health and access to education in some cases prolonged travel times impacted the workplace due to its influence on time management extended social community the community in which gps lived had a direct impact on their work gps are recognised members of the community this was found to have either a positive impact on their work experience with intrinsic rewards …i contribute to the community here and thats where im sort of trying to make my mark or a negative impact as community expectations exerted an external pressure to work in a certain fashion if youre in private practice you are basically a slave for your community of consideration for many gps was the lack of anonymity in a small community the experience of which was mediated by their personality and personal characteristics …i run into patients around and about…that would become a bit of an issue finally the structure of the community itself can influence the type of work a gp is undertaking …theres a lot of people with depression in our community and thats a major part of their presentation gender gender was a complex theme that emerged throughout the interviews it appeared to have a multilayered impact on the individual evidenced by genders influence on the various floors of the wa model and also on the gps interaction with their external environment and family gender also appeared to exert either an amplification or moderation of the influence of family on the wa model female gps attracted different presenting problems in their practice with more complex and emotionally loaded problems leading to a higher emotional burden for the gp and longer consultations which impacted work content and mental health they might have longer visits like gp name … she doesnt see the volume of patients that a few of us see some female gps found that the emotional load from these different presenting problems also necessitated more time for recharge and recuperation in order to maintain what is perceived as a sufficient level of compassion but people tell me as a female gp you get all the tears and smears and its the tears that really drain you at the end of the day the very specific work content that female gps often encountered meant varying their education and upskilling to match the needs of their patient demographic commitments to family also impacted their access to and time for continued education my general practice isnt really general practice its womens health which started when i first came here…i never really ever got to do general practice once i had children because the population came for 1001 pap smears and other things pertaining to womens health in some cases male gps avoided a certain kind of work or patient determined entirely by gender cause theres female doctors in the practice i do less pap smears… female gps also described using different methods to manage their practice to their male counterparts as they defined themselves differently from men it appeared that womens identity was still largely tied to their role as a mother and wife …but as a woman gp i was not valuedthis is a terrible thing to sayi was not valued in my own practice and the culture in my own practice which was an interesting practice was youre playing at general practice youre a mom youre playing at general practice youre not a real gp hence it appeared that womens work ability was more strongly impacted by family than men some women felt that they were perceived as less committed than their male counterparts due to their apparent prioritising of family commitments and the consequential reduction in work discussion the thematic analysis revealed that much of the data could be broadly categorised according to the wa model suggesting that the work ability model can be used to explain elements of sustainable employability amongst ageing gps our findings aligned with previous research 2627 which identified that the areas of particular relevance to rural and regional gps were workforce support rural and regional training opportunities access to continuing professional development flexibility in practice ownership family support and recognition and remuneration however in order to provide a more comprehensive reflection on the factors and dynamics found to underpin work ability in this group of gps required the creation of specific subcategories within the wa model quantitative analyses 2829 using the work ability index have previously pointed to health and functional capacity presenting the highest explanation rate for continued work ability in older workers followed by work factors the current thematic analysis supported these findings for gps in addition to the specific subcategories which emerged from the data entirely new factors were identified worklife balance and lifestyle extended social community and gender hence a modified wa model is proposed to more accurately reflect the components of work ability which forms the basis for sustainable employability in gps worklife balance and lifestyle provided important and previously unidentified connections between the wa house and the external environment where and how a gp chose to live impacted the various elements of their work ability and vice versa this finding supported previous research which has alluded to the importance of worklife balance for gps 113031 the data also revealed that rural gps experienced the added dimension of an extended social community not previously included in the wa model the community in which the gp lived had a direct impact on their work they felt to be recognised members of the community which for some had a positive effect on their work experience while others experienced a negative impact with increased work demands and lack of anonymity further research would be beneficial to ascertain whether the significance of the extended social community could be extrapolated to other professional groups gender was the third emergent theme that could be added as an element to the original wa model to explain gps sustainable employability previous research into the impact of gender on work ability has alluded to women professing greater intolerance to some work challenges earlier than men especially with regard to physical requirements but demonstrated greater tolerance for jobs requiring a high cognitive demand compared to men 32 women have also been found to be exposed to more unfavourable work conditions than men even when they carry out the same work 32 which corroborates the findings of this study gender impacted every floor of the wa house and had a moderating or amplifying effect on the influence of family women gps were predisposed by their roles as mothers and caregivers to be more likely to modify their work hours to accommodate family commitments compared to their male counterparts these findings suggest there may be merit in developing genderspecific sustainable employability frameworks strengths and limitations while care should be taken in generalising the current findings to other gp or professional populations a major strength of this study was the inclusion of a cross section of gps within a welldefined geographical area of new south wales additionally the achievement of data saturation and alignment of the current results with previous research lend support to the validity of the findings studies of larger gp populations from a variety of regionscommunities would provide further empirical validation of this modified model this study would also be strengthened by the inclusion of gps not currently engaged in practice as this may have provided a more accurate picture of the factors contributing to early exit this should ideally be a focus of further research impact of research outcomes this study has revealed the importance of new factors influencing work ability in gps it has provided a more comprehensive model for effectively explaining elements of sustainable employability for gps in the northern rivers region of new south wales the model can ideally be utilised as a basis for addressing workforce planning issues and to assist in the design of programmes to promote sustainable employability amongst gps for example the wa model can be used as a conversation tool to raise awareness and teach individuals such as gps which factors relate to their own workability and how these factors may influence their own sustainable employability 33 conclusions this is the first study that has empirically tested the wa model in a general practice population using qualitative methodologies in our study we tested whether the wa model may lend itself to categorising and exploring factors which influence sustainable employability the wa model can be utilised to understand elements of sustainable employability amongst gps however worklife balance and lifestyle extended social community and gender were aspects of work ability pertinent to gps which did not form part of the original model and required inclusion to more accurately reflect the components contributing to sustainable employability amongst gps appendix themes identified in the current analysis which align with the original wa model wa model first floorhealth and functional capacities physical and mental health while many gps stated that their work was not physically taxing physical health and age were identified as significant factors in the hours they worked and their continuing work ability i really dont view retirement as beinga finite point for me in terms of age because this is not a physical job… my brain still works the lack of physical demands highlighted the importance of mental health of the ability to manage stress and the intellectual and emotional challenges of the work they encountered this is closely interlinked with personality and personal characteristics and with values and attitudes to work i think the first obvious one would be my health which at the moment is good and fine but of course if that changed dramatically i could have to leave at short notice working as a gp was recognised as having a direct effect on health which in turn impacted the ability of the individual to work gps identified the positive aspects like health promotion which increased their work ability but also the negative impacts of workrelated stress alcohol intake is limited because youre on call so thats been goodid probably have a few drinks every night otherwise but i only have a drink a couple of days a week now work and health had a fluctuant and reciprocal relationship which uniquely connected the first floor with the fourth floor in the wa model …i know a couple of people who got ill who rightly or wrongly felt that the stress of their job and not looking after themselves well enough because of the workload was a key component of them getting unwell… age and physical and mental health are connected to upskilling and continuing education an older or overly stressed gp was less likely to have the desire or capacity to pursue further education and enhancement of their skills personality and personal characteristics the resilience and personality of a gp directly impacted their work ability it formed the basis of their desire and ability to work as a gp and interacted with their mental health personality directed motivating factors and intrinsic benefits and affected the workplace shaping interactions with colleagues and patients and attitude to workload i think it has a lot to do with personality i think its a question of resilience or the lack thereof so one has to be resilient i think that personalitywise doctors generally tend to be fairly obsessional people they like to get everything just right and when things dont go just right well they get nervous and anxious and in severe cases get depressed wa model second floorcompetence upskilling and continuing education the ability to pursue and practice in areas of special interest was identified as an intrinsic benefit and having the opportunity to learn new skills impacts the workplace where the gp is able to use these skills for continued interest and challenge a gps physical and mental health influenced their desire and ability to undertake further education and upskilling access to and opportunity for continued education and upskilling is therefore an important factor in sustainable employability …my other interest is dermatology… so that i can actually get my skills up and perhaps doing a lot of sun cancer medicine type thing accessibility to training and education was found to be lacking in some rural centres the educational opportunities arent always great locally… wa model third floorvalues attitudes and motivation values and attitudes the individuals attitude toward work and their personal values had a considerable impact on their work ability and linked closely to personality and personal characteristics some older gps identified a work ethic or attitude that they felt was a product of their era that kept them working i always intend to work till i dieso ill be working forever this work ethic kept gps engaged in their careers and accessing education and upskilling to maintain their competency and work ability …people dont have to work as hard as we did then… the younger generation of gps represented a shift in thinking toward a more balanced view of work and lifestyle that was reflected in their work habits with many working parttime and putting more emphasis on home and family life than their older counterparts this change in attitude also reflected a wider change in societal values indicating the influence of the external environment on this floor of the wa model …the young gps coming through have no intention of ever working fulltime i think thats extremely sensible intrinsic job benefits potent motivating factors were the intrinsic rewards that gps received from working these included the daily challenge of diagnosing and managing patients and the opportunity to explore special interests i think it acute hospital work is a great extension to general practice work i find that for me you know its challenging…im not just looking at my general practice day im also looking at my acute hospital days so it is something there is a motivational force in a way furthermore there was the positive reinforcement of helping a person to change their health for the better as one gp said …thats the feedback that you need to keep going youve got to feel good about what you do… this sense of fulfilment and reward aligns with personality and personal characteristics and has a positive connection and impact on mental health extrinsic job benefits monetary reward and the consequent ability to live a desired lifestyle or satisfy financial requirements was a commonly identified incentive to continue working as a gp this connects the external environment factors of family via the need to provide for them financially and the worklife balance and lifestyle theme which connects the interior to the exterior of the house of the wa model monetary reward also tied in closely with recognition and status and to education and upskilling to enable a gp to pursue more lucrative special interests we all want to be paid better theres no doubt that general practice is the most poorly paid medical specialty… one gp spoke in plain terms that financial reward was not just about income for them highlighting the connection with personality and personal characteristics …people need to feel valued…you dont get paid as much…you know it ranks less flexibility within the theme of extrinsic job benefits is flexibility both in the workplace and in the work the gp is able to do …flexibility i think is really important to keep people in the workforce being able to modify work hours or areas of interest was identified as an important consideration in continuing to work in a particular practice or community this overlaps with many other themes of the wa model the need to be flexible reflects a personal characteristic and the satisfaction of this need would positively impact mental health and potentially physical health if flexibility allowed the gp to engage in more active pursuits flexibility allows for the pursuit of further education finally flexibility has the most influence on workload work content and even on work relationships as it indicated the ability to compromise just by flexibility of the workplace so that if the only time you can get to the gym is between 11 and 12 oclock then as long as youre doing your hours go and do that then wa model fourth floorwork workload the most recurrent and therefore strongest theme identified related to workload this theme encompassed the hours worked the additional pressures and stressors of running a practice or the reduction of same through working as a contractor excessive workload was frequently identified as a barrier to longevity of working as a gp while alternatively the ability to be flexible with the hours worked or to have support in the form of locums and practice nurses was described as essential to continued working so im working fulltime 4 days a week but also working maybe 2 weekends a month…i also work as a vmo at the local hospitali see patients every day there work relationships many gps indicated the importance of their interactions with their work colleagues as an incentive to work a way to alleviate work pressures and increased social connectedness a way to perform better in the workplace due to added support the other gp that i work with gp name we get on really well weve got quite different styles but they work together pretty well and the rest of the staff we all get on very well work relationships therefore appear to have a direct influence on workload which in turn as one gp identified was an important intrinsic benefit i think the number one thing for keeping doctors here is having enough other people to help with the workload i think thats the most important thing its more important than money its more important than the actual work environment work content having the opportunity to utilise existing skills or to focus on an area of special interest within the scope of their work was an important factor for many gps in their continuing interest and sense of positive challenge within the workplace this reflects personality and personal characteristics and competency as the gp needs to be educated in these skills to be able to practise them utilising existing skills or knowledge was also a way for gps to transition into retirement without having to finish working entirely for example as a teacher or mentor for junior doctors and registrars finally there was a sense of personal reward and of recognition of their skills or accumulated knowledge …in an ideal world id like to be doing public procedural work status and recognition another aspect of continued work ability was identified as the need for recognition of the importance of the gp role within the healthcare system this was deemed to be especially desired from work colleagues and the wider community including governing bodies responsible for legislation …people would say to me doctors would say youre not a real doctor anymore because youre not doing emergency hospital anymore so that kind of attitude is not helpful… this theme connects with values and attitudes and with personality and mental health recognition and status also reflect the many years of study required to become a competent gp …i also think that gps are underrewarded or underappreciated from our own medical community physical environment the environment in which the gp practised had an impact on the way they worked and even in their continued desire to work the size of the practice and access to equipment that facilitated their work or areas of interest was described as an important factor of work ability …dermatoscope otoscopes you know that they are accredited practices with suitable medical equipment…i would struggle to work for a practice that didnt have that… patient factors interactions with patients had a significant effect on gps and their work ability and even on the type of medicine they practised the additional external environment theme of extended social community connects with patient factors as particular communities possess a predominance of a certain type of patient which influences the type of medicine a gp practises also patient expectations were identified as a strong influence on how a gp worked affecting hours worked oncall availability and hospital duties yes once youve got your patient basetheir expectations…an example of that is a really popular local doctor here and he really wanted to do the parttime thing but he had thousands of really dependent patients and you know and his personal ethic is always to work really hard and then when he didnt want to work hard there was this sort of backlash patient factors also overlap with intrinsic benefits as one gp said i have good relationships with the patients and i get a lot of enjoyment out of that positive patient interactions also impact mental health finally gps pursued further education and upskilling to meet the needs of their patient base human resources closely associated with workload and workplace interactions was the availability of human resources to support gps in the workplace this included locum support to enable gps to take leave or to distribute their workload weve had a lot of registrars come through in the past none of them really wanted to stay… the inclusion of practice nurses and allied health practitioners helped coordinate care and further share some of the burden of patient management ive worked in just about every capacity i can think of from solo up but since this concept of team care and having practice nurses and practice managers has started were no longer a harassed individual in a single room trying to solve the worlds problems on its own wa modeloperational environment family the gps family was consistently identified as one of the most powerful factors in work ability family affected almost every level in the wa model house family pressures or rewards had a direct impact on stress and mental health as well as physical health for example through physical activity with the children family constraints influenced the ability for a gp to have time and access to further education and training or alternatively influenced the type of training as the gp structured their work around their family financial security for family was an extrinsic benefit and motivating factor finally family influenced hours worked and even location of the workplace my youngest is 15 and will leave or finish school in 3 years and at that stage we plan to leave inland village not because of the job but because of those things social community encompasses relatives friends and acquaintances gps identified the overlap between the work they undertook and the relationships they formed within their community it correlates with intrinsic benefits and motivating factors and physical and mental health i have a medical role with those with the and you know ive got good friends in this area wa modelsociety politics the redtape and paperwork associated with general practice was identified as a significant negative factor in work ability impacting motivation and workload …i think its a pain and i would think it would put people off being a general practitioner were just like scribes …every time the government gets into does something it makes the administrative work more they say that they cut the red tape down and theyve made it longer government policies and bureaucracy were often seen as counterproductive and even antagonistic i think the government…when it suits them they love gps and when it doesnt suit them they attack them there were reciprocal effects on the mental health and personality and personal characteristics played a part in how strongly gps felt impacted by politics and whether they took a political role for themselves operational factors since the global financial crisis some gps found that the external impact on their finances had affected their workload …ive spoken to the gps whove said they need to stay in the workforce longer to top up their super financial independence was identified as a reason a gp might retire early from work …they retired at 60 because they had that nice juicy index pension so theyre comfortably off gps also spoke of the lack of flexibility in reducing their hours or changing to a teaching role as a deterrent to continuing working just your medical indemnity insurance that if youre working less hours it needs to step down…theyre governing bodies addressing it… support gps reported both positive and negative experiences with regard to support from external bodies for example the royal australian college of general practitioners support was beneficial in the areas of providing locums staff practice infrastructure and advocating for gps politically gps indicated that support from advocating bodies had one of the lowest levels of influence on their work ability abbreviations cpd continuing professional development gp general practitioner nrgpn northern rivers general practice network se sustainable employability usa united states of america wa work ability authors contributions study concept and design was led by swp with contribution by vh data was collected by swp the qualitative analyses was conducted by js with significant contributions by vh and swp all authors contributed to the writing read and approved the final manuscript competing interests the authors declare that they have no competing interests

background work ability wa is an indication of how well someones health skills and experience match current job demands the aim of this study was to ascertain whether the work ability model can provide a useful explanatory framework to understand some elements of sustainable employability se amongst gps methods a thematic analysis of 19 indepth interviews with gps in the northern rivers region of nsw australia was conducted and formed the basis for a qualitative validation of the work ability model results in order to provide a more comprehensive reflection on the factors and dynamics found to underpin work ability amongst ageing gps required the creation of specific subcategories within the wa model additionally new themes relevant to general practice also emerged from the data the analyses revealed a set of important new factors and relationships that required additions and refinements to the original model in order to fully explain sustainable employability in this gp sample these new emerging themes that required model extension were worklife balance and lifestyle extended social community and impact of genderwhile the wa model provides a basic explanatory framework for understanding some elements of sustainable employability amongst gps a revision of the current model has been proposed to sufficiently describe the factors impinging on sustainable employability in this group the extended model can potentially be used for addressing workforce planning issues and to assist in programme design to promote sustainable employability amongst gps and could potentially be translated to other health professional groups

background socioeconomic inequalities in mortality have been observed in several highincome countries 1 2 3 4 5 6 7 this is revealed not only when comparing the most advantaged and the most disadvantaged social groupsa gradient can be observed across the entire socioeconomic hierarchy 1 2 3 68 in denmark with its relatively low economic inequality a high level of income protection and universally taxfinanced healthcare the past twenty years have seen increasing inequality in mortality 1 this poses a serious challenge to public health 1 2 3 8 as reflected by the priority given by world health organization to the social determinants of health in its draft for the 12th general work programme for 2014 2019 9 providing for equality in health is a moral obligation as both mackenbach and marmot have emphasized 810 despite a broad recognition of the importance of this subject the reasons for these disparities are still unknown 1 2 3 81112 it is crucial to obtain a comprehensive understanding of their underlying causes as this is vital to prevent the persistence of the disparities 21113 sociological theory explains health disparities by social stratification comprised of three components firstly mobility mechanisms that place individuals into social strata causing differences in the personal characteristics of individuals between strata secondly allocation rules causing differences in distribution of resources to social strata resulting in inequalities between social strata in access to material and immaterial resources thirdly social processes that render some resources of greater value than others ie resources that can be used to avoid health problems 8 additional theories can be related to the social stratification perspective the theory of fundamental causes suggests that social forces underlying the social stratification induce health disparities as opposed to the proximal risk factors such as smoking drinking and eating habits distal resources such as knowledge money power prestige and beneficial social connections that can be applied to enhance health are distributed differently among social strata 814 health disparities may also arise from healthrelated selection during social mobility ie individuals are sorted into social classes based on health or psychosocial determinants as stipulated by the social selection theory 815 the neomaterialist theory propose that disparities in material recourses remain in welfare stats despite of relatively small income inequalities and what remains is still substantial for health disparities partly because material disadvantage is associated with lifestyle diseases resulting from poor healthrelated behaviours such as lack of physical exercise and unhealthy diet etc 815 unequal distribution of psychosocial determinants such as psychosocial stress lack of sense of control and social support may also be of importance in the explanation of health inequalities as suggested by the psychosocial theory 815 moreover the theory of diffusion of innovations emphasizes that health disparities result from faster adaption of new healthy behaviours and earlier pick up of interventions among individuals with a higher socioeconomic status 8 none of these theories are mutually exclusive and they may be apparent simultaneously and reinforce each other 815 researchers have thus proposed various theories on the persistence of health inequalities in welfare states 8 from which potential pathways underlying the inequalities have been developed including behavioural psychological material and social mechanisms 11 12 13 1617 these mechanisms may both independently and in combination by reinforcing each other influence the socioeconomic gradient in mortality 111317 it is crucial to focus on the identification of determinants that may explain the socioeconomic inequalities in mortality 1 2 3 81113 studies have investigated the impact of behavioural determinants on the association between socioeconomic position and mortality these found that the association was substantially accounted for by adjustment for healthrelated behavioural determinants 16 18 19 20 21 22 23 in addition only few studies have combined the study of behaviours in combination with study of table 1 potential mechanisms underlying socioeconomic inequalities in allcause mortality behavioural mechanisms psychological mechanisms differences in socioeconomic strata in terms of healthrelated behaviours and lifestyles including smoking habits alcohol consumption exercise and dietary patterns as well as morbid obesity 815 disparities in personality profile and psychological resources such as cognitive ability knowledge cooping abilities attitude a sense of control and perceived social standing the personality profile is believed to be a determining factor for the socioeconomic position as educational and occupational achievements are dependent on personal talent and effort 8 furthermore psychological stress is hypothesized to increase the risk of premature mortality by producing disruptions in the neuroendocrine system 815 material mechanisms social mechanisms unequal distribution of material resources such as income but also what income enables ie being able to afford healthy food access to goods and services favourable living and housing conditions employment status service provision such as schools and transport and welfare to population health 815 stratified difference in social resources such as social relationships social support interpersonal trust norms of reciprocity and mutual aid power and prestige 815 material or psychosocial determinants 11 12 13 172425 possibly because data on the composition of social strata or on the distribution of immaterial determinants among social groups can be difficult to obtain 8 this study linked data from the north denmark region health survey 2007 with individuallevel data obtained from nationwide administrative registers the selfadministrated health survey obtained information on demographic characteristics lifestyle factors disease quality of life work characteristics social support etc 26 aim the aim of our study was to explore whether behavioural material psychological and social determinants could explain the association between educational status and allcause mortality this was done by investigating the separate and mutual effect for each group of determinants methods design and population a registerbased cohort study of inhabitants in the danish region of northern jutland was conducted with a followup period from the 1st february 2007 to 31st december 2012 the participants had previously answered a postal questionnaire sent to a sample of 23491 citizens in northern jutland denmark aged 1680 years drawn randomly from a population of 438759 inhabitants in the civil registration system 2627 the sample was stratified by the regions 11 municipalities two reminders were sent to citizens who had not returned the health survey 26 for the current study only participants aged ≥30 years were included as final educational status was considered to be acquired at this age this excluded 1266 participants aged 1629 years leaving a total of 10231 participants the response rate was 5179 among subjects aged ≥30 years information on educational status was missing for 125 participants reducing the study population to 10106 subjects only participants with no missing on all of the independent variables were included in the final sample resulting in 8837 subjects socioeconomic status a conceptual challenge exists in defining socioeconomic position on an individual level often used measurements include educational status income or occupational class 2528 it has been demonstrated that these factors cannot be used interchangeably as they are related to different causal processes 28 in this study educational status served as a proxy for the participants socioeconomic position as this is a fundamental determinant of both occupation and income 28 information on individuals highest completed course of education was obtained from the populations education register the register only provides information on education authorised by the danish ministry of education and of a duration of more than 80 hours 29 based on the international standard classification of education 30 we grouped participants according to their highest completed education but deviated from the isced classification for the fourth level ie postsecondary nontertiary education as no such programmes exist in denmark 31 instead programmes at isced level 3 were split into two resulting in five groups a early childhood education primary education and lower secondary education b general upper secondary education high school programmes c vocational upper secondary education vocational training and education d short or mediumlength higher education firstcycle programmes tertiary education bachelor or equivalent e long length higher education secondcycle programmes masters or equivalent or thirdcycle programmes doctoral phd programmes or equivalent allcause mortality information on allcause mortality was obtained from the civil registration system 27 time to death was measured by days from the time of receiving questionnaire the 1st of february 2007 until death emigration or end of followup right censoring on december 31st 2012 resulting in a 58 year followup period demographic information and health status demographic information on age and gender was gathered from civil registration system 27 based on information from the national patient registry comorbidity was measured using the charlson index 32 the register holds information on all admissions and outpatients visits to danish hospitals and specialty clinics all admissions and visits were registered by a primary diagnosis and if appropriate one or more secondary diagnoses according to the international classification of diseases 10th revision 33 objective health was assessed based on charlson comorbidity scores a weighted index that takes into account the number and the seriousness of comorbid diseases each condition was assigned a score of 1 2 3 or 6 depending on the associated risk of dying 32 the objective health variable was formed based on the charlson comorbidity scores 0 1 2 and ≥3 information on subjective selfreported health was obtained from the health survey by the global question in general how do you assess your current health with five response options ranging from very good to very poor and a dont know response 26 the subjective health variable was formed on the basis of the response options healthrelated behavioural material psychological and social determinants our study included a range of determinants in the explanation of the association between educational status and allcause mortality based on the underlying mechanisms the explanatory variables were divided into four groups behavioural material psychological and social determinants as shown in table 1 information on explanatory determinants was obtained from the health survey 26 and the income statistics register 34 the exact wording of the questions and the matching response options used in the selfreported questionnaire are shown in the behavioural determinants the behavioural determinants included smoking patterns alcohol intake body mass index dietary and exercise habit behavioural variables were formed on the basis of the response options with the exception of alcohol intake and bmi alcohol intake was estimated according to danish health and medicines authority recommendations on risk behaviours 35 which are based on the respondents weekly consumption of units participants were categorized into three groups based on consumption and gender ie lowrisk alcohol intake moderaterisk alcohol intake and highrisk alcohol intake 35 the participants bmi was calculated from information on weight and height a standard classification of bmi was used 185 185 249 25299 30 35 and 35 36 psychological determinants the psychological determinants included feeling stress anxiety nervousness restlessness hopelessness unhappiness feeling depressed and having too many worries psychological variables were formed on the basis of the response options material determinants the material determinants included profession income residential area type of residence residential ownership difficulty paying bills and use of neighbourhood facilities with the exception of information on income the material variables were formed on the basis of the response options income information was obtained from the income statistics register which includes information on all tax return forms thus covering all economically active citizens 34 to obtain stable measures for household incomes and individual incomes an average of income in three successive years was calculated three groups were formed for both household and individual incomes low average and high income social determinants the social determinants included time spent with family or friends being able to count on others for help loneliness trust and reciprocity marital status use of cultural facilities social involvement in the local community and association activities social variables were formed on the basis of the response options ethics the study was approved by the danish data protection agency all data were linked and stored in computers held by statistics denmark and made available with deidentified personal information to ensure that individuals could not be identified in accordance with the act on processing of personal data only aggregated statistical analyses and results are published 3738 retrospective anonymized registerbased studies do not require obtained written informed consent and ethical approval 3738 statistical analyses for descriptive statistics continuous variables were compared with analysis of variance tests and discrete variables with chisquare tests to test for difference between groups comparison of survival was performed with proportional hazards cox regression models timeonstudy was used as the timescale hazard ratios and the corresponding 95 confidence intervals were determined educational level c vocational upper secondary education was chosen as the reference group on the basis of size as this group was the largest of the five educational levels analyses were performed in three preselected steps initially a calculation using a model adjusted for age and gender was performed followed by a calculations allowing for further adjustment for objective and subjective health a third model allowed additional adjustment for selected behavioural psychological material and social determinants with a stepwise inclusion of variables subjects were censored at the end of the followup period analyses were conducted applying a design weight to correct for sample selection bias as respondents in the different municipalities did not have equal chances of receiving the questionnaire the proportional hazards assumption and the linearity assumption of the proportional hazards cox regression model were tested and found to be valid schoenfelds residuals were used to test the proportional hazards assumption we examined possible interactions between gender and educational status and potential interactions between age and educational status no statistically significant interactions were detected the level of statistical significance was set at a pvalue 005 for all statistical analyses to detect whether excluding subjects with missing values on any of the independent variables would bias the results we performed a sensitivity analysis conducting the multivariable analyses on the full sample ie using all available data in the different models all data management were performed using sas software version 94 and all analyses were executed using r studio software version 097551 results participants characteristics subjects mean age was 541 years 453 were men additional file 1 table s2 gives in condensed form information on baseline characteristics of the study population by educational status the total distribution of demographic and all explanatory variables according to educational level can be found as additional file 1 tables s2ae educational level a participants whose highest education was primary school were at baseline characterized by a high average age a high proportion of death comorbidity poor selfrated health obesity and were smokers many had low income were tenants and flatdwellers and were pensioners or on early retirement use of community house or centre and clubs for older people were also prevalent in this group educational level b respondents with general upper secondary education were characterized by lower average age a high prevalence of comorbidity stress and difficulties with paying bills educational level c and d respondents with vocational upper secondary education and shorttomedium higher education respectively were nondiverse in terms of baseline characteristics compared to the other educational levels educational level e among respondents with a long higher education high incomes were prevalent as was the use of neighbourhood facilities such as parks cinemas and theatres this group participated in association activities and spent less time with family many were nonsmokers alcohol consumption was high and selfrated health was good unadjusted and adjusted risk of allcause mortality in the 58year followup period 395 deaths occurred allcause mortality was unevenly distributed across educational levels significantly more deaths occurred in the least educated groups using multivariable cox regression models with adjustment for confounding by age and gender we found that the risk of mortality was significantly higher among respondents on levels a and b the midmost level c was chosen as reference group in comparison with level c no figure 1 hazard ratios and 95 confidence intervals for educational status calculated by cox regression models on complete cases statistically significant difference was observed between the highest educational levels d and e further adjustment for the effect of objective and subjective health resulted in comparable patterns for levels d and e the higher risk of mortality also remained statistically significant for the respondents with shortest schooling levels a and b the inequality among groups failed to disappear when adjustment was made for the effect of behavioural psychological material and social determinants the risk of mortality thus remained significantly higher among levels a and b statistical differences remained statistically insignificant when comparing levels d and e with level c the effects of each group of determinants are shown in an additional file model 4 of this figure corresponds to a basic model with adjustment for the confounding effect of age and gender along with objective and subjective health further adjustment for the effect of behavioural determinants the risk of mortality remained significantly higher on levels a and b similar results were found after additionally adjustment for the effect of psychological determinants the mortality risk remained significantly higher on levels a and b after further adjustment for the effect of material determinants the risk of mortality remained significantly higher on levels a and b when comparing with level c the mortality risk did not show significant changes for levels d and e although increased risk was noted neither did additional adjustment for the effect of social determinants affect the risk of mortality which remained significantly higher on levels a and b sensitivity analysis the analysis on the full analytical sample using all available data in the different models produced results similar to those of the main analysis on complete cases discussion our study examined whether behavioural psychological material and social determinants could explain the association between socioeconomic status and allcause mortality the risk of mortality was found to vary across educational levels and to be significantly higher for respondents from the lower socioeconomic strata adjustment for behavioural psychological material and social determinants failed to eliminate the effect of the inequalities as the risk remained significantly higher for the two groups with lowest educational levels when compared with the midmost educational level surprisingly no clear gradient in socioeconomic inequality as measured by educational achievement could be detected as we found no statistically significant difference between the secondhighest and the highest educational levels when compared with the midmost educational level strengths and limitations our study derives part of its strength from our comprehensive approach apparent from the inclusion of healthrelated behavioural psychological and material as well as social determinants furthermore the use of educational status as a proxy for socioeconomic position offered the double advantage of relative stability over a lifespan and the ease of retrieval and recording the risk of selection bias was minimized by the choice of educational status which introduces less reverse causation than its alternative occupational class and income as mobility of individuals with poor health into certain strata is less likely to be effected by differences in educational level selection bias is more likely to influence health differences by occupational class and income as occupation and income tends to decrease when an individual become chronically ill 28 the independent effects of occupation and income were moreover taken into account by making separate adjustments for the effect of each dimension 28 the use of allcause mortality as the outcome measure had several advantages as this endpoint requires no further ascertainment than the time of death thus preventing bias stemming from the classification of cause of death the criterion for selection of registers was content validity weighed against the quantity and relevance of the data the accessibility location and time covered by the register data were also considered 37 overall the data obtained from registers was considered to be of highquality information 2729333437 among the limitations of the study are some unexpected irregularities in educational data these occurred as a consequence of several changes in the educational system over the years hence data from before 1974 and for immigrants with no danish schooling are selfreported which increases the likelihood of misclassification 29 furthermore income data may be biased by the impact of undeclared work etc 34 data obtained from the regional health survey may be biased as to selection because of the nonresponse rate exactness of information obtained as well as missing values analysis on the full sample size using all available data in the different models did however not change the study results as the outcome measure of allcause mortality involves all causes of death an uneven distribution across the groups cannot be ruled out as the outcome measure allcause mortality has the disadvantage of being a concept including many possible causes of death which may be distributed differently across socioeconomic strata the measure furthermore represents a combination of the effect of disease incidence access to treatment and survival hence the observed inequalities may at least partially be due to disparities in survival after disease incidence or in the distribution of more lethal diseases thus caution should be exercised when interpreting the results as determinants of prolonged survival might not be the same as for disease incidence and treatment access data obtained on the explanatory determinants was selfreported and several variables were proxies objective measures and more detailed questions may have yielded a more accurate estimation of the contribution of the various determinants other explanatory determinants may have been needed in order to explain the association furthermore exploring the association between educational level and allcause mortality has methodological shortcomings this approach does not allow for a causal interpretation of the observed changes in hazard ratios and can lead to an underestimation of the effect of the determinants and an overestimation of the effect of educational status on the association 39 additionally we obtained information on many possible confounders such as age gender and comorbidity but despite adjustment for the most relevant ones residual effects may be present as the design does not eliminate unmeasured confounders that could possibly affect the results the response rate was less than 52 and the rate was particularly low among young men low response rates in some subgroups of the study population pose problems in the representativeness of the study population with the background population previous studies have shown a tendency to higher response rates among higher educated subjects 40 and lower mortality rates among participants than nonparticipants 4142 hence it is possible that the contrast in educational level and healthrelated determinants observed in the study population were underrated in proportion to the general population for these reasons caution should be taken when generalizing the results to the general population caution in interpretation is also warranted because of the limited number of deaths occurring in a study population and followup time of this magnitude interpretation the study gave evidence of substantial inequality in allcause mortality among the citizens of northern jutland denmark as significantly more subjects from the lower socioeconomic strata died in the study period our results are similar to those found in comparable studies investigating the distribution of allcause mortality among socioeconomic strata 1 2 3 4 5 6 7 the risk of mortality was significantly higher on the second lowest educational level where the average age was lower thus the cause of death may have been different from those on the other educational levels 43 different causes such as the use of health benefits or coping skills may therefore have been involved the mortality risk remained significantly higher for respondents on lowest socioeconomic levels which could possibly be explained by greater exposure to a wide range of risk factors for poor health over the life course they may moreover have become more homogeneous regarding personal characteristics of significance to health such as cognition knowledge material means social support and healthrelated behaviours as these disparities over time may lead to differences in risk factor profiles and vulnerability to such risk factors across socioeconomic strata 17 a better understanding of the association between socioeconomic status and allcause mortality is necessary to reduce the socioeconomic inequalities in mortality which we were unable to explain by adjusting for behavioural psychological material and social determinants while our results support comparable work 121625 other studies have concluded that the gradient in allcause mortality is explainable after adjustment for material determinants either on their own or in combination with behavioural and psychosocial determinants 111317 in our study adjustment for the effect of material determinants did increase the mortality risk on the lowest socioeconomic levels but we found no indication of a strong effect of material determinants on allcause mortality however unequal access to material resources may lead to differences in life circumstances in youth ultimately resulting in lasting disparities in health a lifecourse perspective focusing on fundamental causes distal factors and habitus 144445 therefore seems required to explain socioeconomic inequalities in allcause mortality our study and previous studies are based on a causation theory explaining inequalities in mortality by stratified differences in health determinants thus an overlap of potential mechanisms should be considered in explaining the socioeconomic inequalities none of these mechanisms are mutually exclusive the different mechanisms could thus be interrelated thereby challenging our ability to account for the effect on the socioeconomic gradient in allcause mortality 111317 these reverse causalities can be categorized as measurement errors leading to possible bias in estimates 12 our simplified study models cannot account for the multiple pathways underlying the inequality ie the methods applied were unable to account for the possible multiple mechanisms underlying the inequalities as only the association between educational level and allcause mortality was assessed to prevent a development towards stronger disparity further exploration into these complex issues is needed we need to understand why an underprivileged socioeconomic position places people at higher risk of death than their betteroff compatriots further exploration of the possibility that the underprivileged groups form a homogenous group is needed as our data may have given an insufficient description a lifecourse perspective to explain the persistent inequalities in allcause mortality seems necessary for progress as we believe this perspective is crucial to allow for the multiple mechanisms and pathways and to account for the inequality in allcause mortality conclusion this study has demonstrated the existence of substantial inequality in allcause mortality among citizens of northern jutland denmark despite the comprehensive approach with incremental adjustment for the effect of a range of determinants we were unable to account for the inequality revealed by the data uncovering the multiple underlying pathways may require less simplified models we recommend that future research takes a lifecourse perspective that includes distal factors while simultaneously accounting for the complexity of the underlying multiple mechanisms and pathways to explain the association between socioeconomic status and allcause mortality additional files additional file 1 table s2a baseline demographic characteristics by educational level table s2b baseline behavioural characteristics by educational level table s2c baseline psychological characteristics by educational level table s2d baseline material characteristics by educational level table s2e baseline social characteristics by educational level additional file 2 figure s3b hazard ratios and 95 confidence intervals for educational status estimated by cox regression models on complete cases additional file 3 figure s3a hazard ratios and 95 confidence intervals for educational status estimated by cox regression models on the full study sample using all available data in the different models additional file 4 figure s3b hazard ratios and 95 confidence intervals for educational status estimated by cox regression models on the full study sample using all available data in the different models competing interests the authors declare that they have no competing interests authors contributions co ctp and lrbuc conceived the concept for the study and are responsible for its design lrbuc carried out the data management process and statistical analyses with help and advice from ctp rnm and lej lrbuc drafted the manuscript ctp co hvn kf hb rnm lej srjk and smh contributed to interpretation of data all authors have critically revised the text for important intellectual content and have read and approved the final manuscript and are accountable for all aspects of the work

background socioeconomic inequalities in mortality pose a serious impediment to enhance public health even in highly developed welfare states this study aimed to improve the understanding of socioeconomic disparities in allcause mortality by using a comprehensive approach including a range of behavioural psychological material and social determinants in the analysis methods data from the north denmark region health survey 2007 among residents in northern jutland denmark were linked with data from nationwide administrative registries to obtain information on death in a 58year followup period 1 st february 200731 st december 2012 socioeconomic position was assessed using educational status as a proxy the study population was assigned to one of five groups according to highest achieved educational level the sample size was 8837 after participants with missing values or aged below 30 years were excluded cox regression models were used to assess the risk of death from all causes according to educational level with a stepwise inclusion of explanatory covariates results participants mean age at baseline was 541 years sd 126 3999 were men 453 in the followup period 395 died 45 with adjustment for age and gender the risk of allcause mortality was significantly higher in the two leasteducated levels hr 15 95 ci 1218 and hr 37 95 ci 2459 respectively compared to the middle educational level after adjustment for the effect of subjective and objective health similar results were obtained hr 14 95 ci 1117 and hr 35 95 ci 2063 respectively further adjustment for the effect of behavioural psychological material and social determinants also failed to eliminate inequalities found among groups the risk remaining significantly higher for the least educated levels hr 14 95 ci 1119 and hr 40 95 ci 2368 respectively in comparison with the middle level the two highest educated levels remained statistically insignificant throughout the entire analysissocioeconomic inequality influenced mortality substantially even when adjusted for a range of determinants that might explain the association further studies are needed to understand this important relationship

introduction theories of religious change have been caught between two opposing paradigms secularization theory and religious economy theory in its strongest form secularization theory argues that religion erodes as modernization proceeds though the metrics of modernization vary by secularization theorist religious economy theory on the other hand contends that religious deregulation leads to increased religious pluralism and in turn higher levels of religious activity for reasons to be discussed however neither of these theories can make sense of the religious change with which this work is concerned anomalous cases do not create cause for abandonment of the theories that fail to explain them but rather present an opportunity for theoretical complication and improvement with a focus on symbolic threat dynamics i here provide a new theoretical approach to understanding religious change theories of religious change have not adequately considered the impact cultural threats have on identity formation and likewise group threat theories have paid scant attention to processes of religious change in this article i contribute to both literatures by integrating the effects of cultural threat into a theoretical discussion of religious change central to this integration is the understanding that salient symbolic traits of a groups identity emerge in the face of a cultural threat while the potential utility of symbolic threat has been considered in discussions of religious identification this factor has yet to be systematically incorporated into any theory of religious change furthermore speculation concerning the connection between symbolic threat and religious change has mostly revolved around situations of religious revival whereas this article uses this dynamic to explain a case of religious decline this work will use the contextual particularities of east and west germany to inform the more general discussion of how threat relates to processes of identity formation in this article secularity will be understood as a central facet of the east german character throughout the reign of the german democratic republic pushing a secular worldview upon east german consciousness was an important objective for the communist regime mediated by the deeply atheistic history of east germany secularization is here presented as a reaction of eastern identification that repeatedly emerges among east germans who perceive cultural threats from outsider groups the case of east germany demands theoretical complication of this kind for it has demonstrated exceptional patterns of religious decline the secularization of east germany shortly after german reunification presents an empirical puzzle to sociologists of religion for neither secularization theory nor religious economy theory can explain this period of religious change with the fall of the soviet union and consequent deregulation of religion a religious revival was observed among the vast majority of eastern bloc nations in the 1990s these spikes in religiosity that came along with religious deregulation clearly align with the claims of religious economy theory anomalous to this pattern however east germany became increasingly secular in the years following reunification and has since become the least religious society in the world 1 this curious religious decline is also no triumph for proponents of secularization theory for the steep drops in religiosity within the mere six years presented in table 1 certainly do not correspond to the extent of modernization that took place within this timeframe 2 as others have noted the claims of secularization theory are also incongruous with the religious revival of other eastern bloc nations furthermore secularization theory falls short of an explanation for the combination of differences between east and west germany namely that the latter is more religious and modernized than the former in this article i find the connection between symbolic threat and identity formation to be a useful mechanism to make sense of religious change central facets of the gdr identity such as socialist voting eastern consumerism and secularity emerged at a time when the eastern identity was perceived to be threatened by the nature of germanys reunification process i connect this mechanism of eastern identification in the 1990s to a more recent symbolic threat namely the growing fear of germanys migrant population although secularity is commonly associated with leftwing ideology this article finds a dramatic reduction in religious activity among the east german rightwing which in recent years has become virtually identical to the leftwing by all tested metrics of religiosity this article explores the role that fear of foreign domination may play in this reactive formation of the secular identity previous research has not connected this process of reactive identification to the recent secularization of the political right to my knowledge this is the first article to find a period of rightwing secularization in any context 3 to make sense of these changes i first describe the mechanisms of group threat theory upon which my core argument relies next i discuss the sharp religious decline during the reign of the gdr in light of the various forms of religious persecution that took place throughout the regimes existence from here i document religious changes in formerly sovietoccupied countries after the collapse of the soviet union and present east germanys exceptionalism as a reaction to the cultural threat of westernled reunification in the following section i connect this same mechanism of reactive secular identification to the more recent threat of migrant arrivals to empirically illustrate these dynamics i test the ways in which political ideology and xenophobia relate to religiosity in east and west germany i find recent spikes in secular identification among the rightwing as well as a strong relationship between secularity and fear of foreign domination finally i discuss the potential extension of this social logic to other contexts and emphasize the ways in which cultural vulnerability and in turn reactivity could pervade country and subject reactive identification the connection between symbolic threat dynamics and religious change relies on the contention that symbolic threat can lead to increases in salient collective characteristics among culturally threatened groups the logic of this theoretical claim is similar to that of competitive threat theory which contends that threat contributes to the development of prejudice and ingroup identification competitive threat theories are primarily concerned with conflict over scarce resources between competing groups as well as the relative size of the threatening outgroup in addition to materialist matters a great deal of research has also been sensitive to the ways in which boundary making and collective identification connect to ideational dimensions such as race religion nationhood language and culture the concept of symbolic threat by itself is thus hardly a novel one it is the connection between threat dynamics and theories of religious change that has been largely overlooked however past research has focused on the relationship between symbolic threat and identity formation though this article analyzes these dynamics over time and integrates them into a discussion of religious change central to the linking of these seemingly disparate theoretical domains is the impact that the outsider has on the formation of identity among members of the threatened group when the dominant group senses that the subordinate group has improved its economic or symbolic position they react defensively and develop feelings of prejudice when this perception is formed they view members of the threatening group not on the basis of their respective individualities but rather on the abstract image of their group membership in turn members of the dominant group develop a collective perception of themselves in relation to the subordinate group for it is the relative position of the latter that defines the boundaries of the former threat thus plays a role in the process of identity formation for such formation is often done in light of the encroachment of the other glaeser for example likens the construction of identity to a pingpong of identifications between self and other this reactive process of identity formation among members of the threatened group necessarily depends upon their relationship with the otherized group reactions to threat vary with context for such reactivity depends upon the overarching historical and cultural particularities through which it is mediated in this article secularity will be understood as an east german ingroup attribute that emerges in reaction to perceived ideational threat i propose that a focus on symbolic threat dynamics can help make sense of east germanys exceptional patterns of religious decline by analyzing this pattern over time i here demonstrate how secularization repeatedly surfaces among east germans who feel a sense of cultural infiltration from outsider groups to understand the nature of this reactive identification it is crucial to be cognizant of the historical and cultural idiosyncrasies at hand religion materialism and the gdr from its founding until its collapse the gdr was committed to promoting scientific materialism through atheist proselytizing when the gdr was founded in 1949 over 90 percent of the population belonged to the church by the time of its dissolution in 1990 this figure had dropped to just under 30 percent in an effort to popularize the socialist personality the gdr attempted to expedite the withering away of religion through several means under the gdr such persecution was justified by the belief that religion was inherently inimical to the advancement of socialist objectives and wholly incompatible with the wissenschaftliche weltanschauung a term which was printed on nearly every gdr document the gdrs framing of an ideological juxtaposition between science and religion is perhaps best exemplified by the jugendweihe the jugendweihe is a ceremony that originated in the midnineteenthcentury was abolished in 1950 and then reintroduced by the gdr in 1954 although it has taken on several meanings since its inception the jugendweihe was an atheistic and socialist ceremony which 14yearolds participated in throughout the reign of the gdr participants swore an oath of loyalty to the socialist state and science as opposed to regressive irrational modes of thought preparatory classes for the jugendweihe involved readings that emphasized pride in gdr culture and presented scientific explanations as superior to religious teaching participation in the ceremony was treated as a prerequisite for educational opportunities and coveted employment it is thus no surprise that jugendweihe participation skyrocketed shortly after its reintroduction in 1955 only 177 percent of adolescents participated though just five years later this figure shot up to 878 percent by 1980 975 percent of gdr youth took part in the ceremony the jugendweihe was meticulously organized to be in competition with religious ritual as it took place on sunday mornings in spring and its structure mirrored that of religious confirmation it appears that the gdr was successful in their efforts of conversion as the sharp rise in jugendweihe participation was accompanied by an equally staggering decline in religious confirmations as can be seen in figure 1 participation in religious confirmation decreased by 457 percent between 1955 and 1960 the church of course did not take kindly to the reintroduction of the jugendweihe nor any of the states attempts to eliminate the religious imagination consequently churchstate relations became particularly fractious in the 1950s and 60s the state harassed pastors and congregations published defamatory articles on religious leaders supervised the churchs regional papers demolished historic churches and significantly reduced church subsidies this is not to suggest that the extremity of churchstate tension did not vary throughout the reign of the gdr with the 1978 church in socialism agreement for example the union of protestant churches committed to political indifference in exchange for greater church autonomy this degree of independence granted dissidents a space for noncompliance evidenced by the formation of about 100 independent peace groups the church of course did not take kindly to the reintroduction of the jugendweihe nor any of the states attempts to eliminate the religious imagination consequently churchstate relations became particularly fractious in the 1950s and 60s the state harassed pastors and congregations published defamatory articles on religious leaders supervised the churchs regional papers demolished historic churches and significantly reduced church subsidies this is not to suggest that the extremity of churchstate tension did not vary throughout the reign of the gdr with the 1978 church in socialism agreement for example the union of protestant churches committed to political indifference in exchange for greater church autonomy this degree of independence granted dissidents a space for noncompliance evidenced by the formation of about 100 independent peace groups open discussion and dissident organization however were nothing but vexations for the gdr which banned church periodicals and physically interfered with protests this dissidence was perhaps most pronounced in the saxon city of leipzig the monday demonstrations in leipzig were arguably the most influential of protests that occurred during the peaceful revolution of 1989 the nikolaikirche a twelfthcentury church in leipzig provided a space for dissidents to escape the reluctant conformity demanded of them in nonautonomous spaces it is also worth noting that the monday demonstrations at which hundreds of thousands of protestors famously chanted wir sind das volk took place right after evening peace prayers as is wellknown the fall of the gdr shortly followed the peaceful revolution of 1989 the new elections in march of 1990 resulted in a coalition government led by lothar de maiziere and in october of the same year the country was reunified fourteen pastors served as members of the transitional parliament and four as members of de maizieres cabinet several holy days became recognized as state holidays and nearly all state pressures against the church were removed with democratization and reunification came a host of societal and political changes including the deregulation of religion participation open discussion and dissident organization however were nothing but vexations for the gdr which banned church periodicals and physically interfered with protests this dissidence was perhaps most pronounced in the saxon city of leipzig the monday demonstrations in leipzig were arguably the most influential of protests that occurred during the peaceful revolution of 1989 the nikolaikirche a twelfthcentury church in leipzig provided a space for dissidents to escape the reluctant conformity demanded of them in nonautonomous spaces it is also worth noting that the monday demonstrations at which hundreds of thousands of protestors famously chanted wir sind das volk took place right after evening peace prayers religious confirmation jugendweihe as is wellknown the fall of the gdr shortly followed the peaceful revolution of 1989 the new elections in march of 1990 resulted in a coalition government led by lothar de maiziere and in october of the same year the country was reunified fourteen pastors served as members of the transitional parliament and four as members of de maizieres cabinet several holy days became recognized as state holidays and nearly all state pressures against the church were removed with democratization and reunification came a host of societal and political changes including the deregulation of religion perceived threat of west german domination proponents of religious economy theory may expect this distancing from gdr culture to be reflected in the change of religious demographics however the continued secularization of east germany in the years following religious deregulation are not cooperative with this postulate proponents of secularization theory can explain east germany no better for the dramatic religious decline between 1990 and 1996 does not correspond to the extent to which east germany modernized within this short sixyear timeframe furthermore the contentions of secularization theory are incongruous with the religious revival of the other postcommunist countries during this time as others have observed east germany is clearly an anomalous case for unlike other eastern bloc nations it cannot be explained by the prevailing theoretical paradigms of religious change to better understand this anomaly and in turn improve upon these theories focus must be directed toward the peculiarities of east german conditions while citizens of the other sovietoccupied countries retained their national identities after the collapse of the soviet union the gdr was subsumed under their western counterparts federal republic of germany east germans were no longer citizens of their former gdr though a sense of two national identities would persist although over 90 percent of east germans were in favor of reunification the unification process was abrupt westernled and perceived as a colonization of east german society unlike west germans east germans were hurled into a new situation in which they had to learn and adapt to their new society and national identity a division within technical unity was palpable throughout all of germany particularly in the eastern regions in a 1993 poll for example only 6 percent of east germans and 14 percent of west germans viewed eastwest relations in a positive light with 68 percent of east germans blaming the west for said polarization by 1997 67 percent of east germans claimed that they feel more east german than german east germans were symbolically ostracized as they were often the recipients of cultural teasing in his ethnographic work on eastern and western berlin police officers glaeser observes how west germans would rarely view east germans as equals often characterizing eastern society as an inferior state from which the west had nothing to learn from the west german perspective eastwest relations were something like that between adults and children where adults do not consult with their children on serious matters until they have grown up to become adults themselves as for materialist concerns it became more difficult for east germans to find employment as many of their formerly legitimate qualifications were deemed obsolete with reunification this was a particularly troubling development for east germany which had an unemployment rate that nearly doubled that of west germany in 1990 over 70 percent of east germans had a positive opinion about the economy though this percentage shrank to slightly below 20 percent by 1996 in 1995 nearly threequarters of east germans agreed that former gdr citizens are treated like secondclass citizens in unified germany this dissatisfaction became so prevalent that nearly half of east germans in 1996 even saw gdr times as good times where everyone was equal and we were all in work in reaction to the sudden westernled changes of the 1990s the phenomena known as ostalgie and nostalgie and trotzidentität surfaced in political and cultural ways between 1990 and 1998 for example sympathy toward socialist views more than tripled among east germans the party of democratic socialism a descendant party of the gdr benefited from this socialist sympathy as the vast majority of their support came from east german states eastern forms of defensiveness were not limited to economic assessments and protest voting but also operated in symbolic domains for example research on consumer trends in the former gdr show that old products of eastern origin became increasingly popular in the midtolate 1990s this was not a mere fad as 45 percent of east germans claimed to deliberately purchase eastern products as often as possible a similar form of this eastern contrariness can be observed in the postreunification revival of the jugendweihe with reunification the ceremony was no longer required for certain employment and educational opportunities jugendweihe participation thus dipped immediately after the fall of the gdr though it surprisingly rose after a few years of experience in unified germany with over 60 percent of east germans voluntarily participating in the ceremony by 1999 with these indications in mind it appears as if it was the collapse of the gdr that led to its symbolic return politically and culturally a reactive connection with the gdr identity materialized throughout east germany shortly after reunification identity formation depends upon the nature of the threat imposed by the otherized group in reaction to the threat of western domination of the east central facets of the eastern identity such as socialist sympathy eastern consumerism and jugendweihe participation were expressed in a voluntary manner among such reactions of eastern contrariness was the secular identity as indicated by the sharp decreases in church attendance belief in god and selfassessment of religiosity in the years following reunification relatedly pollack finds that east germans trust in the church declined rapidly in the 1990s and suggests that this decline could be attributed to the common perception of the church as either being or becoming a western institution literature in social psychology indicates that in reaction to threat groups seek a sense of social order a process which can involve identifying with salient collective traits as demonstrated by the examples here provided this reach for restoring normalcy and tradition could be observed culturally politically and religiously in the years following the collapse of the gdr it is in this light of ostalgie and trotzidentität which the secularization of the 1990s will be understood 4 perceived threat of migrant arrivals more recently a new cultural interaction has led to the materialization of a similar though distinct form of eastern reactivity sharp increases in germanys migrant population have brought immigration and asylum seeking to the center of political discussion in germany between chancellor angela merkels 2005 victory and the 2017 federal election 14534644 immigrants and asylum seekers have arrived to germany resulting in a net migration of 3887599 in 2015 alone 2136954 immigrants and refugees arrived to the country out of all firsttime asylum applicants in european union member states 61 percent registered in germany in the first quarter of 2016 over 20 million residents that being approximately onefourth of the german population reported having a migrant background in 2018 similar to the speed and extent of the countrys demographic changes citizen opinion on immigration has dramatically changed in 2016 414 percent of german respondents rather or entirely agreed that entry of muslims into germany should be prohibited a percentage which has nearly doubled since the 2011 edition of the survey was conducted within the same timeframe 50 percent of germans reported that they feel like a foreigner in their own country a figure that has increased by 198 percent in just 5 years out of all religious groups germans view muslims the most negatively with antimuslim sentiment most prevalent in the eastern regions of the country the majority of east germans perceive islam as a threat to germany and just over 10 percent agree that islam is compatible with german society according to all measurements antiislamic views are on the rise in germany and are particularly strong in the east perhaps the most notable manifestation of this reaction to migrant arrivals is the emergence of the alternative für deutschland or alternative for germany a farright populist party founded in 2013 some of the section headings in the partys manifesto include german as predominant culture instead of multiculturalism islam and its tense relationship with our value system islam does not belong to germany tolerate criticism of islam no public body status for islamic organizations and no fullbody veiling in public spaces consistent with the manifestos content past research has found limiting the arrival of muslim immigrants to be the chief concern of afd supporters ideological prioritizing of this kind is also characteristic of the patriotic europeans against the islamization of the occident a movement which like the afd advocates for the limiting of muslim influence in germany supporters of pegida reference immigration control nationalism and islam among their top reasons for joining the movement with over 80 percent of them fearing the loss of their national identity this nativism has been no more palpable than in the former gdr states particularly in the state of saxony saxony has long been a symbol of pride in german heritage and as has been touched upon was home to some of the most notable demonstrations of the peaceful revolution of 1989 in recent years however wir sind das volk has taken on a jingoist meaning as it is now often found on the signs held at antiimmigrant demonstrations within just six months after their founding pegida held 252 rallies with protestors totaling to approximately 240000 of these some 240000 protestors 80 percent of them protested in saxony like pegida support afd support is primarily concentrated in the eastern regions of the country between the 2013 and 2017 federal elections all of the highest upsurges in electoral support for the afd occurred in east german states saxony thuringia saxonyanhalt brandenburg and mecklenburgwestern pomerania while the afdpegida message has not gained much traction in the western regions of germany it has considerably resonated with east german sensibilities notably church commitment is negatively correlated with afd support and nonreligious voters are substantially more likely to vote for the afd than mainstream political parties such as the christian democratic union and the social democratic party 5 secularization a recurring reaction to symbolic threat among those concerned with the preservation of such symbolic dimensions of their identity we may again be witnessing a reaction of eastern identification in the face of cultural threat not unlike the eastern secularity that surfaced shortly after the westernled process of reunification a considerable number of east germans may now be responding to what they perceive as the newest form of cultural infiltration namely the recent spike in migrant arrivals this more recent cultural contrariness i posit may be associated with the intensification of the eastern personality when a group perceives a threat said group will pursue order and normalcy through a process of reactive identification many among the rightwing perceive the arrival of immigrants as a threat to their identity and thus it may be the case that yet another culturally defensive reaction of secularity is emerging although other researchers have noted the religious decline of the 1990s the literature has yet to explore the more recent secularization of the political right both reactive secularities i contend revolve around the mechanism of defending the eastern identity in the face of cultural threat related research has surfaced in recent years though it would be an overstatement to claim that the literature has achieved scholarly consensus inglehart and norris find a positive association between religiosity and rightwing populist support others have found religiosity to have little effect on radical right voting while other research claims that the relationship is further complicated when religious orthodoxy is brought into the scope of analysis although the relationship between secularity and rightwing ideology has received some attention the change in this relationship over time has been repeatedly overlooked thus the current theoretical backgrounds are severely limited leaving changes in the given political landscape unconsidered to advance toward more lucid determinations future inquiry should be cognizant of the potentially catalytic contextual factors pertinent to their research how these factors have changed over time and in turn affected the given relationship under examination rightwing populist support is a telling phenomenon which provides indications of social logics relevant to the present discussion though it does not entirely encompass the symbolic variant of group threat with which this work is concerned the cultural defensiveness that materializes with the detection of a cultural threat is not only a political but also an emotional reaction which may operate within but also outside of afd voting and rightwing ideology in general this reactive emotionality and identification have more to do with pure antipathy toward and fear of the otherized group than it does with party support andor policy position the conceptual demarcation here is in accordance with a characterization from quillan who notes that prejudice is characterized by irrationality and emotional evaluation thus in addition to considering religious change among the rightwing this work taps into this emotionality by examining fear of foreign domination as it relates to the secular identity in the years following increases in migrant arrivals xenophobic attitudes are on the rise in germany and are particularly prevalent among east germans as well as rightwing groups similar to the ostalgie of the 1990s it is possible that the more recent perceived threat of migrant arrivals has led to a defensive reaction of secular identification among the rightwing and culturally vulnerable in the east assuming this is indeed the case i expect to find a significant religious decline among the east german rightwing between 1999 and 2017 if secularity is a part of the eastern reactivity i have here described then a positive relationship between fear of foreign domination and the secular identity will be found in the context of east germany methods to test these expectations i rely on data from evs and allbus notably i am unable to fully establish construct validity with the available data though this analysis still provides empirical indications that align with my theoretical contentions i use the 1999 and 2017 datasets from evs to examine religious change by political ideology 6 the association between xenophobia and religiosity is measured with the allbus 2018 dataset as it contains a metric that most precisely captures the fear of foreign domination with which this work is concerned dependent variables religiosity is the dependent variable in the current study i measure religiosity with binary indicators of church attendance belief in god and selfassessment of religiosity each dimension of religiosity is analyzed separately to capture their respective nuances when using the evs datasets respondents are coded as attending church if they report attending once a month or more frequently when asked if they believe in god respondents are given yes or no as response options for selfassessed religiosity respondents are coded as religious if they consider themselves to be a religious person as opposed to responses that earn an irreligious categorization not a religious person and a convinced atheist when using the allbus dataset respondents are considered to attend church if they report attending 1 to 3 times a month or more the following responses are categorized as believing in god i believe in god now and i always have or i believe in god now but i didnt used to for selfassessed religiosity respondents are considered religious if they describe themselves as extremely religious very religious or somewhat religious 7 independent variables political ideology and fear of foreign domination are the focal independent variables leftwing moderate and rightwing are the three categories representing political ideology in each dataset this categorization is determined by selfidentification on a scale ranging from 1 to 10 with 1 representing the farthest left and 10 the farthest right respondents who place themselves between 1 and 4 are coded as politically leftwing 5 as political centrists and between 6 and 10 as politically rightwing 8 respondents are considered to exhibit fear of foreign domination if they tend to or completely agree that because of its many resident foreigners germany is dominated by foreign influences to a dangerous degree 9 fear of foreign domination is coded as a binary variable control variables i control for age sex level of education and monthly income allbus 2018 and evs 2017 use slightly different income brackets when using the allbus dataset i divide income level into the following three categories under 2250 euro a month 22503999 euro a month and over 3999 euro a month analytic strategy in the following analyses east and west germany are analyzed separately 10 this comparison assists in conjecturing as to whether the expected relationships are connected to the overarching secular history of the gdr or alternatively if they simply exist throughout all of germany furthermore both secularity and antiimmigrant attitudes are more prevalent in east germany than they are in west germany thus the two regions must be divided in this analysis to address any potential issues pertaining to a regional confounder in west germany i do not expect to find a period of rightwing secularization nor a strong relationship between secularity and fear of foreign domination for western forms of cultural reactivity are not mediated by an atheistic history i thus suspect these findings to be particular to the eastern regions of the country using the evs datasets i report the percent change in religiosity among each political ideology category between 1999 and 2017 to test whether the association between religiosity and political ideology changes over time i use multivariate models that account for controls append the evs 1999 and 2017 datasets and interact time with political ideology specifically i estimate logistic regression models to predict religiosity and interact a binary indicator of survey year with the categorical measure of political ideology following the guidance of ai and norton i do not interpret the coefficient of the interaction term but instead assess the interaction using predicted probabilities and marginal effects the relevant marginal effects calculated as the difference in the predicted probability of religiosity between the leftand rightwing within each year are presented negative views of immigrants are of course not entirely subsumed under the political right to provide further indicative support of my theoretical claims it is thus important to examine not only rightwing ideology but more particularly fear of foreign domination in order to understand the cultural reactivity in the east using the allbus 2018 dataset i estimate additional multivariate logistic regression models to predict religiosity with fear of foreign domination as the focal independent variable the estimates are presented as odds ratios i then test whether the association between fear of foreign domination and religiosity are significantly different by region to do so i interact a binary indicator of region with fear of foreign domination and assess the interaction using predicted probabilities and marginal effects results table 2 shows that the rightwing in east germany have demonstrated sharp drops in religiosity by all of the tested metrics the same degree of religious change cannot be observed among the politically moderate and leftwing which demonstrate slight decreases and increases in religiosity respectively with this period of religious change the rightwing has become as secular as moderate and leftwing respondents in fact the rightwing reports the lowest rates of church attendance among the three ideological categories this pattern appears to only pertain to east germany for secularization is not particular to the rightwing in west germany to be clear it is not the case that east germany including respondents of all ideologies has dramatically secularized between 1999 and 2017 as religiosity rates have remained relatively static within this timeframe rather the period of secularization shown is particular to the east german rightwing who are more likely to exhibit fear of foreign domination than their leftwing and moderate counterparts in figure 2 a significant reduction in religious activity among rightwing respondents can be observed between 1999 and 2017 in east germany in 1999 rightwing respondents in east germany are by all metrics more likely to be religious than are leftwing respondents these relationships are stronger and more significant in the east than they are in the west given the atheist proselytization that took place during the reign of the gdr a perceived incompatibility between religious thought and leftwing ideology was likely not uncommon among east germans in the years following reunification this perception of mutualexclusivity was perhaps not as pronounced in the historically less regulated west in 2017 east germany however the political right has become virtually identical to the political left by every measure of religiosity indeed political ideology is no longer a predictor of religiosity in the way that it was in 1999 the results indicate that this phenomenon is particular to the east as the religious differences between leftand rightwing respondents remain significant in west germany in east germany i find a significant reduction in the religious disparity between the leftand rightwing in terms of church attendance belief in god and selfassessment of religiosity by no metric of religiosity are these changes significant in west germany in the years following increases in migrant arrivals the secular identity has become more common among the political right in east germany this phenomenon is particular to the rightwing as respondents of the other political orientations do not come close to mirroring this degree of secularization in accordance with evs data data from allbus show that political ideology does not predict religiosity in east germany unlike data from evs however table 4 shows that the relationship between political ideology and religiosity is insignificant in west germany while there are no longer significant religious differences across the political aisle fear of foreign domination holds a strong inverse relationship with church attendance belief in god and selfassessment of religiosity in east germany it is clear that this relationship is more palpable in the east as the associations do not achieve statistical significance and vary in direction in the west these results demonstrate that it is not a confounding rightwing ideology in general but more specifically a fear of foreign domination that predicts the secular identity in east germany rightwing as respondents of the other political orientations do not come close to mir ing this degree of secularization while it is a cultural rather than socioeconomic threat with which this work is concerned it is important not to overlook the role of variables related to deprivation east germany is not as economically stable as west germany and thus one could reasonably suspect forms of cultural identification in the east to be linked to economic intimidation as for the reactive secularity under examination however the data do not reflect this anticipation in relation to the tested metrics of religiosity level of education and income are inconsistent in direction and do not once achieve statistical significance in east germany there is no evidence to suggest that socioeconomic variables link to the reactive process of secular identification in this analysis this finding may suggest that this phenomenon is more likely a matter of cultural competition rather than of economic worry discussion although the prevailing theories of religious change cannot explain the case of east germany i have here suggested that a focus on symbolic group threat may help make sense of this empirical puzzle the impact cultural threat can have on identity formation has been largely ignored in discussions of religious change while symbolic threat theorists have been cognizant of the relationship between cultural threat and identity formation my article examines these dynamics over time and integrates them into a discussion of religious change when a group perceives a cultural threat increases in central characteristics of the identity of said group can be observed this article has outlined how against the prevailing theoretical expectations east germany became increasingly secular after the process of reunification and consequent deregulation of religion to understand this exceptionalism i theorize that this period of secularization is connected to the ostalgietrotzidentität phenomena which surfaced in reaction to the threat of west german domination i then contend that a similar mechanism of reactive identification has recently surfaced on the right in the face of a new cultural threat namely the fear of germanys migrant population between 1999 and 2017 the data show that sharp drops in religiosity have occurred among the political right in east germany this is the first article to produce a finding on rightwing secularization in any context these decreases are particular to the east german rightwing as they cannot be observed among leftwing and moderate respondents nor is this pattern found in the context of west germany differences between east and west germany i argue could be understood in light of their respective overarching religious histories secularity for example was inextricable to the character of the gdr in a way that it was not to that of the bonn republic this article also demonstrates that secularity and fear of foreign domination are closely related in the east whereas the associations are not at all noteworthy in the west it appears that the eastern trait of secularity repeatedly emerges among those who perceive cultural threats such as reunification in the 1990s and liberal immigration law in recent years given the cultural and economic differences between east and west germany both materialist and symbolic threats are worthy of consideration within the process of secular contrariness however the results provide little reason to suspect that this reactivity is in connection with materialist concern neither education nor income play a role in the reactive secularity under examination this finding may indicate that it is not economic vulnerability but rather fear of cultural denigration that plays a role in the materialization of the reactive identity further study on this matter is warranted however as previous findings concerning the associations between conditional variables and forms of cultural reactivity have been mixed although it is the intricacies of only one country that i have here examined i encourage other researchers not to overlook the importance of thorough historical political and cultural investigation of a specific context the nature of the reactive identity will depend upon the contextual factors in which it is engulfed indepth analyses of certain conditions particularly when they deviate from prevailing theory and expectation can inform our theoretical development by identifying catalytic factors which would go undetected with broader analyses it is important for detailed examination of this kind to be in conversation with broader comparative approaches for such collaboration can help inform future criteria used in the process of selecting which variables to examine as voas andchaves note religious differences between countries are a matter of history and culture and explaining them always requires a combination of the general and the particular territorial shifts immigration policy and religiosity are certainly not the only factors that could be tested within the theoretical framework i provide when a certain population perceives a threat to their identity a reaction of collective identification may emerge religious change among the respective population could be understood in light of their relation to and the unraveling of the cultural and historical idiosyncrasies of the given context future research could identify one of the many contexts in which a nativist or culturally defensive population exists select an aspect that is central to this populations national character and observe how this trait changes before and after exposure to the perceived threat the variables selected for analysis should vary by context for it is a mechanistic focus on cultural vulnerability and in turn reactivity which could provide potential avenues for replication the emphasis on contextual particularity is especially crucial when attempting to explain anomalous cases in the case of east germany the prevailing theoretical paradigms of religious change fall short of an explanation and thus an opportunity for theoretical improvement presents itself drawing on the peculiarities of east germany i have found a focus on symbolic threat and subsequent identity formation to be a useful point of departure little work has been done to understand the historical and cultural dynamics of secularization to adequately elucidate the dynamics of cultural identification researchers must be sensitive to the complexities of the historical and political conditions relevant to their analyses historicization of this kind can assist in analyzing important changes in light of culturally vulnerable reactions which are by necessity filtered by the overarching national character of the given context as can be seen in table 1 poland also shows a period of religious decline between 1990 and 1996 unlike east germany however poland was a religiously saturated country prior to the collapse of the soviet union 2 although a degree of modernization took place in east germany with democratization it is very unlikely that the sharp decreases in religiousness observed in table 1 could be attributed to the relatively marginal modernization that took place within this very short timeframe of six years i suspect that even the most radical secularization theorist would agree 3 related research has found religiosity to have a weak relationship with farright voting my findings are distinct however as i examine not just rightwing secularity but also rightwing secularization over time it may also be worth noting that relative secularity can be found in certain forms of rightwing populist rhetoric in other contexts such as the rhetoric of geert wilders in the netherlands however whether such rhetoric has spurred secularization has not been demonstrated this is not to suggest other factors did not contribute to this period of religious decline for example the religious decline observed during this time may also be due to factors such as the introduction of church taxes and intergenerational religious change this period of secularization is not limited to either of these factors however while the introduction of church taxes may lower church attendance there is no reason to conclude that it would bring about such abrupt decreases in religious belief or identification the same can be said of the effect of intergenerational religious change within the very short sixyear timeframe contained in table 1 5 in terms of church attendance belief in god and selfassessment of religiosity data from the european values study show that the afd consistently report the second lowest rates of religiosity among all party constituencies in germany the only constituency less religious than the afd is die linke which is no surprise considering that die linke is the current descendant party of the gdr 6 the 2017 data are from the integrated dataset matrix design dataset this was the latest version of the dataset when this project began it can be made available upon request by contacting gesis leibniz institute for the social sciences 7 belief in god and selfassessment of religiosity are contained in the international social survey programme module of the dataset and thus there are fewer cases to observe for these metrics than there are for church attendance 8 although it may appear that this coding would minimize the potential size of the moderates group it must be noted that 5 is by far the most frequent selfcategorization with 1465 cases this coding is a function of the distribution of the ideology variable as 9 and 10 are the two smallest categories reporting 50 and 102 cases respectively even among afd supporters 5 6 7 and 8 are each individually more frequent selfassessments than 9 and 10 there are considerably more cases on the lower end of the ideological spectrum with 156 and 242 respondents categorizing themselves as 1 and 2 respectively with the coding scheme employed for this dataset there are 1705 leftwing cases 1465 moderate cases and 1553 rightwing cases 9 respondents who tend to and completely agree are analyzed together rather than separately to assure that there are enough cases to conduct the analysis combining these responses in the generation of this variable of fear of foreign domination is particularly important because this metric comes from the allbus dataset in which two of the three metrics of religiosity are contained in the international social survey programme module which is a subsample of the allbus dataset 10 evs 2017 does not divide berlin into its former east and west territories to assure accurate geographical representation is achieved i test both possible categorizations of berlin for analyses using evs 2017 data in this article berlin respondents are excluded from the east german category and instead categorized as west germans however i perform the same analyses with berlin categorized as an east german city this recategorization does not affect the results in a meaningful way data availability statement the 2017 data are from the integrated dataset matrix design dataset this was the latest version of the dataset when this project began it can be made available upon request by contacting gesis leibniz institute for the social sciences the 2018 allbus data are publicly available accessed on 1 may 2023 appendix a

in this article i integrate symbolic threat dynamics into a theoretical discussion of religious change specifically this article demonstrates how symbolic threat can lead to increases in salient collective characteristics among members of the threatened group to make this case i examine the religious and historical idiosyncrasies of east and west germany in the context of east germany i find a dramatic reduction in religious activity among the rightwing between 1999 and 2017 as well as a strong relationship between secularity and fear of foreign domination mediated by the deeply atheistic history of east germany secularization is here presented as a reaction of eastern identification that repeatedly emerges in the face of cultural threat to empirically illustrate my theoretical contentions i rely on survey data from the european values study evs and german general social survey allbus

introduction in 2011 the groundbreaking exploring health disparities in integrated communities study found that racial disparities in hypertension diabetes obesity among women and use of health services either disappeared or substantially diminished when comparing a sample of black and white residents of baltimore maryland who lived in racially integrated neighborhoods under comparable living conditions 1 the results suggested that the social environment may largely drive racial health outcomes in us populations emphasizing the role of place in understanding health disparities however that study left the question of whether despite equal health outcomes racial disparities in health expenditures would disappear or diminish even at equal levels of health racial disparities in health care expenditures could arise due to care that is delayed not recommended or avoided because of structural and interpersonal racism 2 or due to differences in quality of insurance or treatment 3 expenditures may be higher for black individuals if delays lead to higher health care expenditures when unmet health needs escalate and become urgent and critical or if patients are shifted into more costly health insurance plans expenditures could be lower if black adults are unable to be retained in care due to biases in the health care system 2 or if care is underused due to differences in which practitioners are in network or due to insurance reimbursement structures given the persistence and size of health disparities between black and white individuals 4 and in followup to the ehdic study 1 our analysis intended to answer the question of whether health care expenditure differences are minimized when black and white individuals live in similar areas in the us we defined areas that are similar by levels of racial and economic segregation as an advancement from previous studies that have looked at health care outcomes in 1 city 156 our analysis focused on health care expenditures of black and white residents in census tracts across the entire us we hypothesized that there would be no difference in health care expenditures by race when black and white adults live under similar conditions of economic and racial segregation in line with previous studies that suggest no difference in health outcomes by race when black and white people live under similar conditions 156 methods data sources study population the analytic sample included 7062 black or white meps participants aged 21 years or older who live in 2238 of 2275 us census tracts from 47 states where the population is at least 5 black we excluded participants with outlier expenditures and any participant for whom we could not calculate an index of concentration at the extremes value another 335 participants were excluded from the analytical sample who did not have positive sampling weight the efigure in supplement 1 presents the flowchart of sample selection we excluded participants of hispanic ethnicity and persons of other race groups given the nature and history of segregation of black and white individuals in the us as well as the unique needs of more recently immigrated populations the mechanisms underlying differences in health care expenditures for these other populations may be different and warrant separate analysis health care expenditures the dependent variables were a binary variable that indicated health care expenditure and a continuous variable for the total amount of health care expenditure on health care services in 2016 in addition variables were generated for 2016 health care expenditure by category of health service officebased visits outpatient visits emergency department visits inpatient hospital stays prescription medicines and dental care visits expenditures in the meps are defined as the sum of direct payments which include both the outofpocket payments and payments made by insurance race and raceincome segregation the independent variable was meps participant race categorized as nonhispanic black or nonhispanic white we excluded participants of hispanic ethnicity and of other race groups the analysis was stratified by census tractlevel ice values for race and income a marker of racialized economic segregation 8 the ice measure was calculated as the difference between the number of white persons in highincome households and black persons in lowincome households divided by the total population with known income in the same census tract 9 quintiles were selected to define strata to be consistent with prior research 9 using the ice measure quintiles for the ice measure were computed based on the distribution among census tracts of all meps participants aged 21 years or older who lived in census tracts where at least 5 of the population was black ice q1 had the most population concentrated into the most deprived groups and ice q5 had the most population concentrated into the most privileged groups statistical analysis characteristics and health care expenditures of participants were summarized and compared across ice quintiles using the pearson χ 2 statistic for categorical variables and the wald test after fitting weighted linear regression for continuous variables next characteristics of black participants were compared with characteristics of white participants living in ice q1 and q5 and q3 twopart models were constructed to model health care expenditures comparing black participants with white participants living in the same ice quintile next the incremental expenditures comparing black participants with white participants were estimated based on the combined part 1 and part 2 of the models part 1 of the model was a logit model estimating the odds of having any expenditures yielding odds ratios of having any total or typespecific health care expenditures comparing results of the total 7062 meps black or white respondents who lived in census tracts with a 5 or greater black population in 2016 331 identified as black and 669 identified as white as indicated in table 1 the distributions of age and sex were similar across incomerace ice quintiles however most other demographic characteristics of residents in these census tracts varied significantly by incomerace ice quintiles higher ice quintiles had significantly fewer black respondents more people with posthigh school education higher income less poverty higher levels of employment and insurance better mental and physical health fewer comorbidities fewer reports of difficulty paying medical bills and highest access to a usual source of care as shown in table 2 across incomerace quintiles there was an increasing trend in the median amount and likelihood of expenditures in total health care officebased care prescription drug use and dental services from q1 to q5 with a decreasing gradient in ed expenditures mean outpatient and inpatient expenditures showed no clear pattern across the gradient across all expenditure categories the percentage having any expenditure followed similar patterns a comparison of black and white respondents suggested that even in areas where black and white populations live under similar conditions their landscapes are different in q1 black respondents were more likely to be female have fewer years of education have lower family income have higher rates of public insurance or uninsurance and have better mental health than white respondents in q3 black respondents were more likely to be employed and to have no comorbidities but were otherwise demographically similar to white respondents in q5 black respondents were younger and had lower income greater exposure to poverty nearly 3 times the rate of uninsurance and almost twice the likelihood of having problems paying medical bills the number of comorbidities was similar for black and white respondents in q1 and q5 although black respondents were likely to have fewer comorbidities in q3 ratings of good physical and mental health were similar for black and white respondents in q1 q3 and q5 except for a significantly greater percentage of black compared with white respondents reporting good mental health in q1 in the part 1 fully adjusted models of expenditure within each of the incomerace ice quintiles for black and white respondents was in q3 the most racially and economically integrated area discussion our analysis sought to answer the question of whether differences in health care spending among black and white adults would be minimized when black and white adults lived under similar conditions our results offer 2 key takeaways differences in the uptake and amount of annual health care spending by black and white adults were minimal in areas where black and white adults lived under similar conditions of minimal racial and economic privilege and in contrast black adults had 56 lower odds of having any total health care expenditures in areas of mostly white highincome adults and among those with any expenditures spent 30 less on health care black adults in areas of mostly white highincome adults had increased odds of having any ed expenditures and reduced odds of having prescription drug or dental care expenditures likely driven by the significantly higher rates of uninsurance for black adults in these areas there was no significant difference in the amounts spent when looking only among black and white people who had any expenditurea proxy for equitable health care access altogether our results suggest that expenditure disparities may disappear but only under conditions of both racial and economic equity and equitable health care access black adults who spent at all on health care spent equal to or significantly less than their white counterparts who lived under similar social and economic contexts with the exception of higher outpatient expenditures in q2 in the areas that were mostly high income with mostly white residents this amounted to 2145 less spent annually by black adults it is possible that black adults have reduced odds of health care expenditures because they are healthier and do not need the care this hypothesis might be supported by the body of research suggesting that due to longstanding disinvestment in black neighborhoods white people living in predominantly black areas have poorer health than white people living in nonblack segregated areas 1415 however in the following paragraph we point to several results to support that lower odds and amounts of health care spending are more likely because black adults are missing out on care that they need in areas of extreme racial and economic deprivation or privilege black and white adults had equally good physical health and similar comorbidities yet black adults still had reduced odds of any health expenditures and lower spending in the most integrated areas black adults had fewer comorbidities yet similar overall health spending among those who did any spending black adults in somewhat integrated areas spent 64 more on outpatient care in the most integrated areas but 38 less on inpatient expenditures which white respondents could be driven by these fewer comorbidities the specific category of care driving reduced odds of having any health care expenditure was dental care not inpatient or outpatient care as would be expected for comorbidities routine dental care is considered elective care and incurs high expenditures that those with few resources or reserves might forgo low use of dental services may be a better marker of a health disparity than having healthy oral care 16 these findings work against the idea that reduced odds of spending by black adults is due to better health because even at equal levels of health black adults have lower odds of having health care expenditures than white adults rather it may be that black adults are forgoing care and may be underserved despite being at equal health as white adults lower odds of health care spending may be attributable to lower access to health insurance or poorer quality of insurance which would be supported by our findings that most differences in health care expenditures disappeared when only looking at patients with any health care spendinga proxy for people who have entry to at least a minimum of health care furthermore black adults in the areas of highest white racial and economic privilege were 3 times as likely to be uninsured and have significantly lower income in those areas such low rates of insurance and lower economic resources likely mean lower use of health care even when needed because of affordability barriers several studies have suggested that insurance access remains a barrier to timely and affordable care even after implementation of the patient protection and affordable care act and leads to avoiding or paying higher outofpocket costs for care 17 even with insurance black adults often do not get highvalue care and have fewer insurance options from which to choose 18 which may reflect systems of structural racism in health care because our study could not assess the reasons for health expenditures we cannot know whether for example patients receiving lowvalue care at the ed could have otherwise received highvalue primary care or whether their lack of primary care led to a more advanced condition that warranted ed care a recent analysis found that black medicare beneficiaries are more likely than white beneficiaries to be admitted to a hospital or to seek care in an ed for conditions that would otherwise be managed through good primary care 17 the referral to lowvalue care is often a response to poor insurance coverage which our findings also support in the thricehigher rates of uninsured black adults in q5 coinciding with lower use of officebased services and greater use of ed expenses another analysis found that areas with high black concentrations had fewer insurers participating possibly suggesting that even when black residents of these areas have access to health insurance there are fewer offerings of insurers and fewer physicians offering innetwork services 18 thus similar to what we found for the area with the highest concentration of black adults higher expenditures on care may be due to less spending for officebased care with greater spending on ed care to compensate another possible explanation for the lower expenditures for black adults is that white adults are overusing care or receiving care at facilities that have higher costs for services although our study cannot assess the extent to which white patients are overcharged previous work supports that white adults have more extensive use of health care services than black adults 19 have greater health care spending even when under the same insurance plans and at equal levels of health as black adults and spend a greater proportion on primary care or specialty care than ed care 20 although we cannot rule out the possibility of overuse or being charged at higher costs the differences in distributions of socioeconomic position and health insurance for black and white adults suggest that black and white people in areas that are equal in racial and economic segregation may still live very differently and have different access to health care quality limitations this study has some limitations although our study aimed to explore differences in health care expenditures in areas where black and white people lived under similar conditions and expanded on previous studies by looking at both racial and economic segregation our analysis may not fully capture how black and white adults live in similar conditions our analysis was restricted to census tracts with 5 or more black residents in doing so many white respondents were excluded whereas black respondents were more evenly distributed across the incomerace quintiles however this criterion also yielded more black respondents in the highest quintile which we otherwise would not have been able to assess because of few black respondents dr dean had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis

importance evidence suggests that racial disparities in health outcomes disappear or diminish when black and white adults in the us live under comparable living conditions however whether racial disparities in health care expenditures concomitantly disappear or diminish is unknownto examine whether disparities in health care expenditures are minimized when black and white us adults live in similar areas of racial composition and economic condition design setting and participants this crosssectional study used a nationally representative sample of 7062 nonhispanic black or white adults who live in 2238 of 2275 us census tracts with a 5 or greater black population and who participated in the medical expenditure panel study meps in 2016 differences in total health care expenditures and 6 specific categories of health care expenditures were assessed twopart regression models compared expenditures between black and white adults living in the same index of concentration at the extremes ice quintile a measure of racialized economic segregation estimated dollar amount differences in expenditures were calculated all analyses were weighted to account for the complex sampling design of the meps data

introduction modernization is a broad concept that refers to major social changes that occur when a preindustrial society develops economically such as industrialization urbanization and bureaucratization since the reform and opening up in 1978 china has been moving toward modernization with some specific features first china is becoming an aging society from 1999 to 2018 the number of senior citizens of 65 years or older in china increased from 86 to 166 million however low fertility since the late 1970s especially in urban areas led many young chinese to not have siblings to share the traditional elderly care obligations increasing their burdens second western technology political systems and culture became a referential frame for the modernization of china although some scholars attempted to preserve chinese traditions regardless of modernization others considered modernization to be a transformation of essence in the sense of general social consciousness production and lifestyles for example two research studies conducted in urban and rural areas in china have both claimed that the chinese society is on the path toward individualization with the pursuit of privacy independence choice and personal happiness being popularized and becoming the new family ideal for chinese people however some research has held a middle ground for example ji claimed that chinese individuals are embracing modernization individual identity and independence and compromising tradition when necessary although they still subscribe to patriarchal norms third modernization changed the power relationships in chinese society modernization theory said modernization diminishes the status of older adults and disadvantages older generations consequently people living in more modernized societies may hold more negative attitudes toward the aging people and the elderly than those living in less technologically developed countries in traditional chinese culture people respect seniors regarding them as having wisdom and authority however an old chinese saying suffering will occur if you do not listen to seniors advice has been restated nowadays by young chinese adults as happiness will last for years if you do not listen to seniors advice the stereotype content model categorizes two dimensions of stereotype warmth and competence and their crosscultural study found that globally people regarded seniors as high in warmth but low in competence including people from hong kong china some studies have also shown that although china is still on the path to modernization the image and status of older people have already been negatively affected luo et al found that chinese students were more negative about their older adults than were their american counterparts even though china is less modernized than the united states this result cannot be explained by modernization theory vauclair et al suggested that cultural differences in ageism are more nuanced than suggested by modernization theory other studies turned to the role of antecedents of ageism such as knowledge and anxiety about aging luo et al also claimed that a lack of gerontological curriculum in the chinese educational system the caregiving burden faced by the onechild generation compounded with a lack of governmental support for caregiving as well as the rising youthoriented consumerist culture may account for chinese students more negative attitudes toward the aging people and the elderly fourth modernization leads to the breakdown of the traditional extended family and the emergence of the individualistic nuclear family yan said that the individualization of china leads to the pursuit of independence of youth replacing the traditional big family ideal traditionally children lived under the same roof with and took care of their aging parents nowadays the emptynest living arrangement is becoming increasingly common for chinese seniors and the number of emptynest elderly people who are living without children is increasing some researchers found that compared to nonemptynest elders emptynest elderly people had lower psychological wellbeing and poorer mental health more loneliness and depression however other researchers found that emptynesters were no different from nonemptynesters concerning loneliness and subjective wellbeing emptynest elderly people were higher in subjective wellbeing and life satisfaction than nonemptynest elders although these research studies have produced inconsistent conclusions some researchers blamed young chinese adults for the emergence of emptynest elderly people accusing them of abandoning their filial piety obligations filial piety is an important cultural concept in traditional china and other eastern countries it requires children to make sacrifices for their parents to ensure the continuation of their parents happinessnot only by respecting older generations but also by taking care of aging parents by living together it was said that people in china were looking forward to entering into old age where they will enjoy prestigious roles and statuses both within the family and in society however modernization theory maintains that as society becomes modernized filial piety diminishes according to this theory ageism may increase with modernization and children may live independently with parentsleaving many elders as empty nesters yet some researchers have not supported modernization theory completely according to the traditionalmodern theory of attitude change when traditional cultural ideas conflict with modern culture important traditional constructs will continue in the traditional direction while unimportant traditional constructs will change in a modern direction filial piety is an important traditional construct in china so it should continue in a traditional way however research has found that explicitly this was the case but implicitly filial piety was changing in a modern direction affected by modern individualistic westerninfluenced cultural ideas bedford and yeh discussed the evolution of the conceptualization of filial piety and developed the dual filial piety model this model suggests two kinds of filial piety reciprocal and authoritarian reciprocal filial piety is defined as affectionbased gratitude and respect for parents efforts while authoritarian filial piety refers to the relationship hierarchies and role obligations that demand childrens compliance with their parents yeh and bedford found that college students had higher levels of reciprocal filial piety than authoritarian filial piety feng argued that chinese filial piety is going to be more reciprocal and less authoritarian young chinese adults will still respect elders but will not completely obey them aforementioned contradictory results were almost all from quantitative studies using predetermined closedended questions about the attitudes of the participants these methods may limit the participants answers and fail to shed light on their attitudes in the context of chinese modernization aging and low fertility increased elderly care burdens on young chinese people young chinese people are still the main force of elderly care and will continue this in the near future because to date there is no functioning nonfamilial elderly care system in china and 90 of seniors still rely on familial care will young chinese people be ageist will they hold onto some positive attitudes about seniors and seniors attitude dimensions apart from warmth and competence if so what would these attitudes be moreover what exactly are the attitudes of young chinese adults toward living independently from their parents are they less willing to take care of seniors and live together in general will modernization lead young chinese people to be less filial understanding these questions is important because they relate to future elderly care problems in china however we need more exploratory methods to answer these questions we assumed that in the context of modernization and between the conflicts of traditional and modern cultures answers may be more complicated than filial versus unfilial ageist versus not ageist prefer to live independently versus do not prefer qualitative methods offer us a way to hear about the different attitudes and the various voices among young chinese people through openended questions about both common attitudes and rare attitudes materials and methods researchers yzh jt and tl served as the primary research team and yzu and qh provided an outside audit to check on the findings of the research team in qualitative research it is crucial that researchers address possible biases that might contaminate the coding and analysis of the data although they may be firmly committed to honoring the data no researchers are without bias therefore we tried to articulate these biases at the outset of the study by exploring and discussing our attitudes toward aging and living with parents as well as our research hypotheses in the team setting them aside during the analyses and reflecting on their effect on the analyses by writing reflection memos and discussing these with team members as has typically been suggested for those involved in qualitative research for readers to evaluate the validity of results we share the attitudes of the research team yzh said she agreed that living independently with children is not necessarily bad for old parents but it could be an active choice of old parents jt said she thinks being old is unimaginable and lonely she wants to be with family when she is old so she also wants to accompany her parents when they are old tl said he wants to be a filial son and wants to have his own career but he thinks the two are not contradictory because living a good life is another kind of filiality yzu said she believes that young chinese should respect seniors but it was unnecessary that they should live together because there will be lots of familial conflicts by living together and qh said she thinks people could age gracefully and be productive and old parents should not live together with children when old parents could not take care of themselves children could hire senior workers to take care of their parents indepth interviews a demographic form about age hometown etc was provided to interviewees to fulfill before interviews semistructured interview protocols were used with all interviews modifications were made after several interviews questions in the final protocol are motivations to attend this study eg why do you want to attend this study attitudes toward older adults and aging eg what are your perceptions of older adults and aging attitudes toward living independently eg what are your perceptions of older adults living without children and coping with aging in the future eg what will you do when your parentsyou become old in the future each member of the primary research team interviewed 15 participants in chinese each interview lasted from 20 to 50 min after an interview was finished it was transcribed and analyzed in a week by the interviewer transcripts were assigned a code number to maintain confidentiality data analysis data were managed and analyzed according to consensus qualitative research methods in nvivo 120 case summary before coding a certain transcript a research member read the transcript briefly and created a case summary which included about 200 words describing the attitudes of aging and living independently of the participant as well as the readers initial ideas and feelings after reading the transcript although hill et al recommended keeping memos or notes about impressions and comments immediately after the interview we wrote case summaries after transcription the reason for this was that emotional involvement after an interview could sometimes be overwhelming case summarizing after transcription provided a step distance creating an emotional connection without getting too involved however this does not mean that researchers were forbidden from keeping memos after the interviews if they wanted to they were free to do so these memos and case summaries worked as both search tools for us to search basic information of participants quickly and reflection memos because initial thoughts and feelings were more intuitive less susceptible to bias and research expectations and more conducive to finding situations that are different from what we assumed coding of themes the primary team members examined the first three transcripts individually and placed each block of data related to the same idea into initial themes later transcripts were coded according to these initial themes but when initial themes were not applicable either theme was modified or a new theme was generated disagreements about themes and how to block the data were discussed until the team reached a consensus which was audited by yzu and qh and then reviewed again on the basis of their comments four major themes were identified diverse attitudes toward older adults perceptions of reasons that lead to unhappinesshappiness in old age attitudes toward living with and without children and attitudes and coping strategies when parentsthemselves are old results were translated into english coding of categories after blocking data into themes the three primary team members independently read data within a given theme and coded them sentence by sentence each member then categorized codes and devised hierarchical categories after that the team met as a group to discuss their codebooks and to arrive at a consensus about the categories and how to word them the themes and categories were continually modified throughout the process to reflect the teams ongoing understanding of the data audit codebooks were then sent to the two auditors who read them suggested additions and deletions and returned them to the primary team for further discussion and revision the primary team then reviewed each case to make sure they had been consistent over time and to be certain that they had remained true to the participants perspectives revisions were made to the themes and about what was included in the themes for each case the team added notes where appropriate to help them remember issues and questions that occurred to them but these were not directly stated in the data then every case was examined again by the team members who arrived at a consensus over changes crossanalysis using the consensus versions of the codebooks the primary team met and conducted crossanalysis for all transcripts the purpose of doing the crossanalyses was to compare the codebooks to determine consistency across the transcripts we also wanted to ensure that we were applying the same criteria across transcripts we reviewed each theme separately and evaluated categories when a category was identified for certain cases we returned to the raw data to determine whether the same category also fits other cases during this process the team developed dimensions for some categories the team then calculated the number of participants who mentioned a certain dimension of each category for comparison although some researchers did not support counting exact numbers because participants were not asked the same questions in the same way therefore counting numbers could be misleading nonetheless we counted the number of participants rather than using the labels general typical and variant as in cqr to replace numbers this was the case because the number of participants in our study was much larger than in the regular cqr process so that most of the categories were typical thus only showing labels could not provide enough information for comparison however using numbers was not meant to convey generalizability beyond the study population stability check after we interviewed the 40th participant and analyzed the transcripts no new themes or categories were added assuming that the data were saturated or stable even though hill et al recommended a sample size between 8 and 15 participants we interviewed more participants because we could not reach saturation with 15 participants moreover to check whether the data were truly saturated five more interviews were conducted each of the categories for the five cases was placed into the existing crossanalysis by the two auditors no new categories were added the new cases only changed the frequency of each category consequently we determined that the data were stable and that additional cases were unlikely to change the results in any significant way in total we conducted 45 interviews bias control to ensure greater credibility first each team member was conscious of her or his attitudes about aging and living independently second each researcher wrote independent methodological and reflective memos about the impact of herhis attitudes on the collected data third the team met on a weekly basis to discuss the degree to which the researchers attitudes might have influenced the analysis of the data and the level of openness of the participants fourth the team discussed data analyses and translations weekly and reached a consensus on both the results and the translations compliance with ethical standards according to the accepted research standards incorporated by this study the privacy of each participant interviewed has been protected the research team did not use the real names of the participants nor any identifiable information all participants were aware that they were participating in a study knew the research objectives and consented to participate in the qualitative research it was explained to the participants that their participation was totally voluntary and if they chose not to participate or answer certain questions there would not be any negative repercussions signed informed consent was obtained for both the interview and audiotaping two participants did not consent to be audiotaped however their signed consent for notetaking was obtained at the conclusion of the interviews the participants were thanked for their participation and contribution to the research and were offered 15 rmb for participating results results were translated into english the team reached a consensus on both the results and translations quotations are followed by the identifier of the participant for a clearer presentation of results supplementary tables 25 are provided in supplementary materials in these tables comparisons are shown along the same rows for example in supplementary table 2 the two opposite phrases lonely and not lonely are in the same row the number of participants that mentioned lonely was 15 whereas only one participant mentioned not lonely thus the readers can compare the two opposite attitudes about older adults easily and see that more participants said that older adults are lonely diverse attitudes about older adults we divided participants attitudes about older adults into four categories attitudes concerning physicalmental health quality of life social support and personality of older adults we also assigned valence to each attitude as negative positive neutral or unclassifiable based on the information provided by participants and research members reached a consensus on the valence assignment attitudes about older adults physicalmental health more participants held a negative attitude about the physical and mental health of seniors than those who held a positive attitude some participants mentioned that they think seniors are unhealthy physically lonely unhappy anxious feeling hopeless and useless to their families and society in contrast only few participants said seniors are healthy physically happy and not lonely attitudes about older adults quality of life we categorized the quality of life of seniors into four subcategories overall qol busy with labor work richness of leisure activities and economic affluence overall qol one participant said elders overall qol is just soso not too bad not too good some participants said this kind of life suits seniors well even though their lives are not that colorful with less vigor and vitality compared to our young people it suits them well however the sentence may imply participants latent attitudes that colorful lives did not suit seniors busy with labor work participants attitudes lay on a continuum from idle to at ease to laborious these attitudes were held by nearly the same number of participants in this continuum idle and laborious were problematic in the eyes of the participants while at ease represented a good living status however six participants considered that seniors want to keep themselves busy although they did not need to do things from these participants views laborious work is not a bad thing because it is seniors who chose to do things rather than being forced to do them richness of leisure activities several participants mentioned that seniors have rich leisure activities however many participants described older individuals lives as in a low or medium level of richness but used different words as for the low level of richness some participants described it by using words like boring which reflected a negative attitude in chinese while some used words like simple which reflected a positive attitude in chinese as for a medium level of richness some participants described it by using the word repetitive which reflected a negative attitude in chinese while some participants described it by using words like regular which reflected a neutral or positive attitude in chinese economic affluence several participants mentioned the economic affluence level of seniors however they used words in opposition affluent and poor attitudes about social support for older adults all the five participants who mentioned this category held negative attitudes concerning the social support for older adults they said seniors have bad marital relationships have nobody to talk to have few friends and have no constant companions for example children attitudes about personal traits of older adults participants used several contradictory wordsphrases to describe seniors closed and open have no hobbies and have many hobbies lazy and industrious selfcentered and do not care about the self but only care about children and family dirty and clean and dependent and independent further seven participants mentioned thrift one mentioned brave and another mentioned nagging in sum participants expressed diverse attitudes about older adults and some participants attitudes were in opposition or they used varied terms to describe the same thing however according to the categories mentioned most by the participants we summarized participants general attitude toward the seniors as follows lonely live lives with a low or medium level of richness have poor social support closed have no hobbies industrious thrifty do not care about themselves but only care about children and family perceptions of reasons for unhappyhappy late life since participants held diverse yet general negative attitudes toward seniors what do they think are the reasons why seniors were unhappy and what makes seniors happy five categories emerged out of participants perceptions of reasons for unhappyhappy late life four categories were the same as above physicalmental health qol social support and personal factors the novel category was society physicalmental health as a reason for an unhappyhappy late life in this category physical health ranked first as the main reason for happiness and unhappiness in old age moreover for some participants feeling lonely and losing control were reasons for unhappiness while feelings of belongingness and being respected were reasons for happiness quality of life as a reason for an unhappyhappy late life economy was the chief reason mentioned by several participants as a reason for unhappiness and happiness in old age other participants said that having hard work to do or having nothing to do were both harmful to older adults happiness not needing to work but having a rich life were reasons for perceived happiness which again indicates the difference between a choice and being forced to do something other descriptions of happiness in old age included living a regular quiet and peaceful life without having big stressful life events social support as a reason for an unhappyhappy late life over half the participants mentioned bad social support as the reason for unhappiness in old age in this category childrens lack of filiality was the chief reason including not being around not accompanying or visiting aging parents having bad relationships with ones parents or bringing shame to the family some participants did not separate children from other family members and they used the term family generally having family conflicts may lead to unhappiness in old age other reasons mentioned by participants that made older adults unhappy were living alone the death of a partner and living in nursing home in contrast 27 participants mentioned good social support as the reason for happiness in old age childrens filiality was the chief reason includes being around accompanying or visiting aging parents having good relationships with ones parents or bringing glory to the family having good family relationships having friends having good neighborhood relationships and having people to accompany them may also make older adults happy personal traits as a reason for an unhappyhappy late life notably more participants mentioned personal traits of seniors as reasons that made older adults happy than those who mentioned personal traits as reasons that made older adults unhappy having hobbies ranked first in personal factors for happiness in old age while only three participants mentioned having no hobbies as a reason for unhappiness in old age other personal traits associated with unhappiness and happiness included being closed and keeping pace with the time respectively not content and content respectively pessimistic and optimistic respectively and bad character and good character respectively other personal factors for happiness in old age were having an ability having faith and being resilient society as a reason for an unhappyhappy late life this category was only mentioned by one participant as a reason for unhappiness in old age the reasons for an unhappy late life is becausenot only the childrenhowever also the outside society the whole society treats the elders unfairly they did not enjoy the benefits they should have enjoyed notably four participants said that they did not notice any older adults being unhappy they just saw unhappy older adults in the news however one participant was negative about aging and said that all older adults were the sameno one is happier and no one is unhappier in sum participants reasons for happiness and unhappiness in old age were almost the same in both content and frequency however participants considered personal factors to be more important for happiness in old age as compared to unhappiness attitudes toward living with and without children since traditional filial piety is deeprooted in chinese culture and participants ranked childrens filiality as the chief reason for the happiness of seniors we then analyzed participants attitudes toward seniors living with or without children participants compared the cons and pros of the two kinds of living arrangements and considered that they were different in the four categories mental health qol social support and personality attitudes toward influences of living arrangements on older adults mental health many participants stated that it is better for old parents mental health to live together with children than to live separately from children first some participants mentioned that elders living with children were happier than elders living without children because they have children to depend on were less lonely do not have a sense of loss do not need to suffer from missing their children and do not need to worry about their children some participants said that living with children helps elders feel spiritually supported by children which may also help elders to feel safe two participants said that when living with children elders need to help children do some household duties this may bring elders a feeling of being useful one participant said living with children brings older adults a feeling of superiority because her children could take care of her another participant said living without children may lead to some mental illness on the contrary only one participant stated that it is better for elders happiness to live separately from their children because they have more freedom they do not need to depend on children and they can decide what to eat to buy when to eat and when to sleep two participants said that whether an older adult is happy depends on whether hisher children are filial rather than whether hisher children are living with them moreover eight participants stated that being old is lonely regardless of who you live with because children are too busy to care for elders regularly although she lives with us my parents have to work and i have classes we only meet in the evenings in a whole day what can she do at home she could not read she could not watch tv the only thing she could do is sit there attitudes toward influences of living arrangements on the qol of older adults concerning qol three participants said life is more colorful if children are around another three participants said living with children gives elders things to do and one participant said living with children enriches elders lives in contrast three participants regarded living with children as a disturbance to elders and another three participants said it burdened elders they said elders should be taken care of by their children however when living with children some elders had to take care of their children instead the nanny with grandchildren although she lives with children and her husband she does all household duties i feel shes tired and shes getting older and older her children wont help i think she may have some resent but another nanny because she didnt live with her children if she wants she could also go to visit her children usually she visits neighbors i feel shes very happy attitudes toward influences of living arrangements on older adults social support two participants said it is better for family relationships if elders are living with children while one participant said that if they live together there will be lots of mother and daughterinlaw conflicts so it is worse for family relationships attitudes toward influences of living arrangements on older adults personality one participant stated that living with children helps elders to be modern and keep pace with the time although one participant said that it depended on elders and that older adults can have their own lives regardless of their living arrangement in sum more participants thought that living with children was better for elders mental health than living without children however there were perceived equal pros and cons concerning qol social support and personal factors attitudes and coping strategies when parentsthemselves are old results before were general attitudes and perceptions of aging and living independently of participants but in the last part we invited participants to take a more insiders view talking about their parents aging and their own aging including living independently from their parents when their parents are old and living independently from their children when they themselves are old below we compare participants attitudes and coping strategies separately attitudes toward living independently from parents when parents are old at the time of interviews many participants were studying away from home however many could not accept separating from their parents when their parents were old they said they would not let their older parents live alone because they would worry about them ten participants said they could accept living separately from their old parents because it is an evitable trend they did not want to live with them and parents have their own lives two participants said that their parents could adapt to living without children nearby when they are old furthermore three participants were struggling with this issue on the one hand they wanted to take care of their parents on the other hand they wanted to have their own lives and pursue their dreams attitudes toward living independently from children when participants themselves are old many participants said they can accept living without children when they are old because it is an evitable trend for parents and children to live separately in the future they do not want to live with children or they do not need to live with children nine participants said it is good for children to live separately because it reduces family conflicts and children can focus on individual development ten participants could accept living separately from children conditionally as long as their children are living nearby children visit often children are filial and they have others to accompany them moreover three participants reluctantly accepted living separately from children if they do have to go outside to work i cant force them to live with me just live my own life only one participant said she cannot be apart from her children when she is old because the parentchild relationship is the most important thing in the world blood is thicker than water how to take care of parents when parents are old participants provided several strategies to care for aging parents the strategy mentioned by the most participants was try my best that is participants would try their best to balance the needs of parents and themselvesthe needs of filial piety and independence this strategy included visiting parents often staying close to home living in the same city traveling with parents calling parents on the phone or video calls asking others to take care of parents and buying things for parents however the try my best strategy implies that they would not live with their parents the second strategy was to change parents which includes encouraging parents to have their own lives i tell them to find some hobbies or go outside and move to the city where the participants might live maybe ill pick them up if im living in a city someday ill try not to let them live alone the third strategy was the if then strategy that is participants will make choices about how to take care of parents according to varied situations for example if i have a good development i will take parents over to the place i live if i have a bad development i will go back to the place my parents live the fourth strategy was to change themselves they said they would give up their career in big cities to go back home and accompany their parents when they are old one participant said that no matter what happens she will not live with her parents when her parents became old and one participant said he will try to reach an agreement with his parents about their living arrangement how to be happy when participants themselves are old according to most participants when they are old they will depend on themselves for happiness only two participants said that they would try to educate children to be filial to ensure happiness many participants said they would get hobbies such as traveling handcrafts music and painting some participants said they would make friends expand their social circle beyond their children five participants said they would have a good socioeconomic status because that determines qol in sum although many participants mentioned that they cannot accept living separately from their parents when their parents are old many could accept living separately from their children when they themselves are old as for coping strategies most participants did not actually consider living with parents in the future they are struggling between filial piety and independence however it seems that independence wins participants prefer to depend on themselves rather than on their children for a happy later life discussion first participants held diverse attitudes about older adults however we did find that participants regarded seniors as low in competence and high in warmth as claimed by the stereotype content model instead the four dimensions we divided in the results were physicalmental health qol social support and personality the results suggested a need for an openended method in future studies about stereotypes or ageism moreover results revealed that participants held diverse attitudes about older adults but the general attitudes were that older adults are lonely financially disadvantaged have poor social support lack hobbies and care about their children more than themselves it appears that our study supported that young chinese people held negative attitudes toward older adults however was this because of modernization or other antecedents an antecedent of ageism is the anxiety of aging from a developmental perspective being independent is an important task since college students have just gained independence imagining returning to live with ones parents or future children may be a source of anxiety which then reinforces negative attitudes toward aging however whether being independent is an important developmental milestone is culturally dependent many researchers have shown that traditional eastern countries emphasize interdependence more than independence jensen outlined the culturaldevelopmental template to illustrate that the development of three ethicsautonomy community and divinityvaries across cultures she gave an example of religious conservatives and showed that there may be some decrease in the ethics of autonomy over their lifespan because of the emphasis on renouncing selfinterest inference in reverse the negative stereotype in our research may still be a result of modernization which leads to the individualization of china and the increasing need for independence among young chinese people another antecedent of ageism is the knowledge of aging however we will argue that it may not be the insufficient knowledge of aging but the wrong knowledge of aging that leads to ageism in our results participants regarded personality such as being independent modern and keeping pace with the times as positive and considered personal traits especially having hobbies to be more important for happiness in old age as compared to unhappiness this is in accord with the dialogs of active aging that being old is not necessarily negative while seniors could be active healthy independent and productive the new dialogs of aging are sweeping the world in modernized areas however it has an implication for individualism by applying a prescription that independence is normative and good in old age ranzijn argued that the active aging dialogs may paradoxically reinforce negative stereotypes of seniors as ill dependent and nonproductive it is also underpinned politically and economically to empower individual responsibilities but reduce the burden on family and society second it seems the two contradictory valuesfilial piety and independencecoexist in chinese young adults for example we found that children were the most important reason for older adults happiness or unhappiness living with children was considered better for elders mental health than living without children these results implied that young chinese adults may still be affected by filial pietythe responsibility to ensure old parents happiness this was confirmed again in the results that participants could not accept living separately from their parents when their parents are old on the contrary many of them could accept living separately from their children when they themselves are old moreover they prefer to depend on themselves rather than their children for a happy later life this phenomenon has also been found in other cultures for example mount found that middleclass indian women were pressured to conform to the facets of traditional womanhood while also aligning themselves with modernity however when tradition meets modern what will win the traditionalmodern theory of attitude change argues that individuals are motivated to reduce the conflicts between traditional and modern cultures by changing their attitudes to semitraditional or semimodern more important traditional concepts will change in a traditional direction while the unimportant concepts will change in a modern direction since filial piety is ranked as the most important traditional concept by both lay people and experts in china according to tm theory it should change in a traditional direction that is people may place more value on filial piety when traditional meets modernity however our results refuted this speculation and revealed the superiority of independence which was consistent with the findings of zhang et al that implicitly all traditional concepts are changing in a modern direction affected by western individualistic ideas for example some participants said regardless of who you live with being old is lonely because children are too busy to take care of the old parents instead seniors had to take care of their children if they were living together it seems that the relationship between children and parents is changing in a direction as suggested by modernization theory that modernization diminishes the status of seniors moreover although many participants mentioned that they cannot accept living separately from their parents when their parents are old most participants did not actually consider living with their parents in the future they said they will try their best to visit parents often stay close to home live in the same city and make phonevideo calls however the try my best strategy implies that parents will be sacrificed while filial piety requires children to sacrifice nonetheless we do not think this implies the death of filial piety as some researchers have claimed although preferring not to live together our participants said they would still be filial to parents in other ways therefore perhaps just the construct of filial piety has changed living together with parents was not regarded as a necessary component of filial piety one survey from the 1990s showed that chinese residents preferred to live close to but not necessarily with ones parents prior results of dual models of filial piety found the weakening of authoritarian filial piety but the maintenance of reciprocal filial piety in conclusion our results suggest that chinese college students are affected both by traditional filial piety and individualism however of the two they seem place greater value on independence moreover traditional filial piety is changing in a modern direction affected by western ideas of individualism the status of older people is diminishing and living with ones parents is not regarded as a necessary component implications the study had several implications first our results suggested that young chinese people held generally negative attitudes toward aging in four dimensions physicalmental health qol social support and personal factors rather than in the two dimensions of the stereotype content modelwarmth and competence further studies about stereotypes should not be limited in their scope and could use more openended methods second we should be cautious about active aging dialogs by assuming that being healthy and independent are normative in old age and thus reinforcing negative stereotypes of seniors as ill and dependent third young chinese adults prefer to be independent and live independently from their parents therefore we predict that the chinese elderly care model will become more westernized in the future however nonfamilialcare in china is underdeveloped and the increasing number of emptynest elderly people will require care consequently the chinese government and nongovernment institutions should determine how to develop nonfamilial care for elders fourth young chinese adults are also affected by traditional filial piety but the content of filial piety is changing to compromise with the need of pursuing personal development and happiness thus we could accommodate the change by providing children more opportunities to live near their parents instead of living with their parents to video chat with them and to pay visits to their parents limitations and strength this study had some limitations its main limitation is sample bias as a qualitative study it only enrolled a small number of participants specifically participants came from a university in shanghai were in their 20s and many of their parents were in their 40s and most of them were female and an only child therefore this studys generalizability is limited and its results cannot be generalized to other groups this limitation may be inevitable for all qualitative research here qualitative research findings are not intended to be generalized but rather they aim to shed light on the attitudes or experiences of participants revealing other voices our research also aims to share the various attitudes toward aging and living with parents of chinese youth however whether these voices are representative of all chinese youth is still questionable the risk of sample bias means that we should be cautious about our conclusions which could be reexamined by quantitative studies in the future second we presented some information that we think may affect the validity of the results such as participants motivation for taking part in the study and researchers gender age expectations and bias however how they may affect this studys validity is unclear future qualitative methodology studies could explore these aspects more deeply yet providing background information is still important for readers to grasp the context of the story third participants answered questions about their assumed attitudes and coping strategies when their parents and themselves get old longitudinal studies that address participants attitude changes in the future should be considered despite these limitations this study advanced an exploration of the attitudes of young chinese adults about aging and living independently and more specifically and deeply helped to better understand chinese youth undergoing social change the study also suggested other dimensions of age stereotyping and methods to study stereotypes pointing out the potentially negative effect of active aging on ageism and future elderly care models and strategies data availability statement the datasets presented in this article are not readily available because some interviews may include identifiable personal information requests to access the datasets should be directed to yz ethics statement the studies involving human participants were reviewed and approved by east china normal university the patientsparticipants provided their written informed consent to participate in this study supplementary material the supplementary material for this article can be found online at 609736full supplementarymaterial conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest

modernization in china is accompanied by some specific features aging individualization the emergence of the nuclear family and changing filial piety while young chinese people are still the main caregivers for older adults understanding the attitudes of young chinese people toward aging and living independently in the context of modernization is important because it relates to future elderly care problems in china by using indepth interviews and qualitative methods 45 participants were enrolled in the study 38 8444 were women and 37 8222 had no siblings the ages ranged from 17 to 25 years mean age 1928 sd 174 results revealed that participants held diverse attitudes about older adults but the general attitudes were that older adults are lonely financially disadvantaged have poor social support lack hobbies and care about their children more than themselves chinese college students were affected both by traditional filial piety and individualism however of the two they seemed put greater value on independence moreover traditional filial piety is changing in a modern direction affected by western ideas of individualism the status of the senior is diminishing and living with ones parents is no longer regarded as a necessary component implications concerning age stereotypes elderly care policies and strategies are discussed

introduction violence in intimate unions has been widely researched since the 1970s and gained momentum after makepeace pioneered a study on violence among dating couple in the 1980s cohabitation as a form of first union started rising in both developed and developing countries indeed cohabitation is said to be influencing nuptiality patterns as a first coresidential union in recent times in response to these trends recent research on family demography has become increasingly interested in understanding differences between cohabitation and marriage along several dimensions accompanying this paradigm shift is the argument in the emerging literature that because of their characteristics cohabiting unions are more violent than marital unions in a study conducted in peru flake reported cohabitating union as a familylevel risk marker to increase a womans likelihood of abuse in uganda as in many parts of africa both violence in intimate unions and cohabitation are on the rise for instance the proportion of women aged 1549 in cohabiting unions increased from 14 in 2001 to about 27 in 2011 icf international inc 2012 lwanga et al 2018 notable however is the increase in the proportion of intimate partner sexual violence among women while on the one hand cohabitation can offer intimacy and a familylike environment with egalitarian family structures on the other it offers a lower level of economic consolidation and a weakened relationship short of an intrinsic barrier against union separation as a result less violence among women in cohabiting unions than in the married would be expected previous studies have demonstrated the contrarythat cohabiting women have an increased risk of experiencing violence in union than married women using data from hong kong medical charts between 2010 and 2014 wong et al also found cohabiting women to be nearly two times as likely as married women to experience multiple injuries and physical violence nock theorizes that the difference in the level of intimate partner violence among cohabiting and married unions is that marriage is governed by an institution whose relationship is enforced by social and legal rules unlike cohabitation ellis for instance argues that the presence of marital norms and greater investment in union common among the married contribute to lower levels of violence in marriage prior research has also been consistent wilson and daly for example argue that the social and financial costs of ending a marriage are higher than the costs of ending a cohabiting relationship thus the marrieds invest a lot in developing strategies used to mitigate ipv in uganda where research on cohabitation and ipv is relatively new past research on the relationship between cohabitation and violence in union has been limited however available studies typically involve investigating cohabitation and union dissolution with regard to intimate violence past research has examined the link between empowerment partners control and ipv elsewhere there have been attempts to link ipv and pregnant women however less studied is whether being in a cohabiting union is at first sight a licence to intimate partner physical violence and whether the relationship varies between birth cohort numerous studies have investigated the relationship between ipv among women and empowerment modern contraception maternal health services and partners behaviours however there is no known study that has specifically focused on the study of violence against intimate female partners the current study used selfreported data on physical aggression against currently married or cohabiting women extracted from the 2016 uganda demographic and health survey to examine whether ipv is more pronounced in cohabiting than in married unions to assess whether the association varies between birth cohorts and to examine other factors that influence physical violence among women in union theoretical consideration a number of theories and research findings on how cohabitation or marriage may influence ipv among women have been inconsistent and inconclusive according to the social learning theory observations of how parents and significant others in intimate relationships behave provide an initial learning of behavioural alternatives appropriate for such relationships this theory fails to separate the effect of witnessing and experiencing violence in the natal family however the argument behind it suggests that if a family of origin managed stress and frustration by using anger and violence children from such a home environment would be at a great risk of exhibiting the same behaviours witnessed or experienced when growingup this argument is consistent with the intergeneration theory of violence in the present context the theory exposes children to violence and also teaches them the use of partner violence as being acceptable and an effective way of solving problems this description is consistent with patriarchal norms as well as beliefs that are the foundation of maletofemale partner violence enshrined in the malepeer support theory where anticipated rewards seem to be greater than social and nonsocial costs the social context theory posits that lack of social support to integrate cohabiters in society and the lower support from family and friends than for marriage can lead to intimate violence they argue that because parents and kin are not involved in the decision to cohabit they are unlikely to be engaged whenever there is union instability in addition to reduced social support cohabiters have other issues such as lack of commitment which inhibits couple investment and creates a context for diminishing relationship quality among cohabiters and this contextual explanation appears to be related to the differential selection perspective as cohabiting unions become larger and more children are born within such relationships cohabitation may be taking on more of the functions of marriage the three study hypotheses were first that there is no significant difference in ipv between cohabitation and marriage unions second that where differences do occur they are likely to be across birth cohorts and third that couples with higher levels of education are likely to have lower rates of violence methods with permission from the icf international website data were obtained from the 2016 uganda demographic and health survey the dhs surveys are currently part of the worldwide survey programmes and are a source of nationally representative data capturing individualand householdlevel sociodemographic health and sexual activity maternal and child health mortality fertility family planning and nutrition data the uganda dhs was implemented by the uganda bureau of statistics with technical assistance from icf international and funded by the united states agency for international development data were collected from a sample of female respondents aged 1549 and male respondents aged 1554 selected from 112 administrative districts the survey was based on a probabilistic sample originating from multistage cluster sampling and was stratified by rural and urban areas the dhs programme has been collecting information on intimate partner violence in uganda since 2006 using a domestic violence module which addresses womens and mens experience of interpersonal violence in violencerelated studies it is more likely for one partner to report having experienced violence than for both to agree that they have ever experienced it this is based on the claim that individuals are more likely to report no violence where it has been experienced than to report violence where it hasnt this is particularly true in a patriarchal society where anecdotal information has it that women believe that a husband is justified in beating his wife in response to this assertion the studys dependent variable was constructed using couple data couple data were obtained by merging data from women and their partners living within the same household yielding a sample size of 2479 couples measures of outcome variable physical intimate partner violence is a dummy variable created from a general question asked to all men who had ever been or who were currently in a union have you ever hit pushed or shook slapped punched with fist arm twisted kicked or dragged strangled or burnt or done anything else to physically hurt your at times when she was not already beating or physically hurting you based on the mans response a dummy variable was created indicating whether he physically violated his wife or partner in this paper whoever perpetuated less severe or severe violence was coded as 1 and as 0 otherwise measures of explanatory variables the main explanatory variable was marital status categorized as married or living with a partner this was included in the model as a categorical variable indicating whether a women was married or living with a partner other independent variables included birth cohort wealth index education type of residence region children ever born working status religion and a wifefemale partner earns more than her husbandmale partner these variables were selected based on previous studies the variable birth cohort was generated from current age categorized as 20012005 19962000 19911995 19861990 19811985 19761980 19711975 and 19661970 the wealth index was based on couples combined income grouped as poorest poorer middle richer and richest education level was categorized as no education primary secondary and postsecondary but modelled as less than secondary education those with secondary education and those with above secondary education religious affiliation was categorized as catholic anglican pentecostal seventh day adventist and other type of residence was grouped as rural and urban employment was coded as working and not working a separate dummy variable for whether the female respondent earned more than her husbandpartner was grouped and recoded as yes and no and years since union was grouped as 04 59 1014 1519 2024 2529 and 30 years statistical analysis frequency distributions were used to describe and summarize the characteristics of the women in the sample then the characteristics of cohabiting and married women were compared the relationship between the dependent variable measured whether or not a woman was physically abused and explanatory variables were established at a bivariate level and tested using the chisquared test set at p 005 in the data about 29 of men reported having perpetrated physical violence indicating that this is a rare event and a possibility of biases resulting from perfect separation and the maximum likelihood estimation method perfect separation usually happens when the outcome variable separates the predictor variable for these two reasons firths panelized logistic regression models were used with explanatory variables to examine the context of physical associated with women in cohabiting union in comparison with the married the results for the panelized model are presented in the form of odd ratios with their corresponding 95 confidence intervals while it is important to apply weights to account for complex survey design clustering and stratification this was not done because firthlogit estimates do not support the svy prefix the fitted model was subjected to the linktest to examine whether the explanatory variables were specified correctly and also assess the goodnessoffit of the model the test uses the hat and hatsquared statistic when the model describes the data correctly and is appropriate the hatsquared should not be significant before fitting the model a multicollinearity test among explanatory variables was conducted the variable duration in a relationship though significant at bivariate level was found to be highly correlated with the variables children ever born and birth cohort the interest in this variable was to create an interaction effect with the variable current marital status which would help to test for selection bias however since the main explanatory variable was not significant the interaction term would most likely not be significant thus in modelling this variable was dropped relatedly the variables children ever born and birth cohort had a positive correlation when attempts were made to remove birth cohort and keep the number of children everborn in the model there was a negligible change in the model diagnostic test results with hatsquared still being insignificant consequently the variable was put back in the model in statistics literature missing data in logistic models influence regression coefficients standard errors and statistical power however in this study it was assumed that missing data were missing completely at random and did not bias inferences results distribution of respondents by sociodemographic characteristics table 1 presents the distribution of respondents by sociodemographic factors nearly 29 of the male respondents in the couple sample had perpetrated physical violence against their partners among all women included in the couple data approximately 41 of the respondents were affiliated to the catholic and 3 to other minority religious groups the distribution of the women by wealth index shows that nearly 24 were in the poorest category and 15 were in the richest tertile of income the majority of the women had primary education while 6 had no education the majority of the women were born between 1976 and 1995 and had given birth to no more than 5 children approximately 18 lived in the central and 27 in the western regions nearly 23 of the women had been in union for no more than 4 years and 3 for more than 30 years the majority of the female respondents were working about 11 of female respondents reported earning more than their partnershusbands and 72 said that they earned less differentials in experience of intimate physical violence by socioeconomic characteristics table 2 presents the differentials in victimization by selected socioeconomic variables whether married or cohabiting number of unions education level and religious affiliation were not significantly associated with physical ipv the prevalence of the perpetration of physical violence by married men was nearly 30 and about 27 by cohabiting men physical violence varied significantly by wealth status birth cohort type of residence region of residence number of children everborn and duration in union but was weakly associated with women who were working and wivesfemale partners earning more than the husbandsmale partners multivariate results in isolating the net effects of each independent variable on physical ipv a final model was built based on the identified predictors explained by the bivariate analysis in this case all significant independent variables at the bivariate level were included in the model in which the dependent variable was the perpetration of physical violence in union these included wealth index birth cohort type of place of residence region of residence children ever born currently working and woman earns more than her husbandpartner education level and religious affiliation were not significant however education level and religious affiliation were found to be significant in uganda among married women current marital status was not significant but it was found to be significant in hong kong and this is central to the main argument behind this study based on these studies current marital status education level and religious affiliation were also included in the final model table 3 presents the results of the firthlogistic model the table shows that the odds of women in the poorer wealth tertile experiencing physical violence were 196 times higher 175 times significantly higher for the middle income tertile and 20 times higher for the richer income tertile relative to women in the poorest category the odds of experiencing physical violence decreased among women born in 19962000 199104092 p004 1995 19811985 19761980 19711975 and19661970 compared with those born in 20012005 furthermore there was increased likelihood of experiencing physical violence among women from both the eastern and northern regions compared with the central region women affiliated to the catholic church were more likely to experience physical violence than those affiliated to the anglican church in addition women with six or more children were nearly two times more likely to be victims of physical violence relative to those who had fewer than six children although there was no significant difference between married women and those in cohabiting union women in cohabiting relationships were 118 times more likely to be victims of physical violence regarding the diagnostic test of the model the specification error results demonstrate that the firthlogit model was well specified as predicted by the hat and hatsq statistics discussion this study addressed three questions is intimate partner violence more pronounced in cohabiting than in married unions does the association between marital status and ipv vary across birth cohorts and what other factors influence physical violence victimization among women in union no significant difference was found in physical ipv victimization between women in cohabiting and married unions these results contradict the findings of wong et al in hong kong who found cohabiting women to be 20 times more likely to suffer from physical violence than married women the insignificant difference in the level of physical violence experienced by cohabiting compared with married women may be understood from four arguments the first is the transition of the ugandan society from being highly patriarchal to become more egalitarian this has led to status compatibility which negates the powercontrol theory the second is that an increase in cohabitation is currently being experienced in uganda implying that marital status is undergoing social change the implication of this as suggested by kiernan is that the stages of cohabitation can be described as a partnership transition traditionally it was taken to be a deviant phenomenon practised by a small group of people then as a probation stage to assess couples commitment to marriage later as a socially accepted alternative to marriage and finally as indistinguishable to marriage in recent decades the growing tolerance of cohabitation by the ugandan society might also explain the insignificant difference in experience of physical violence in cohabiting compared with married women third in the ugandan context entry into cohabitation or marriage is unlikely to depend on natural selection theory where partners showing low level or no violence would enter marriage and those in abusive relationships enter cohabitation as it used to be in the past fourth as cohabiting unions become larger and children are born within a relationship cohabitation may be taking much of the functions of marriage which suppresses the wouldbe difference in ipv it is surprising to find that women of poorer or middle income status or those of richer income status were more likely to suffer from physical violence than those of poorest income status this may be explained by two arguments first women of poorest income status may share available family income between family expenditure and investment or may engage in a joint family business with their partners but as women become financially betteroff they may decide to be financially independent as a result such women may follow the equality principles for power in a relationship and if there is tension and conflict it could increase or worsen into physical violence second social status and access to income might affect the distribution of power and control within a relationship leading to status incompatibility and reversal if this is in favour of women in a patriarchal society where they are taken to be inferior it might make them vulnerable to ipv the reason is that men can feel threatened by wivespartners who outrank them economically and socially the lower levels of physical violence victimization for older cohorts compared with younger ones is not surprising and might be explained by two perspectives the first is the life course development viewpoint in uganda as with other societies older people are more likely to possess positive relationship skills than younger ones in addition they are less likely to use violent behaviour when dealing with conflicts in intimate or romantic partnerships second younger women might be in different types of relationships with varying levels of intimate partner violence and commitment the study found that women from eastern and northern uganda were at a higher risk of experiencing physical violence than those in the central region the risk was 223 times for the eastern and 184 times for the northern region this is not surprising given that these two regions have high rates of child marriage compared with either the central or western region in this case the inequitable gender norms that give rise to child marriages may increase the risk of conflict and physical violence some characteristics of women might increase the risk of experiencing physical violence results from this study show that being affiliated to the catholic faith is a risk factor for ipv the odds increasing by 39 compared with being affiliated to the anglican faith the effect of other religious denominations was not significant this is surprising because one would expect religious people to have lower rates of ipv victimization increased risk among catholics could be explained by the difference between religious affiliation and religiosity women could be affiliated to the catholic faith but attendance at religious services which has been shown to be associated with lower rates of ipv could be low women with six or more children were found to suffer from physical violence more than those with five or fewer children three perspectives are advanced to explain this finding first an increase in number of children might cause emotional and economic strain second it could mean that child care attention is divided and third it might coincide with advance in age which is often associated with men having extramarital relations all these might lead to conflict and consequently physical violence in most societies in uganda issues regarding physical violence are always limited to the couple and to the paternal aunt in summary this study used couple data and the firthlogit model to assess whether physical intimate partner violence victimization is more pronounced among women in cohabiting union than those in married couples it also assessed whether the association varied across birth cohorts and whether other factors influence physical violence among women in married and cohabiting unions these results will be useful to inform policy dialogue and formulation given the rising trend in domestic violence in uganda future studies should endeavour to collect more data to explore further the linkage between cohabitation as a form of union education type of place of residence work status womens income being higher than husbandpartners and physical violence there are some limitations that can be addressed for future studies first this study used selfreported data and in this case ipv perpetration could be lower due to recall bias sensitivity of reporting violence perpetration and the humiliation of doing so some of the perpetrators could have withheld information regarding their private experiences because of the culture of silence concerning ipv and union second the data used were crosssectional in nature and therefore the reported results are associations only and do not imply a causative relationship in conclusion there is no evidence that a woman in a cohabiting relationships has an increased risk of experiencing physical violence compared with women in marriage in uganda the study findings suggest that ipv victimization among women in uganda is influenced by birth cohort wealth residing in eastern and northern regions affiliation to the catholic faith and have six or more children conflicts of interest the authors have no conflicts of interest to declare ethical approval this study used secondary data and the authors declare that all procedures contributing to this work conform with the ethical standards of the relevant national and institutional committees on human experimentation and with the helsinki declaration of 1975 as revised in 2008

the study examined the argument that cohabitation as a form of union increases physical violence victimization among women the studys aim was to assess the association between physical violence and other sociodemographic factors that influence physical violence among women selfreported data were extracted from the 2016 uganda demographic and health survey udhs with a sample of 2479 couples from the couple file chisquared tests and multivariate firthlogit regression models were used to examine the relationship between intimate partner violence ipv victimization and marital status controlling for other socialdemographic factors there was no significant evidence that women in cohabiting union have a higher risk of exposure to physical violence in the ugandan context the risk of experiencing physical violence perpetration varied by birth cohort with the most recent cohorts exhibiting a slightly higher risk of experiencing partner violence than previous cohorts significant factors found to be associated with an increased risk of experiencing ipv included being in the poorer middle and richer compared with the poorest wealth tertile of income residing in eastern or northern regions compared with the central region being affiliated to the catholic faith compared with anglican and having five or more children compared with 4 or fewer children in conclusion there is no evidence that physical violence is more pronounced among women in cohabiting unions compared with married women in uganda

daunted at the range and complexity of threats to sustainability particularly at the landscape scale there are scientifically justified reasons for hope emanating from the socialecological systems research community for example scholars have recently collected a host of examples of bottomup sciencesociety collaborative initiatives whose activities have led communities towards more positive sustainable futures this perspective article uses similar logic and projects similar optimism recognizing the benefits of learning from bright spots at a time when we are coming to terms with the fact that humanity is dangerously exceeding planetary boundaries in this essay we offer an example of organizational transformation toward greater sustainability building on three decades of socialecological research and innovation in science administration social ecology the intellectual tradition with which we identify aims to generate the knowledge necessary to understand this sustainability crisis and to react to it in the sense of helping establish the ought state of societal nature relations like landscape ecology social ecology studies humanenvironment interactions at the landscape scale we view these fields of study as overlapping and complementary they both adopt holistic transdisciplinary research approaches and are both concerned with addressing questions of sustainability the subject matter scale of analysis research methodologies andwith particular pertinence for this essaythe normative values and assumptions are often shared between the two fields despite evolving via different intellectual histories recent scholarship has enjoined researchers to apply their skills towards addressing the environmental degradation and social inequities that accompany exceeding planetary boundaries these researchers call for systemic transformations based on the idea that in order to catalyze effective change scientists should focus on addressing deeper societal trends driving environmental degradation rather than trying to change easier though ultimately superficial characteristics meadows suggested that acting on such strategic leverage points could have a profound ripple effect on society leading to broader systemic changes along these lines abson and colleagues proposed three realms of leverage for sustainability research strengthening humannature interactions reconfiguring organizational dynamics and sustainabilityrelated knowledge creation and use based on these premises they call for research and knowledge production on interventions that simultaneously address organizational reform humannature interactions and knowledge productions towards the same goal of catalyzing sustainability transformations scholars have called for greater transdisciplinarity in research in which scholars practitioners and stakeholders coproduce knowledge about systems in order to collaboratively advance integrated sustainability knowledge of the system and the direct uptake of this knowledge into planning policy and management ses research is interand transdisciplinary by nature and the need for effective collaboration between ses research and practice and stronger sciencepolicy interfaces have been emphasized results of a study of 31 projects found that practitioners of td approaches conceptualized the impact of their work in three ways advancing the knowledge necessary for …more informed and equitable decisionmaking fostering social learning for collective action and enhancing competencies for reflective leadership while these are clearly desirable steps towards sustainability transitions assessments of longterm systemic change were more ambivalent td projects were not able to claim more meaningful impact this was due to the complexity of the ses in which they worked the broad diversity of actors and interests affecting the system and the difficulty of assessing these interacting and overlapping elements td research is only as robust as its ability to incorporate different types of knowledge in a single project or endeavor the integration of natural sciences and social sciences knowledge is a common challenge vol of transdisciplinary work one challenge of integration lies in agreeing upon conceptual frameworks and methods that can be used for td work by diverse collaborators another challenge lies in the debate between the importance of contextdependent science and the need to improve capacity to make generalizations from case study research in this perspective we use the elter ri1 as a case study to analyze how an infrastructure for ses research can effectively support knowledge integration more effective stakeholder engagement and a more equitable contextaware way of doing science in particular we describe how the elter ri has initiated a process of actualizing its potential for societal impact not only by rethinking and recalibrating what science is done but in how it is done we tell this storyof how a large transnational ecosystem research network began to internalize emerging knowledge regarding the benefits of interand transdisciplinarity and how it has begun to institutionalize particular td values into its administrative structure and research program we will elaborate on how elter has incorporated a new conceptual framework ethical commitments assessment protocols stakeholder engagement approaches and other measures intended to support td research toward sustainability transformations these changes can be seen to constitute interventions that simultaneously address organizational reform humannature interactions and knowledge productions and therefore offer important lessons for those interested in organizational transformations toward sustainability we show how program changes constitute the seeds of organizational transformation in doing so we highlight the necessity of holistic shifts in thought and action from changes in organizational policies to changes in the way individuals think communicate and conduct research we hope that sharing this story will provide examples and inspiration for others seeking to change the status quo in socialecological science at the landscape scale we the authors have both played roles in the elter ri by carrying out an eufunded audit of ltser research platforms deo has held a leadership role in preparing the ppp and plus grants discussed below as well as advancing some of the strategic documents outlined in the third section below we believe that our intimate engagement with the ri and the processes described in this paper enable us to share details that improve the transparency of what is often an insider process in the spirit of td research we attempt to be selfaware introspective and critical when necessary in order to provide a candid and effective critique of the described organizational transition the roots of lter and early efforts to integrate social ecology the us lter network was founded in 1980 its primary focus during its initial years was on ecosystem properties and their biophysical variables if human aspects were integrated into lter research it was primarily via studies of the negative impacts of human activities on ecosystem function in the 1990s us lter scientists discussed integrating the social sciences into the networks research program but tangible activities were not immediately initiated in its 2002 review of lter the us national science foundation made 27 recommendations including an explicit call for lter to collaborate with social scientists the establishment of crosssite projects and a focus on synthesis science redman and colleagues therefore suggested a conceptual framework for integrating activities and delineated key interdisciplinary questions for lter to consider their approach advocated addressing questions of societal importance which were associated with longterm ecosystem processes and which were better studied across a network of sites over the next two decades social dimensions were integrated into two urban lter sites in the us and elsewhere ultimately contributing to the development of novel frameworks for transdisciplinary research and the study of urban socioecology the nsf as a key mentor of lter activities was intent on making the global lter network independent of us lter an international lter vol network was established in 1993 its focus was initially on longterm ecosystem observation but it grew to engage in sitebased ecological and socioeconomic research representing a powerful network of ecosystem research facilities comprising 40 national member networks by 2008 in 2001 concurrent to the us lter review a european environment agency report critiqued the fragmentation of ecosystem research in europe and called for stronger links between ecosystem research and monitoring ltereurope or elter as it is called today evolved out of a europeanfunded network of excellence alternet although elters conceptual research framework embraced an ses approach from its inception implementing this approach has proven challenging within elter ses research was organized around longterm socioecological research platforms these platforms are geographical areas that typically encompass classic lter sites but also include broader geographic regions thereby integrating key cultural administrative historic economic and other social dimensions an ses approach was further advanced by a series of publications which advocated for a comprehensive shift from lter to ltser set out the theoretical justification for this shift developed a blueprint for the physical structure of ltser platforms and presented case studies of ltser platforms while ontheground research and ecosystem observation continued to focus primarily on natural sciences expertise and methodological approaches over the next decade numerous training workshops and exploratory research projects were conducted to strengthen td competencies of elter scientists during the years 20142018 with generous funding of a european h2020 grant elter conducted a comprehensive audit of its capacities to conduct ses research and its output results summarized in a trio of articles by the current authors and others yielded the following observations and recommendations among others 1 observation ltser platform leaders strive to do transdisciplinary ses research but platform infrastructure lacks frameworks capacities and training to enable effective td work recommendation ltser platforms can begin to address this issue by better leveraging the benefits of network membership such as harmonized datasets site access longterm funding and planning for a coordinated research agenda with local needs for data knowledge and relationshipbuilding with stakeholders 2 observation platforms were reported to be dominated by ecosystem research with only 28 social research and platform research programs were typically maintained by 35 staff members recommendation strengthen the role of the social sciences and humanities encourage macroecological approaches and strengthen stakeholder participation increase knowledge exchange reciprocity and responsiveness between interdisciplinary scientists particularly social scientists and natural scientists and scientists and other stakeholders and interfacing with other landscape approach concepts ltser platforms should start organizational change processes by clearly defining objectives outlining protocols and clearly defining roles for personnel these findings and recommendations highlight the ltser platform as a key infrastructure for conducting ses research in europe further the findings imply that an ses approach does not just advocate adopting a novel research field or agenda but also requires an alignment of underlying values commitments towards working with stakeholders and building new partnerships and an adjustment of research agendas to fit stakeholder needs at the landscape scale in subsequent iterations of elter development the importance of these aspects for advancing ltser platforms in europe were recognized by elter coordinators and served as triggers for change we discuss these transformations below vol the path to sustainability elter doubles down on transdisciplinarity formalizing strategic features of elter ris transdisciplinary research program strategic features are elements of a longterm research platform that are designed and deployed to support multisectoral interdisciplinary and transdisciplinary collaborations they depend upon multiple sectors and disciplines and are used to create communities data and knowledge systems this section narrates how elter has used recent opportunities to formalize strategic features that have been in formation for some time to advance desired outcomes throughout its history ilter and elter have emphasized that their greatest potential contribution to global sustainability is through their research and data but these networks also internalized as axiomatic that a sustainability agenda could be best served through the adoption and implementation of a particular way of doing research ie socialecological transdisciplinary research yet the audit of elters ses agenda described above revealed a significant gap between its aspirations and its implementation in 2018 elter took the opportunity of being accepted into the european strategy forum on research infrastructures to institute broad and deep changes in its physical administrative and scientific structure esfri is an advisory body to the european union which seeks to strengthen the sciencepolicy interface through the development of acceptance to the esfri roadmap favorably positioned elter ri to win h2020 grants for two largescale projects elter preparatory phase project and elter advanced community project though interacting these two projects differ substantively in their content with ppp focusing on establishing the legal financial and technical specifications of the ri and plus enabling proofofconcept research based on the conceptual approach and physical capacities of the ri to date proposalwriting and subsequent project implementation has afforded elter the opportunity to make another strong push towards fuller integration of td principles into ri activities and realization of the underlying values embodied in transdisciplinarity elter has made formal commitments to leveraging science in the service of sustainability through its ppp and plus grants thereby highlighting its potential to contribute to europe meeting its sustainable development goals the ris ses research is touted as the primary mechanism to realizing its contribution to sustainability but as we demonstrate below elter is building an array of tools and mechanisms into all the details and processes of doing science through fig 1 major milestones in the evolution of elter ris organizational orientation strengthening its potential for sustainability impact information compiled from redman et al 2004 mirtl and krauze 2007 aronova et al 2010 knapp et al 2012 vanderbilt and gaiser 2017 mirtl 2018a 2018b mirtl et al 2018 and dick et al 2018 design ronit cohenseffer vol which it is hoped it can maximize its contribution to sustainability a new vision made real through new documents strategic plan ethical frameworks and formative assessments what follows is an inventory of conceptual frameworks tools and mechanisms recently developed as part of the institutionalization of elter ri to focus and support the ris efforts to pursue its objective to help foster societal sustainability transitions most of these are noted explicitly in elters newly adopted strategic plan and each is currently being further developed and documented as ppp and plus deliverables it is important to note that these tools and mechanisms for change were developed in a highly iterative process of collective discussion consultation debate and compromise across multiple stakeholder groups grand challenges in its proposals strategic plan and major publications elter designates four global ecological challenges derived from the eus 7th environment action programme and other global calls to frame its research endeavors they include biodiversity loss climate change adaptation and mitigation food security and threats to soil and water and sustainable management of natural resources accordingly in elter plus each one of these themes was assigned an ri scientist to serve as a theme lead to assure that ri research data collection and community engagement focus on these four themes and integration between them and to promote knowledge products to the policy community and the public whole systems approach in its farreaching effort to demonstrate its commitment to interdisciplinarity elter conceptualizes social and biophysical systems into a single ses with multidirectional feedbacks together with critical zone research which links the disciplines associated with water air life rock and soil research accordingly each of its research monitoring and data services is developed within this holistic perspective strategic plan a strategic plan succinctly clarifies the organizations raison detat its goals and objectives and the paths through which the organization intends to reach those goals as the organization evolves a strategic plan serves as a reference point for where the organization would like to go and what it intends to achieve elters strategic plan adopted in 2021 sets out its institutional vision to use ecosystem science and research in service of environmental sustainability environmental sustainability can only be achieved on the basis of the robust knowledge and empirical evidence needed to identify and mitigate human impacts on ecosystems elter catalyzes scientific discovery and insights through its stateoftheart research infrastructure collaborative working culture and td expertise this enables the development and application of evidencebased solutions for the wellbeing of current and future generations in other words elter is committed to developing a research infrastructure that will contribute to sustainability not only through data and research products but also via institutional operating procedures all of the elements included in this list are introduced in the strategic plan as organic to the infrastructures identity and working culture ethical framework promoting inclusive societies free of discrimination and reducing inequalities are ubiquitous themes across all of the uns sdgs recognizing the tight link between environmental sustainability on the one hand and values and ethical conduct on the other elter has invested in defining a widereaching and ambitious ethical framework in april 2021 elter ri published its gender equality program which included clear commitments to address systemic and pervasive prejudices faced by women in the scientific and academic communities and outlined a series of actions that elter will take to address these issues within the infrastructure and beyond in particular it pledges parity in gender representation in decisionmaking positions and scientific leadership and implements internal mechanisms to address gender bias in elter and to educate towards inclusivity in october 2022 elter ri published its ethical guidelines which expanded elters commitment to work for greater inclusion and prevent discrimination to include all demographics as specified in the european charter of fundamental rights in order to assure these commitments are fulfilled a volunteer gender equity and nondiscrimination ombudsperson position was created to provide an address for potential complaints and to oversee education programming for elter staff and researchers the ethical guidelines also include sections on research process and conduct data collection management and dissemination and organizational environmental performance each with performance criteria to assure compliance finally the ethical guidelines provide for the creation of an ethical advisory board to assess progress and provide oversight since 2020 elter has given explicit public expression to its ethical commitments including official statements regarding elters potential contribution to assessing covid19 impact4 and its condemnation of the 2022 violent invasion of ukraine5 elter has also issued public announcements and organized events commemorating international day of women and girls in science and international womens day 6the holistic socioeconomic impact assessment td theory emphasizes selfreflection both as a means to consider the effectiveness of teamwork and collaboration and the impacts of research activities on outcomes and also as a mechanism for empowering stakeholders in the process of knowledge coproduction regarding research impacts elter ri will implement a periodic review process in which the impacts of its activities are regularly assessed according to predefined indicators selected to reflect three levels of impact for six categories defined in the strategic plan this reflects elters commitment to hold itself both to high standards for scientific social and economic impacts and also to address esfris expectations for ris accepted onto the roadmap within this assessment framework indicators will assess transdisciplinarity giving ri researchers administrators and other stakeholders the tools to determine whether beyond the documents and good intent a sustainability transition is actually happening in the ri integrated governance and stakeholder engagement td work in general and ses research in particular is predicated on the assumption that research and its outputs can make a stronger contribution to sustainability when conducted in collaboration with stakeholders within elters ppp project comprehensive stakeholder mapping was conducted in which stakeholder communities were defined at multiple spatial scales this was done with the explicit goal of developing participation channels and forums for stakeholders to provide input on elters research agenda and to tailor data collection and services to the specific needs of stakeholder communities further various advisory committees were formed and consulted on elters progress and recommendations from these stakeholders were collected processed and integrated into decision making processes these advisory committees include the scientific advisory board the interim council and the site and platform managers forum each of which contributed input into the formulation of elter policies which were substantially modified according to this input stakeholder engagement at the local and regional scale is a fundamental explicitly recognized component of ltser platform operation elter ris spatial units for ses institutionalizing socioecological platform structure and objectives while the idea of dedicated landscapescale platforms in which to conduct ses research has been a prominent feature of elter for almost two decades the 2018 assessment of ltser platforms described above revealed a looselycoordinated set of platforms across europe conducting an eclectic mix of activities of varying import and impact elter ppp and plus set out to make order in the ri and strengthen the impact and longevity of the ltser platform structure by developing strict parameters by which a platform is recognized and how it operates this includes setting standards for program elements such as which data sets are mandatory or optional and how these data are collected stored and made accessible to stakeholders staffing platforms with the necessary skill sets for both ses research and stakeholder engagement and the necessity of a memorandum of understanding to specify which organizations are responsible for overseeing platform research and operations and which stakeholder groups are partnered with the platform importantly these criteriawhich are currently being established in parallel for longterm ecological research sitestreat the ses research within elter on par with its ecological observations and research program if the recent push for institutionalizing the ltser platform succeeds then ses research within elter will no longer be a side project but integral to all of elters operations metzger and colleagues assessed the geographic coverage of ltser platforms in europe identifying a lack of geographical representativeness of ltser platforms specifically regarding socioecological systems and urban and disturbed regions they also identified a persistent bias in favor of traditional ecological research and noted that mediterranean and iberian landscapes received relatively little attention nearly a decade following that study mollenhauer and colleagues conducted another study to determine the ses coverage vol of elter ri while they found that mediterranean regions continued to be underrepresented in the ri they also concluded that there had been improvement due to the impact of strategic efforts made by ltereurope in recent years to inform and encourage national lter site network developments to close gaps or support the development in countries located in underrepresented areas incidentally in a separate analysis of global distribution of ilter sites wohner and colleagues found overrepresentation in mediterranean zones and areas of high economic density a gap identified at the european though not the global scale the ri can and should continue to identify gaps in spatial coverage and encourage filling gaps through establishment of new sites and platforms or colocating research sites and platforms with sibling ris and research initiatives such as the programme on ecosystem change and society 7 natura and its affiliated organizations8 and unesco biosphere reserves9 increasing relevance to diverse stakeholder communities as of this writing elter ri is only two years into major projects to develop the ri so measuring the impact of these innovations would be premature however innovative tools to strengthen engagement and integration of stakeholders are already in development for example elter scientists have introduced two online tools that enable interested individuals to access and process socioeconomic and demographic statistical data and biophysical data extracted from satellite sensors specific to ltser platforms across europe thereby facilitating ses research at the platform scale and at the crossplatform continental scale further efforts are being invested in a continentalscale citizen science initiative to track biodiversity across platforms via the online app inaturalist these examples illustrate how elter is prioritizing engagement in science by stakeholders and the public discussion infrastructure changes signal organizational transformation we claim here that the elter ri provides a realtime example of an organization undergoing a significant change to strengthen its potential contribution to a broader societal sustainability transition organizational change happens simultaneously at the individual organizational and extraorganizational levels this type of significant change requires an array of actions from cultivating new skills and competencies of members to implementing new practices across portfolios in a holistic manner to applying relevant external standards to the organization the changes in elter ri policies detailed above encourage participating scientists to adapt their outlook and adjust the process of doing scienceto be more inclusive to include nonscientist stakeholders in meaningful and appropriate ways to think ahead about the intended impacts of research to engage is periodic selfassessment regarding gaps between activities and objectives and to plan for everpresent uncertainty and risk a clear empiricallybased foundation for supporting these changes is based on diverse bodies of literature including ses research organizational change and more however these upgrades are not entirely due to the aspiration to fulfill the recommendations of sustainability research they also fulfill the practical requirements of eu funders that set requirements for stakeholder integration gender equality transparency and other issues however while elter leadership may have initiated these aspects of science because they are mandated they have stated that they envision that these organizational changes will improve research output and actionability toward addressing grand sustainability challenges elters current efforts reflect a process of formalization of its conceptual framework and ethical vol values formalization is important for triggering shifts in how individuals think about td in their scientific work for serving as external motivation when old habits creep back in and for creating boundary objects that partners and participants can refer to moving forward importantly the commitments described above are living documents that will be subjected to periodic review and assessment to facilitate adaptation to changing circumstances the elter ri leadership can attest to the growing pains that come with changing ways of thinking and collaborating but it is often through a bit of discomfort that individuals realize changes they need to make to become more effective collaborators challenges of realizing these strategic priorities the aspirational objectives outlined here along with the tools to actualize them does not diminish the importance of reflecting upon present and future challenges first among the challenges is executing effective longterm transdisciplinary socialecological research in the field the challenge of producing transdisciplinary policyrelevant research and maintaining it for extended time periods was analyzed by holzer and colleagues and the challenges described there presented here in table 1 continue to be relevant today elter ri scientists continue to search for and initiate proofofconcept research that not only reflects that td research is actually happening but exemplifies the success of the approach in contributing to landscapescale sustainability in other words examples of research that engages stakeholders meaningfully conducts policyrelevant research and shows desirable socioecological impacts are few but elter is taking steps to grow in this area one productive working example that is exceptional within the ri is research in the french zone atelier plaine et val de sévre which exemplifies all three of these elements as outlined in berthet et al platform scientists from zone atelier plaine et val de sévre have been working closely with farmers for nearly three decades during which their research program has become increasing holistic evolving from a purely ecological perspective to one that also focuses on socioecosystem dynamics this research group has expanded its focus on a broadening range of agroecological and biological conservation issues and involved a wider range of scientists and stakeholders reproducing this success across elter ri would profoundly advance a second challenge is realizing elters formalized ethical commitments for example the ri has been engaged in intense debate regarding the environmental impact of flying but after cessation of travel for two years during the covid 19 pandemic there has been a strong desire to reestablish close working relationships that distanced during the pandemic compromises are being tested to reduce the amount of flying for instance by holding regional meetings with smaller work teams and setting centrallylocated meeting venues with easy access by groundbased transportation nonetheless flying is still considered an absolute necessity by many ri scientists the first meatfree meeting was also not received positively by many of the workshop participants when the approach was tested but the ri continues to reduce the amount of meat at its meetings for most of the other ethical commitments more time will be needed to see if the guidelines and the tools for their implementation will be successful conclusion will greater transdisciplinarity lead to greater sustainability we recognize that implementing the ambitious holistic approach outlined in this perspective is beyond the capacity of most individual scholars it necessitates a collaborative network with effective communication conducting effective team science is an everpresent challenge for elter as it is for td science in general this challenge encompasses cultivating teams with a common language and accessible boundary objects to communicate effectively constant vigilance renewal review and selfassessment introspection frequent reminders that we are meant to do things differently and guidelines and leadership to integrate knowledge when individuals begin to revert back to their individual expertise the elter experience shows that significant opportunities to advance these efforts arise when they are explicitly required by granting and government agencies while only three years have passed since the 2019 assessment findings were shared elter leadership has institutionalized an ses research approach by defining criteria for platform establishment and operation defining essential ses variables and developing tools to compile and disseminate data freely and easily they have begun to document commitments to td principles including a strategic plan and elter ethical guidelines these changes magnify the potential of elter to contribute to sustainability goals through its institutional structure and ethical commitments through the production of knowledge and data and through partnerships with stakeholders that can magnify this work it is too early to tell whether these organizational changes will directly spur sustainability transitions in ltser platforms but elter as a network of scientists and stakeholders scientific infrastructure and knowledge production is already a more resilient institution as a result of the due diligence reflexivity and tough conversations that are shifting the status quo of doing ses science across europe images or other third party material in this article are included in the articles creative commons licence unless indicated otherwise in a credit line to the material if material is not included in the articles creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use you will need to obtain permission directly from the copyright holder to view a copy of this licence visit creat iveco mmons org licen ses by4 0 author contributions jmh and deo both contributed to the conceptualization writing editing and reviewing of this paper funding the authors have not disclosed any funding competing interests the authors declare no competing interests open access this article is licensed under a creative commons attribution 40 international license which permits use sharing adaptation distribution and reproduction in any medium or format as long as you give appropriate credit to the original author and the source 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context scholars across holistic transdisciplinary placebased fields of research such as landscape ecology and social ecology have increasingly called for an allhandsondeck approach for transformations toward greater sustainability of socialecological systems this perspective showcases organizational transformation toward sustainability in the context of a research network dedicated to placebased socialecological research in europe objectives using the european lter research infrastructure elter ri as a case we analyze recent organizationallevel shifts motivated by desires to increase sustainability impact these shifts include knowledge integration between the natural and social sciences stakeholder engagement and a reformulation of administrative guidelines and practices methods following a program evaluation new conversations led to new initiatives in the elter ri as researchers who were involved in the program evaluation and the development of new initiatives we rely on our professional experience and participant observation to provide insights about this process and its developments results recommendations from a recent assessment that critiqued and provided recommendations for the research infrastructure have recently been implemented in the elter ri elter has leveraged a unique and timely opportunityformal recognition and project funding by the euto upscale and standardize its infrastructure by creating novel protocols and enacting steps towards implementation conclusions this perspective demonstrates how elters research agenda and related protocols have evolved to better integrate multiple knowledge types promote stakeholder integration into research and foster greater equity and reflexivity in doing science all of which are considered necessary to increase sustainability impact we conclude by considering current and potential future challenges

online impression formation sticky cues this notion that some information is weighted differently than other information is not necessarily new a number of fields have long considered what information matters in judging another from warmth and competence to beauty to negativity and extremity scholars have long been interested the basic idea of meaningful cues this particular research seeks to advance this tradition in its newest iteration impression formation online one understanding for how judgments arise from online impressions comes from social information processing theory the sipt framework suggests that when forming an impression of another via an online profile the perceiver utilizes all the available information whether it is in the form of pictures or text and each bit of information is referred to as a cue moreover some cues matter more than others cues that are especially informative about a message sources credibility have been deemed sticky cues for they grab the attention of a perceiver in the impression formation process and influence judgment more so than other cues previous research has already indicated the presence cues that might be deemed sticky in online profiles first research has supported visual primacy in online impressions when photographic and textual selfdisclosures are presented together on a facebook profile photographs more strongly influenced social orientation judgments photographs are seen as more credible and weighed heavier in impression formation in applying patterns of visual primacy and online impression formation to a population of incoming college students there are some distinct predictions possible we hypothesize that when a college freshman is considering whether to drink with a new friend the new friends facebook photos will receive stronger consideration and more extreme responses than any textual selfdisclosures h1 for incoming college students considering pictures on a new friends facebook profile will lead to more extreme responses on likelihood to drink intentions whether positive or negative compared to status updates another form of information that may represent a sticky cue is a wall post a wallpost is a textual statement written by another individual that appears on ones own profile page research has supported the warranting theory online which predicts that othergenerated cues have a greater impression weight than usergenerated cues it follows that a wallpost on facebook would carry greater value than a personal picture this occurs as a photo angle can be selectively chosen and posted oneself whereas it might take more effort to convince friends to complement ones appearance on a facebook wall applying warranting theory to a context of first year collegiate students is again insightful if a first year student were judging a new friend and considering how to act with that new friend based on viewing their facebook profile it is likely that the strongest judgments would arise from reactions to what that individual has contained on their wall the clearest othergenerated cue thus a second hypothesis can be posited h2 for incoming college students wallposts on a new friends facebook profile will produce more extreme responses on likelihood to drink intentions whether positive or negative compared to pictures positive and negative cues finally research has indicated that the online context in which personality information is presented can affect how it is interpreted specifically d angelo and van der heide identified positivity and negativity effects which can arise in impression formation simply put cues that are not expected in a given online context will be judged in respect to their valence in that online context the positivity and negativity effect allow for certain predictions about personality judgments in an online environment for example it is likely that individuals about to begin their freshman year of college will not have been exposed to many drinking references from sameage friends on facebook as alcohol references tend to emerge during the first year of college additionally older adolescents today know the public nature of anything they post online and such postings are taboo among this population for whom drinking is illegal thus any postings of reference to drinking would likely be frowned upon coming off as negative while the negativity effect may emerge from drinking references there is also the possibility of a positivity effect emerging from prosocial messages here prosocial is defined as any type of cue that indicates a desire to better ones self or others for example discussion of a study group may occur on an individuals wall and seeing such uncommon prosocial cues on a new friends facebook profile may produce a positive judgment of that individuals character predictions of these positive and negative responses are strengthened when considering processes of adolescent development specifically there is a welldocumented concept associated with adolescent development resiliency resilience has been deemed an ordinary phenomenon whereby adolescents even when faced with threats will achieve positive outcomes combining what is known about negativity and positivity effects with the notion of resilience certain predictions can be made given that drinking itself is a rather normative behavior on many college campuses and expected aspect of college it is likely that even underage students will participate however at the same time the notion of resilience suggests that these individuals would be more likely to place themselves in a safe situation with a responsible individual to partake in alcohol than with an individual who they may deem as irresponsible unsafe or unintelligent thus the following hypothesis can be stated h3 for incoming college students prosocial facebook cues on a new friends profile will lead to higher likelihood to drink intentions compared to drinking related facebook cues internalizing social networks cues as schema understanding how individuals view and form impressions of online profiles is an important task however online profiles are no longer just online they are often discussed in person over a conversational audio channel sipt the theory upon which the notion of sticky cues and the nonnormativity effect are built is a theory about visual processing however facebook wallposts and status updates are common conversational topics for collegiate students and others thus the final aspect of this research attends to the movement of cues away from being simply screenbased structures importantly in verbal conversation these structures of online communication lack the visual aspects that allow a perceiver to clearly judge wallposts as othergenerated and perhaps more credible than pictures or textual selfstatements however it is possible that certain features of online communication have become ingrained in communicators to the degree that that they are automatically interpreted as being more or less important regardless of visual cues if this is the case it is possible that credibility of certain cues are so familiar to college aged students that they may be considered schema a personal mental framework that allows individuals to process information in an effective and automatic manner a schema is generally believed to have some level of activation which also triggers other related schema thus acting as a cognitive shortcut similar to a heuristic if wallposts and pictures are schema the associated heuristic might be a signal of credibility or importance for judging an individual hence this research aims to test the stickiness of cues through an auditory channel thus entertaining the notion of facebook cues as schema method participants this study took place at two large public universities one western and one located in the midwest students were randomly selected from the registrars lists of incoming freshmen students from both universities and deemed eligible if they were between the ages of 18 and 19 years and enrolled as full time freshmen for fall 2011 at one of these two universities this sample focused on incoming freshman for two reasons first this research represents the first stages of a longitudinal study involving these students second the measures taken at this time were deemed an important line of investigation given the likely position of facebook in the friendship formation and uncertainty reduction processes during the first year of college a total of 338 participants were interviewed 190 of whom were female and 148 of whom were male with 198 from the midwestern university and 139 from the western university of these participants 252 identified as caucasian 39 as asian 21 as more than one ethnicity 13 as hispanic and 5 as african american given that the aim of this study involved predicting likelihood to drink nondrinkers were screened out of analyses there were a total of 50 nondrinkers removed from this sample leaving 288 total participants considered in the analyses interviews after providing consent all participants completed a phone interview interviews were conducted by trained research assistants and lasted between 40 and 60 minutes on average during interviews data were recorded onto a collection spreadsheet interviews included a vignette vignette to assess the influence of facebook cues on intention to use alcohol a vignette was utilized vignettes systematically elaborated descriptions of concrete situations are a valid and comprehensive method for assessing exploring peoples perceptions beliefs and meanings about specific situations vignettes allow for the manipulation of important study variables in a manner that would not be feasible in an observational study as well as the collection of information from a large number of participants simultaneously further vignettes allow for avoidance of observer effect and ethical dilemmas and the control of confounding effects the vignette was designed to assess participant views of how displayed facebook content would impact their intention to drink in a particular setting to develop alcohol references past databases of coded facebook information were reviewed and example references to alcohol use were noted to develop nonalcohol related posts active facebook profiles were reviewed to identify references that were nonalcohol related for the purposes of consistency within this study these prompts were intended to have a prosocial tone these vignettes were then tested on a pilot sample of participants and edited in response to comments these vignettes presented a scenario in which the participant was invited to a party by a senior student that they just met the student was then asked to imagine that they were currently looking at the senior students facebook profile prior to going out to that party tonight then the participants were presented with a number of different cues that they might see on this individuals profile and asked to respond with their likelihood to drink with this individual at the party after viewing each cue cues varied in type and valence with dummy prompts of interests and groups also included see appendix a for full vignette prompt results taken together the hypotheses 1 through 3 predict a distinct pattern of means specifically when assessed with response on likelihood to drink the cue pattern was predicted to move from least likelihood to greatest likelihood as follows drinkingrelated wall post drinkingrelated picture drinkingstatus update prosocial status update prosocial picture prosocial wall post in order to assess the predicted pattern of differences a repeated measures anova was conducted and the data was tested for a linear trend while controlling for gender ethnicity and university as predicted there was a significant effect of cue type on likelihood to drink f 5915 p 01 partial η 2 02 additionally there was a significant linear trend f 779 p 01 partial η 2 03 indicating that likelihood to drink in response to cues increased proportionately as predicted by hypotheses 1 through 3 however while the hypotheses received statistical support the effect sizes were rather small figure 1 illustrates the pattern of means as is evident the pattern of means falls in the manner that was predicted by the hypotheses specifically hypothesis 1 was supported with pictures receiving more extreme ratings than status updates and hypothesis 2 was supported with the wallposts receiving the most extreme ratings additionally prosocial cues lead to an overall higher likelihood of drinking with drinking cues leading to a lower likelihood of drinking thus supporting hypothesis 3 given these results specific differences among cue types were tested in order to test these predictions first score differences were computed this was done to access the strength of response to particular cue types for example wallposts with drinking related references lead to the least likely intention to drink whereas wallposts with prosocial references lead to the highest intention leaving wall posts with the greatest computed difference thus wallposts led to the most extreme reactions compared to the range of reactions from pictures and status updates using these difference scores bonferroni corrected paired ttests were conducted as suggested by field to compare levels of difference scores as the independent variable as predicted likelihood changes based on pictures were more extreme than the difference between status updates and likelihood changes based on wall posts were more extreme than the difference between pictures thus supporting h1 and h2 respectively see table 1 for means and ttest results discussion while college students readily consume both facebook andalcohol little is known about how one activity may affect the other how the impression formation process impacts intended behavior moreover the impact of this process may be taking place both through visual channels when individuals interact with computer screens and through auditory channels as discussion of facebook is becoming as staple of facetoface conversation thus this research presented a vignette to examine how cues presented on facebook which were either alcoholrelated or prosocial impacted college students selfreported intentions to drink alcohol findings indicated that some cues do matter more some cues were stickier than others additionally findings indicated that viewing prosocial cues led to a higher selfreported likelihood to drink with a target individual for first year college students finally this research found that these predicted patterns emerge when being tested over an auditory channel suggesting that sticky cues are not only an element of visual perception and impression formation but rather are making their way into the very schema of interpersonal communication with such findings this research provides further empirical evidence of visual primacy and the warranting effect in the impression formation process however it does so by enhancing the conceptualization of sticky cues according to these findings wallposts are the stickiest cues associated with facebook page followed by photographs followed by textual selfdisclosures the second contribution of this research comes in the more practical findings concerning the interaction of facebook and collegiate drinking we found that prosocial cues were associated with increased reported intention to drink compared to alcoholrelated cues this pattern may be predicted by the negativity and positivity effect associated with online impression formation as drinking related references are likely seen as negative for this population which is likely aware of online privacy and legality issues additionally the resiliency framework for adolescent development suggests that older adolescents will not knowingly put themselves into a harmful situation rather seeking a responsible route if given the time and right decision making context suggesting a prosocial post might be judged as positive for the context of facebook and acted on as such finally this research takes a theoretical leap in consideration of the importance of cues online many processes identified in cmc find their foundation in communication processes established first in facetoface communication the nonnormativity effect was drawn from correspondence inference theory andvisual primacy emerges from work evaluating visual and verbal cues patterns emerged in face to face communicative action and were found to exist in computermediated communication as well now in this study we see that this may hold true in the opposite direction the findings from this study support impression formation predictions that do not end when the phone or computer are turned off cues that are important online may be internalized and have impact even when no screen is present a wallpost may have started as an impression formation based cue but its importance is even clear when discussed via facetoface communication thus this research both indicates which cues are stickiest in impression formation and supports that sticky cues exist not only on the webpage but rather as learned schema within the mind limitations and future directions this study has limitations which must be considered first the vignette methodology though informative as a step forward in research has a number of incorporated considerations a possible source of error includes the fact that each participant was exposed to a single questionnaire with all cues while the cues were not presented in the order of means hypothesized it is possible that there were order effects further there was no control variable assessed within this vignette while it is clear prosocial cues lead to a higher likelihood to drink than drinking related cues it is unknown how these cues relate to baseline intentions thus future research should seek to establish these effects in a randomized experiment between subjects and also assess how these cues relate to baseline drinking likelihoods additionally this vignette did not specify the gender of the senior college student it is possible that individuals might have interpreted this senior student as samesex or opposite sex and responded to the prompt differently because of this assumption future research should explore the impact of gender in association with college alcohol use and influence on facebook a second limitation comes in the population sample the sample was taken specifically of incoming freshman students from two universities the gender and demographic characteristics of the sample are consistent with those of the larger universities suggesting the population was generalizable to larger schools however the generalizability of the results cannot extend beyond this population thus future research should examine different types of school settings and whether these patterns of cue influence extend over time especially in a manner that addresses the evolving norms of social and networked life that a college student can experience additionally it is questionable whether these patterns exist in populations with different drinking and posting norms a third limitation comes in in the consideration of the evidence for warranting theory over visual primacy while this finding has theoretical and empirical support within this paper a stronger manipulation would involve and actual simulation administered via screen this would allow the hypothesized mechanisms behind these theories to occur naturally thus further research is needed before this particular hierarchy can be established with strong evidence a fourth limitation arises from the consideration of alcohol consumption likelihoods our study did not assess intended or actual drinking frequency or quantity future research on facebook cue influence in this domain should consider both participant drinking behaviors and participant drinking intentions in a more specific manner while it is clear future work is necessary to further understand the influence of facebook cues on collegiate alcohol consumption the findings of this research represent a strong first step to understanding the visceral impact of a virtual environment mean difference ttests supplementary material refer to web version on pubmed central for supplementary material

alcohol displays on facebook are everpresent and can be socially desirable for college students as problematic drinking is a concern for college students this research sought to understand how different types of information on a facebook page influence likelihood to drink telephone interviews were conducted with 338 incoming college freshmen from two large national universities data were obtained from a vignette prompt which presented a scenario in which a senior college students facebook profile displayed wallposts pictures and status updates that were drinkingrelated or prosocial in nature participants were asked to report intention to drink alcohol with that student if together at a party findings supported the hypotheses wallposts were most influential the stickiest followed by pictures followed by status updates findings provide additional empirical support for established online impression formation patterns and additionally provide evidence that virtual cues are being ingrained as schema in interpersonal communication these results are discussed in relation to the conception of sticky cues in impression formation the way that individuals meet is fundamentally changing while the forming of an acquaintance and initiation of a relationship was once characterized by a process of gradual disclosure altman taylor 1973 today it is possible to rapidly access an avalanche of information about acquaintances whether this occurs as online daters google each other for additional information gibbs ellison lai 2011 or as adolescents explore a new friends social network postings courtois all vanwynsberghe 2010 personal information is readily available after a few clicks on the computer one can form impressions of an individual based off of everything from their vacation pictures to what others say to them on their social networking profile one population for whom online impressions likely play a significant role in the friendship formation process is that of college students among college students the use of online social networking sties snss has become ubiquitous with up to 995 of students

introduction during the late 1950s when homosexuality was still viewed as a psychiatric disorder nonclinical populationbased studies in the visible lesbian bisexual or gay individual community repeatedly found no elevation of the natural occurrence of mental disorders in lbgs compared to heterosexual people since the early 1990s however research with improved study designs and less selective inclusion of lbg individuals reported increased rates of mental disorders in lbgs compared to htss a metaanalysis of 25 studies calculated odds ratios of 15 for depression anxiety and substance abuse disorders and a twofold excess in suicide attempts in a large majority of studies however psychosis was not investigated as a mental health outcome sexual minority status has been associated with a higher prevalence of psychotic symptoms in general population studies in the uk and the netherlands to the best of our knowledge these are the only two studies comparing risk for psychotic disorders and psychotic symptoms between lbgs and htss respectively the current study aimed to investigate the association between lbg status and the risk for psychotic disorders and to explore potential pathways social adversity and social stress over the life course may be a substantial mediator of psychological problems and mental illness in lbgs social stress occurs when the social self is threatened due to maltreatment stigmatization discrimination or exclusion such socialevaluative threats are more likely to occur for those belonging to ethnic and sexual minority groups and may increase the risk for psychiatric disorders the prevalence of childhood sexual and physical abuse is up to four times more likely to occur in lbgs gay boys are 46 times and lesbian girls are 24 times more likely to be bullied during high school compared to hts adolescents there is tentative evidence for a doseresponse relationship between victimization through bullying and mental health problems moreover childhood bullying is specifically thought by some to influence cognitive and biological mechanisms of psychotic ideation in those atrisk mental states in early adolescence to our knowledge associations between sexual minority status and psychotic disorders have not been studied a fair amount however has been published on the socially adverse environmental risk factors for nonaffective psychotic disorder the association between childhood trauma and psychosis has been quantified to a substantial or of 28 childhood bullying increases the risk for psychotic mental disease lastly perceived discrimination too has been associated with an increased risk of psychotic symptoms in clinical minority studies within lbg populations the degree of perceived discrimination by means of sexual prejudice has been associated with mental health problems factors of social adversity thought to mediate associations between lbg and psychosis are shown in fig 1 a previous crosssectional study found that perceived discrimination in particular mediated the twofold increased psychotic symptom development in a community sample of lbgs the current study investigated the prevalence of lbg in a large populationbased cohort of patients with psychotic disorders their siblings and healthy controls we aimed to examine whether the proportion of lbgs is higher in patients with psychotic disorders compared to individuals without psychotic disorder and if so to explore possible mediating pathways we hypothesized that sexual minority status is more common in patients than in siblings and healthy controls that patients less often disclose their sexual identity to others and that ct experiences of bullying and perceived discrimination contribute to an increased risk for napd methods data were collected from the genetic risk and outcome in psychosis study a large longitudinal observational populationbased cohort study conducted in dutch mental health institutes affiliated with four academic medical centers in the netherlands and in regional psychotic disorder services in belgium the procedure of recruitment and population characteristics has been described in detail elsewhere the groupstudy was approved by the medical ethics committee of the academic medical center of utrecht all subjects gave written informed consent the current study uses data from the third group assessment 6 years after baseline subjects patients were asked to participate in the group study if they met the following inclusion criteria age range 1650 years diagnosis of napd and good command of the dutch language control subjects were selected through a system of random mailings to addresses in corresponding geographical areas controls were excluded if they had a firstdegree relative with a psychotic disorder established with the family interview for genetic studies siblings of included patients were also approached to take part in the group study if they did not have a history of psychotic disorder if controls or relatives developed a psychosis during the study period they were allocated to the patient group measurements diagnostic instruments detailed medical and psychiatric histories were collected including the comprehensive assessment of symptoms and history a semistructured interview for assessing diagnosis and psychopathology or schedules for clinical assessment for neuropsychiatry trained psychologists or psychiatrist with extensive clinical experience using the diagnostic and statistical manual of mental disordersiv criteria made diagnostic classification sexual orientation and behavior homosexuality has several dimensions including selfidentification samesex attraction and samesex behavior in order to capture the best dimension of sexual orientation participants were asked if their predominant orientation was samesex participants were classified as lbg if they replied yes missing data for sexual minority status ie i dont know or refuse to answer were recoded as no and assigned subjects to the hts group in a sensitivity analysis we psychological medicine recoded i dont know and refuse to answer into yes in order to compare both results all participants were also asked to what extent they had disclosed their sexual orientation to people in their environment sexual identity disclosure can be seen as weakening effect modifier of stress the latter was illustrated by findings of lower cortisol levels and less psychiatric symptoms in adult lgbs who had disclosed their sexual identity compared to those who had not disclosure is also associated with affiliation and formation of social circuits which are likely to reduce the impact of social stress sociodemographic variables sociodemographic variables included age gender ethnicity living with a partner education urban living and lifetime cannabis use social adversity and social stress ct was assessed with the dutch version of the childhood trauma questionnaireshort form the dutch ctqsf effectively screens for maltreatment between clinical and nonclinical samples the ctqsf is a 25item retrospective selfreport questionnaire designed to assess five dimensions of childhood maltreatment physical abuse emotional abuse sexual abuse physical neglect and emotional neglect the total mean score of all child trauma experiences was used for analysis bullying was assessed as follows participants were asked if they had ever been bullied by another child or teenager during elementary middle or high school and asked to rate the severity of bullying on a fivepoint scale lifetime discrimination experiences were assessed with a series of dichotomous yes or no questions on the following situations ever been fired not hired for a job not been promoted detained questioned or threatened by police badly treated by the justice system discouraged from further education prevented to buylet a house badly treated by neighbors denied a loanmortgage received bad service or been badly treated in either medical care or public transport the mean cumulative score was used as a measure of perceived discrimination in contrast to ct which was assessed at wave 2 bullying discrimination and sexual minority were all assessed at wave 3 statistical analysis statistical analysis was performed using spss 170 pearson χ 2 test of independence independent samples t test and anova were used to test sociodemographic and clinical differences between patients and controls and between lbg and hts groups binary logistic regression analyses were used to compare the risk of patients with a psychotic disorder being lbg compared to people without a psychotic disorder a priori determined confounding variables of age and gender were adjusted for to investigate whether ct bullying and perceived discrimination mediated the association between lbg and napd a bootstrapped multiple mediation analysis was conducted with the process macro developed by hayes release 60 of the group database was used for analyses controls were significantly more likely to be livingmarried with someone than patients the proportion of people with high education was lower in patients than in controls lbg patients had significantly higher mean scores for ct when compared to hts patients in the lbg group 395 of patients reported often bullying v 20 in the control group in hts participants this was 203 and 81 respectively discrimination scores were also significantly higher in the lbg participants with 29 of patients and 50 of controls reported never to have experienced discrimination v 39 and 62 in hts counterparts data of all 1546 subjects were used to calculate binary regression estimates compared to controls the or of lbg status was 161 for patients with napd and for siblings was 158 of the lbg participants 78 of controls 38 of siblings and 29 of patients had disclosed their sexual orientation to almost everyone in their lives and not a single control 4 of siblings and 16 of patients reported that no one knew of their sexual orientation multiple mediation analysis showed that perceived discrimination ct and bullying all partially mediated the association between lbg status and napd the indirect effect of discrimination controlling for the other mediators was the greatest in predicting psychosis in lbgs b 023 the second greatest indirect effect was that of ct b 012 and the last was bullying b 006 in sensitivity analyses with participants who responded i do not know or refuse to answer added to the lbg category 66 patients 36 siblings and 23 controls were classified as lbg the unadjusted or for lbg status was 137 for patients compared to controls ageand genderadjusted or was 142 discussion main findings this large populationbased casecontrol study found that the prevalence of a sexual minority status was higher in patients with napd than in siblings and in healthy controls whereas approximately 80 of controls had disclosed their sexual identity to almost everyone in their lives only 30 of patients had done so our study results provide preliminary evidence that sexual minority status is a risk factor for napd with a positive significant association or of 16 mean scores of social adversity with the exception of ct were significantly higher in lbgs than in htss also within the patient group ct a history of bullying and perceived discrimination partially mediated the association between sexual minority status and napd comparison to previous studies and interpretation chakraborty et al 2011 found elevated rates of psychotic disorders in nonhts individuals 375 unadjusted or similarly in the netherlands in another general population study gevonden et al found elevated rates of psychotic symptoms in lbg population compared with hts during two consecutive periods nemesis1 and nemesis2 in the current clinical sample an or of lbg status of 16 for patients with napd correspondingly perceived discrimination outcomes were higher for lbgs in both of the aforementioned studies and thought to act as a social stressor toward the genesis of psychopathology our mediation results confirm these reports by finding similar factors mediating the association between lbg status and napd specifically our results are also consistent with previous health mediation risk findings of data from 9188 9th12th grade students from massachusetts and vermont of whom 315 were lbgs they showed a combined effect of sexual minority status and victimization to be consistently associated with higher levels of risk indices such as substance use or suicide attempts in our data bullying experiences were more prevalent amongst lbg than hts subjects and the indirect effect psychological medicine of bullying on napd risk was significant compared to ct and discrimination however the effect of bullying was smaller the reason for this may be that in the aforementioned study bullying was ascertained in real time while our study participants were older and recall error could have led to an underreporting of bullying furthermore 16 of our sexual minority patients had not disclosed their sexual identity which also may have contributed to lower bullying scores sexual minority status is likely to represent environmental factors that increase the risk for psychotic symptoms and disorders current environmental theories of psychosis emphasize a central role for adversive experiences over the life course childhood adversities in particular recurrent experiences of hostility and threat have been consistently associated with increased risk for psychotic disorder similarly higher rates of psychosis in immigrants and their offspring are likely to be explained by a negative social minority position being part of a group that is viewed as inferior by the majority population and chronic stress due to social exclusion discrimination and social defeat such experiences are common in lgb individuals even if they have not disclosed their sexual identity by identification with the minority group indeed aversive social experiences partially mediated the effect of lgb status on the risk for psychotic disorder in our sample several authors hypothesize that exposure to social stressors during critical periods of brain development leads to sensitization resulting in permanent excess of basal presynaptic transmission of dopamine which is thought to increase the risk for psychosis pathogenic effects of social stressors on neurochemical systems are similar for both napd and lbgs sexual identity disclosure has been shown to improve the overall mental health of lbg youth and adult lbgs who have disclosed their sexual preference show lower cortisol levels and less psychiatric symptoms compared to lbgs who have not it is plausible that these neurodevelopmental and biological mechanisms if present are more pronounced in lbgs considering the trying conditions under which lbgs become of age and live in thereafter lbgs are known to achieve important milestones such as a steadfast identity settling down with a partner and family planning later in life in spite of the netherlands renowned international gayfriendly reputation our results show that lbgs experience increased psychological strain during their life course by means of social adversity the formation of biased cognitive schemas is more likely to occur after negative social experiences and are exacerbated and perpetuated by having an outsider status on the other hand selfdisclosure at a young age which appears to be a trend may lead to increased social adversity and exclusion in individuals not yet psychologically equipped to handle the adversity this in turn might explain why the prevalence of psychiatric disorder in young lbgs has not declined over recent decades despite positive changes in social attitudes in western countries in addition to the abovementioned socioneurodevelopmental theories other potential mediators of association between lbgs and psychotic disorders should also be considered such as healthy identity and bodyimage formation a recent dutch survey study of lbgs showed that in men higher levels of gender nonconformity predicted the experiences of ct by an adult family member which in turn predicted the higher level of adult revictimization if lbgs are more victimized as children by primary caregivers they are also more likely to be deprived of the developmental conditions needed to form a steadfast sense of self and a healthy bodyimage difficulties in establishing a steadfast sense of self are reported by patients with psychosis strengths and limitations the results of this study should be interpreted in the light of several methodological issues selection bias may have occurred while the large patient group of the group study can be argued to be representative of the napd population at the third assessment 48 of the original patient sample was lost to followup the results would be biased if hts patients were more likely to drop out than lbg patients or if healthy lbgs were less likely to participate in the study than hts controls we tackled possible responder bias by allocating the refuse to answer and i dont know a substantial total of 13 participants to the hts group a recent population survey found that approximately 4 and 3 of dutch men and women respectively are homosexual this corresponds well with the lbg rate in our control group we conceptualized predominant samesex attraction as a measure of sexual minority identity yet we recognize that we did not also ask about samesex behavior and predominant attraction does not per se necessitate samesex behavior or selfidentification as an lbg individual however dissonance between sexual identity in which case samesex attraction is a key question to pose and samesex behavior occurs particularly in adolescents whereas the mean age in our minority patients was 349 years of age a further potential concern is the measurement error of sexual minority status it is conceivable that sexual identity is a part of delusional ideas in some patients with napd sexual orientation was measured 6 years after baseline making incorrect classification as lbg as a result of actual psychosis less likely furthermore mediators must precede the occurrence of the outcome in time this is true for ct and bullying but not necessarily for perceived discrimination as this was measured lifetime and could therefore may have occurred after the onset of psychosis another limitation of the current study is the small lbg sample size we did not have enough statistical power to control for urban living and cannabis use lbgs tend to live in densely populated urban areas higher occurrence of substance abuse amongst lbgs is a wellreplicated finding and is by some hypothesized to be more normalized within the lbg culture andor used as a coping mechanism for minority stress it should be acknowledged that these variables had many missing values in third wave data which limits their interpretation our data suggest that cannabis use was lower in lbgs than htss which implies it is probably not a substantial factor in explaining the increased risk for psychosis in this population as we did not have detailed information on cannabis use and data were not available for a third of participants conclusions should be regarded with caution the results of this study implicate that lbgs have even more increased mental health risks than previously known social defeat factors such as ct discrimination and bullying especially need to be addressed

background lesbian bisexual or gay individuals lbgs have an increased risk for mental health problems compared to heterosexuals but this association has sparsely been investigated for psychotic disorders the aim of this study was 1 to examine whether lbg sexual orientation is more prevalent in individuals with a nonaffective psychotic disorder napd than in people without a psychotic disorder and if so 2 to explore possible mediating pathways methods sexual orientation was assessed in the 6year followup assessment of the dutch genetic risk and outcome of psychosis study group a casecontrol study with 1547 participants 582 patients with psychotic disorder 604 siblings and 361 controls binary logistic regression analyses were used to calculate the risk of patients with a psychotic disorder being lbg compared to siblings and controls perceived discrimination history of bullying childhood trauma ct and sexual identity disclosure were investigated as potential mediating variables results the proportion of individuals with lbg orientation was 68 in patients n 40 43 in siblings n 26 and 25 in controls n 10 the ageand genderadjusted odds ratio of lbg for patients was 157 95 ci 108227 p 0019 compared to siblings and controls discrimination bullying and ct all partially mediated this association conclusions adverse social experiences related to sexual minority status may increase the risk for napd sexual identity behavior and difficulties need more attention in everyday clinical practice

introduction starting from the 1970s chinas economy skyrocketed due to the reformed policy and the process of urbanization thus accelerated at the same time an increasing number of workers from rural areas chose to migrate to the city hoping for higher salaries however due to the high living expenses and the policies that do not support countryside dwellers registration as permanent residents most workers cannot move to the city with their family members in this background situation a great number of children were left behind in the countryside living with their grandparents or other relatives lacking the caring from parents without emotional relations and communication with parents the psychological development of these leftbehind children was highly worried by society in this article multiple research projects about the psychological development of leftbehind children in china will be studied summarized and compared considering the leftbehind childrens growingup environment the education they received and the thoughts they may have this article finds out that leftbehind children face severe psychological problems in life and study this studys aims are to summarize the recent studies of leftbehind children and give suggestions about the problems faced by them literature review to study leftbehind childrens psychological development the first thing that needs to be studied is what kind of thoughts they may have and what problems they may meet without the role of parents in their lives in wangs case study the researcher used survey questionnaires facetoface interviews and monitoring group projects to learn about the leftbehind childrens emotional situations after 6 months spent with the rural area leftbehind children the researcher found that the three main concerns are earning anxiety loneliness tendency and relationship anxiety in other words childrens interpersonal and absorbing knowledge abilities didnt expand well in the absence of parents 1 in the other case study in jiangxi province the leftbehind children were found with psychological problems like anxiety lack of selfcontrol low study interest and motivation extreme sensitivity and stubbornness the possible causes of these situations were proposed as inconvenient transportation lack of cooperation and guidance and lack of sense of belonging 2 a similar result was also concluded in research from central china normal university by comparing several subgroups with different frequency and length of parent contact showing that leftbehind children have a disadvantage in emotional adjustment 3 also by inputting 861 leftbehind children as study objects via linear regression studies age and gender were found to perform as negative factors in their psychological situations in other words high school male students have more problem behaviors like fewer school engagement and worse peer relationships major psychological problem faced by lbc in rural areas learning disability the psychological problem of the leftbehind children in rural china is represented in their study aspect poor behavior in academics bad relationships with teachers and peers absence from classes and bullies are the main performances these problems will seriously influence their academic performance and later social life after they enter society without excellent academic scores to prove their cognitive abilities they will not be able to find themselves a wellpaid job also they are not aware of how to get along well with their peer workers and bosses and dealing with conflict with others will be a serious problem for them low selfesteem the lack of parents role in lbcs life also affects their confidence and their understanding of themselves and society they have feelings of being betrayed and being given up which leads to their sensitive characteristics and loneliness tendency they will be afraid that others will hurt their feelings with such a single look as a result they will hardly trust other people and try everything to avoid social contact with others this will seriously affect their normal life and beget many mentalrelated diseases the leftbehind middle school students showed more loneliness selfblame allergies and physical symptoms there are significant differences in the mental health status of leftbehind children of different genders and the mental health level of girls is lower than that of boys li qi conducted a questionnaire survey on the mental health problems of leftbehind children in 5 rural primary schools and 3 township middle schools in nanfeng county and the results showed that the mental health problems of leftbehind children mainly focused on learning anxiety interpersonal communication emotions and other aspects 2 also parental contact is of great importance among the leftbehind characteristics investigated in this study the frequency of parental contact had the broadest impact on lbcs adaption parental contact was beneficial to lbcs mental health children who had the most frequent contact with their parents suffered less from loneliness and depression and reported the highest life satisfaction and selfesteem 3 stubborn living with their grandparents most leftbehind children were spoiled or lacked correct guidance in life also the rapidly expanding internet the access to smartphones and the rising popular tiktoklike short videos make the knowledge and information go to the children without any previous check or selection this will lead to a distorted value and ideology and will affect negatively their future job opportunities and their chance of getting promoted also parents tend to put their children in two different perspectives one is too dependent on the traditional education model not enough rational and flexible guidance the other is coddling and letting go 2 these two polarized attitudes toward students also cause the stubbornness of some of them because they are already used to being overlooked or coddled solutions after knowing their problems various researchers suggested necessary strategies to the government parents and social unions more parent contact less spoiled from grandparents and more education investment are proposed by almost every research in wangs case study after the intervention of teachers and classmates the psychological situation of the child was highly improved 1 that is to say a nice school environment can work as a kind of substitute to offer some emotional support 1 schools are also encouraged to offer psychological education for both children and their guardians to raise awareness and emphasis on emotional problems 4 in conclusion the main problems the leftbehind children in china may meet are anxiety poor relationships learning disabilities and low selfesteem the government schools and parents are called to put more emphasis and input on their psychological situations 5 however conflict in the highlydeveloped society between highpaid jobs and limited education opportunities rising living expenses in cities the lack of highquality education in the countryside the inequality between provinces and districts the relatively low covering of childrens psychological education and caring make this revolution a long way to go 6 7 8 conclusion with the deepening of research on leftbehind children all sectors of society have also invested more attention on leftbehind children and adopted various assistance measures to help leftbehind children in rural areas solve their education learning psychology behavior and other problems they face among them this paper mainly discusses the causes of mental health problems of leftbehind children the main research focus of this paper is the leftbehind childrens mental health problems and countermeasures this thesis is mainly about some studies about the psychological problems faced by leftbehind children such as learning disabilities low selfesteem and stubbornness in addition the solutions to these problems are also mentioned in this work the governments should take responsibility to lower the charge of leaving behind children for their studies and life and make sure that the environment around the school is suitable for their academic lives schools should consider highly on students mental heath and build more psychological counseling rooms for students who have mental decease childrens problem behaviors were also investigated because difficulties with behavioral adjustment negatively impact both physical and mental health to get their problem solved or to be relieved for the families of left behind children 4 they are capable of using modern technology such as facetime to keep track of their childrens mental situation and if there is something wrong the parents can comfort and support their children in time whats more there are some shortcomings in this thesis for example i didnt do reallife research such as asking leftbehind children in rural areas or doing some questionnaire research to get firsthand results i will improve this drawback through browsing the field studies of other researchers and after knowing the correct process of doing reallife research i will make a questionnaire about this topic and visit those leftbehind children and make friends with them in order to get to know them deeper and better this future research will mainly focus on the relationship between the family members of the rural family in which the parents are always absent and leave their children in the village in order to help the children who are left behind more the author sincerely suggests that the studies of leftbehind children should not just stop at the suggestions but should spur the real movements of government teachers families and students

as china continues to urbanize rapidly an increasing number of adults from rural areas are making the move they choose to leave their families and migrate to the city hoping for a betterpaid job the paper explores the psychological development issues faced by children left behind lbc for short in the paper in rural areas and how to address them by means of a literature review the paper finds that we should raise the awareness of families schools and society about the psychological issues besetting the lbc in rural areas making the families pay attention to the emotional education of the children the school to assert the importance of psychological education and the government to rectify the undesirable practices and modify some laws that have something to do with urban household registration system

background the kingdom of eswatini formerly swaziland has one of the worlds most widespread hiv epidemics with more than 27 of adults aged 1549 living with hiv in 2014 1 encouragingly in eswatini and other countries with a generalized hiv epidemic there has been a decrease in hiv incidence in recent years due to a coordinated response and increase in hiv prevention program coverage including antiretroviral therapy and prevention of mothertochild transmission 23 however the hiv prevalence among key populations including gay men and other men who have sex with men as well as transgender women is significant in particular hiv incidence among young msm is increasing in almost every part of the world 4 5 6 subsequently increasing effort is being dedicated to researching and addressing the hiv epidemic among these key populations even in the context of more broadly generalized epidemics 78 for cisgender msm and transgender women the potential effectiveness of hiv prevention and treatment programing may be limited by structuraland communitylevel factors such as stigmas pertaining to sexual behaviors and gender identity which contribute to suboptimal healthseeking behaviors 910 for example culturallyinsensitive health workers may result in cismsm and transgender women avoiding hiv prevention services or cismsm and transgender women living with hiv may avoid hiv treatment services altogether reduced utilization of health and hiv services by cismsm and transgender women due to enacted or perceived discrimination may limit knowledge of the risks of condomless anal intercourse and opportunities for access to novel and emerging prevention services such as preexposure prophylaxis as it becomes increasingly available 1112 sexual behavior stigma may also increase risk for depression and other adverse mental health outcomes 1314 in turn adverse mental health outcomes may further increase risk for hiv by decreasing selfefficacy and increasing sexual risk behaviors including condomless anal sex with hiv statusunknown partners 15 16 17 and by affecting the desire or ability of cismsm and transgender women to engage in healthcare 18 sexual behavior stigma among these key populations may also limit stable couple formations resulting in larger sexual networks in which people are less likely to know the hiv status of their sexual partners and may ultimately result in increased risk of hiv infection 1920 experienced sexual behavior stigma is often greater for cismsm and transgender women who have disclosed and are open about their identity or practices even if these individuals are also more likely to be financially selfsufficient comfortable about their sexuality and have reduced minority stress after disclosure 20 21 22 23 potentially this is because they are more easily identified as targets for discrimination or harassment by broader community members 2224 however nondisclosure of sexual behaviors can lead to poorer mental health reduced engagement in hiv prevention services and increased sexual risktaking behaviors 25 26 27 thus there is a paradox whereby coming out is associated with greater experiences of stigma even if it can result in improved mental health and hivrelated outcomes and greater awareness and acceptance of gay and transgender communities among msm in eswatini sexual orientation has been estimated to be threefifths identifying as gay or homosexual twofifths as bisexual and a small proportion reporting as heterosexual 28 a study of transgender women and cismsm across 8 african countries showed eswatini had a higher proportion of transgender participants than malawi lesotho togo and the gambia 29 there is a need to better understand the role of stigma in driving the persistent hiv epidemic among cismsm and transgender women in eswatini especially considering the context of eswatini with an estimated hiv prevalence of 13 among cismsm and transgender women 30 where same sex relations is a common law offence 31 and where stigma poses a potentially significant barrier to prevention programs and services the objectives of this study are 1 to conduct a latent class analysis to determine the latent constructs of stigma and disclosure status among cismsm and transgender women in eswatini and 2 to determine associations with underlying stigma constructs and sexual risk behaviors potentially putting these individuals at increased risk for hiv infection we chose an lca approach in order to explore how clusters of stigma and disclosure status were related to risk behaviors lca is a personcentered methodological approach to identify unobservable groups through patterns of responses across individuals this approach aims to identify homogeneous groups that would be challenging to determine by assessing indicators individually 32 stigma attributable to sexual behavior is driven through social processes and may manifest through multidirectional and mutually reinforcing mechanisms 33 therefore utilizing a personcentered latent approach to assess sexual stigma outness depression sexual risk behaviors and sociodemographics help to better understand these complex patterns by capturing the multiplicity of the stigmaoutness items the objective was to better understand how these items can be conceptualized and captured in relation to sexual risk behavior among these individuals methods study population and design a total of 532 individuals were recruited across 5 cities towns and surrounding regions in eswatini through peerreferral sampling from october december 2014 in order to be eligible for the study participants had to report being assigned the male sex at birth being aged 18 years or older having insertive andor receptive anal sex with a man within the past 12 months speaking siswati or english and being capable of providing written informed consent this study was approved by the johns hopkins bloomberg school of public health institutional review board and the eswatini scientific and ethics committee data collection and key measures during the study visit trained interviewers administered a structured questionnaire through a facetoface interview in a private location the questionnaire included questions about demographics stigma disclosure about having sex with men and mental and sexual health demographics a twostep gender assessment was used to distinguish between cismsm and transgender women in this study this assessment included reported sex at birth and reported current gender identity 3435 individuals who reported a gender identity as female or intersex were considered transgender women in these analyses participants who reported a gender identity of male are defined as cismsm for these analyses we included information on age highest level of completed education gender identity employment status and whether the study site was located in an urban or periurban area in order to perform the lca each of these variables was dichotomized into binary indicators sexual behavior stigma stigma attributable to having sex with men was measured by asking a series of yes or no questions which have been used in several previous studies of cismsm and transgender women in subsaharan africa 1036 this sexual behavior stigma was comprised of stigma from personal social and healthcare settings personallife stigma included feeling excluded at family gatherings feeling that family members made discriminatory remarks or gossiped or feeling rejected by friends social stigma included feeling that the police refused to protect you feeling scared to walk around in public places being verbally harassed blackmailed physically hurt or tortured as well as experience of violence finally healthcare stigma included feeling that you were not treated well in a healthcare center hearing healthcare providers gossip feeling afraid to go to healthcare services or avoiding healthcare services out about having sex with men participants were asked have you told any member of your family that you have sex with men or that you are attracted to other men as well as does anyone in your family know that you have sex with other men or that you are attracted to other men other than those who you have told participants who reported yes to either were considered being out to family members participants who responded yes to the question was there a time when any health care provider learned that you have sex with other men or that you are attracted to other men were considered being out to heath care workers depression a positive depression screen was defined as a patient health questionnaire score of 10 or greater 37 the phq9 measures the frequency of depression symptoms within the past two weeks this scale has been used previously in subsaharan african populations 3839 and had good internal consistency in our study sample sexual risk practices participants were asked how often condoms were used within the past 12 months for receptive and insertive anal sex these measures were dichotomized into a single indicator for condomless anal sex that included any or none in addition participants were asked if there was any time in the last 12 months that they had multiple regular sexual partnerships at the same time that is involved in two or more ongoing sexual partnerships either with males or female partners these measures were dichotomized into a single indicator for concurrent sexual partnerships that included any or none statistical analyses we tabulated descriptive characteristics of participants using frequencies and percentages bivariate logistic regression was used to test associations between being out about having sex with men and sexual behavior stigma these analyses were conducted using sas software version 94 in a twostep process we first used lca to identify classes based on selfreported measures of stigma and whether or not it was known to family or healthcare workers that the participant had sex with men twothrough sixlatent class models were produced iteratively the number of classes was selected based on theoretical and practically meaningful patterns as well as model fit criteria fit indices included the likelihood ratio test statistic the akaike information criterion the bayesian information criterion the consistent aic and entropy 40 smaller values of aic and bic and higher values of entropy indicate better fit next multinomial logistic regression was used to identify demographic characteristics sexual risk behaviors and mental health characteristics that were associated with class membership these variables were first analyzed individually and then simultaneously in a multivariable model all covariates except for age and reporting more than a high school education were found to be significant predictors of membership in at least one latent class in the bivariate analyses demographic variables considered to have theoretical importance were kept in the final model regardless of their level of statistical significance as a result no variables were dropped from the final model for both the lca and logistic regression participants with missing data were excluded less than 1 of data were missing for all variables in the lca and fewer than 4 were missing for variables in the logistic regression the twostep process analyses were performed using sas proc lca 4142 results participant characteristics prevalence of participant characteristics is presented in table 2 a total of 532 individuals participated in this study including 419 cismsm and 109 transgender women participants ranged in age from 18 to 50 years with a median age of 24 years and an interquartile range of 2228 years less than onequarter had completed secondary school or less whereas 511 had completed high school and 276 completed more than a high school education the majority of participants were sampled from an urban study site and a little more than onehalf were employed or students experiences of stigma ranged in prevalence from 109437 depending on the type of stigma almost 44 were out to family members whereas 205 were out to healthcare providers associations between sexual behavior stigma and being out being out to a family member was associated with feeling excluded by family members feeling gossiped about by family members feeling rejected by friends feeling like police refused to protect feeling scared to walk around in public places being verbally harassed and being blackmailed it was not significantly associated with being physically hurt being tortured being treated poorly in a healthcare setting being gossiped about by a healthcare worker being afraid to seek healthcare services or avoiding seeking healthcare services being out to a healthcare worker was associated with being treated poorly in a healthcare setting being gossiped about by a healthcare worker avoiding seeking healthcare services feeling excluded by family members feeling like family members gossiped feeling rejected by friends being verbally harassed and being blackmailed it was not significantly associated with feeling like police refused to protect feeling scared to walk around in public places being physically hurt being tortured or being afraid to seek healthcare services latent class analysis identification of latent classes aic bic and caic values began to leveloff at 3 latent classes and were primarily leveledoff at 4 classes purely based on model fit indices a 4class model might have been selected however after comparing conditional probability distributions between the 3class and 4class models a 3class model was selected based on the existence of meaningful risk profiles for participants 40 42 43 44 in brief for the 4class model the high risk not out class appeared to divide into two groups both had high levels of family gossip and verbal harassment whereas one group had higher levels of perceived healthcare stigma we considered these to be subgroups of the high risk not out class and maintained the 3class model for ease of interpretation the first class consisted of cismsm and transgender women who demonstrated overall low probabilities of stigma as a result of having sex with men the conditional probability of being out to family members and healthcare workers was 38 and 15 respectively which suggests that some of the participants in this class were out to family members and healthcare workers although it was not a defining feature of this class individuals in the second class exhibited high probabilities of physical violence torture and fearavoidance of seeking healthcare and were less likely to have their sexual identities known by family members or healthcare workers finally the third class demonstrated high probabilities of being excluded by or gossiped about by family members verbal harassment feeling scared to walk around in public fearavoidance of healthcare workers and were more likely to have their sexual identities known by family members or healthcare workers relationships with class membership in the final adjusted multinomial model depression was associated with both high stigma classes relative to the low stigma class reporting concurrent sex partners was associated with membership in the high stigma not out class whereas condomless anal sex was associated with membership in the high stigma out class being employed and identifying with femaleother gender was associated with reduced likelihood of membership in the high stigma not out class relative to the low stigma class completing high school and more than a high school education were both associated with membership in the high stigma not out class relative to the low stigma class being sampled from an urban area study site was associated with membership in the high stigma out class age was not associated with class membership discussion sexual behavior stigma is affecting cismsm and transgender women across subsaharan africa 13 45 46 47 and is likely exacerbated by the illegality of same sex practices with punishments including fines or imprisonment 48 stigma and discrimination towards cismsm and transgender women have previously been associated with poor hivrelated health outcomes including reduced rates of hiv testing increased risk for hiv infection lower likelihood of discussing or disclosing hiv aids status with male partners and engagement in hiv treatment for those living with hiv and increased condomless anal sex 49 50 51 52 in these analyses we found that outness about sexual behaviors grouped together with increased burden of multiple forms of stigma and that these latent stigmaoutness classes were associated with different types of sexual risk behaviors in eswatini there is persistent societal discrimination against the lgbt community backed by colonialera legislation that prohibits anal sex between men 53 as a result lgbt individuals risk the loss of family members friends and employment if they disclose or are out about their sexual behaviors or gender identity this structurallevel stigma is manifested at the individuallevel in our study for example participants who reported that family members knew about their sexual behaviors greatly increased the odds of reporting feeling excluded and gossiped about by family members similarly having healthcare workers who knew about ones sexual behaviors increased the odds of reporting poor treatment from healthcare workers being gossiped about by healthcare workers and avoiding seeking healthcare services this is additionally problematic because disclosure of sexual practices to healthcare workers is necessary for obtaining accurate sexual histories and meaningful assessments of hiv risk but in reality disclosure can be very challenging in the context of hiv prevention and treatment strategies in eswatini if cismsm and transgender women face stigma for disclosing their sexual practices they may be less likely to disclose and subsequently less likely to be identified as appropriate candidates for novel biomedical hiv prevention services including preexposure prophylaxis in the latent class regression those with concurrent male or female sexual partners were more likely to belong to the high stigma not out class this finding is consistent with results from recent qualitative work examining intersecting stigmas among msm in eswatini where participants reported that the secretive nature of msm relationships led to greater numbers of sexual partners and more casual types of partners in some cases 19 participants indicated that because their msm relationships are kept secret families do not play a role in relationship counseling and peacekeeping in the same way that they might for heterosexual couples it is also common for msm in eswatini and other regions to have girlfriends or wives potentially to fulfill cultural expectations further challenging the formation of stable male couples 1920 in other settings msm who also have sex with women showed a higher risk of experiencing intimate partner violence including physical violence and being threatened with disclosure of sexual orientation than msm with only male partners 54 this may provide insight on the high probability of experienced violence among the high stigma not out class in this study prevention science theoreticians and practitioners have called for combination hiv prevention strategies which would integrate a package of biomedical behavioral and structural interventions to address multiple layers of hiv risk 55 56 57 58 59 these combination tactics are likely even more efficient for high risk msm and transgender women in reducing hiv incidence 60 61 62 but given the increased instances of condomless anal sex among those in the high stigma out group in this study this suggests that structural interventions to address stigma will also be needed to reduce hiv risk behaviors such as sensitivity training for healthcare workers and political advocacy to reduce or mitigate the effects of stigma in eswatini the implementation and optimization of combination approaches are currently challenged by punitive policies and stigma affecting msm 5557 those who identified with a nonmale gender were least likely to belong to the high stigma and not out class they were more likely to belong to the high stigma and out class although this was not found to be statistically significant previous work indicates that transgender women or individuals assigned male sex at birth but who identify as a woman are more likely to experience high levels of stigma in comparison even to msm 296364 thus our findings may reflect the notion that transgender women are more likely to be visible in the community as compared to msm who follow more traditional gender norms and thus may be more easily targeted for stigma discrimination and other forms of abuse living in an urban residence being associated with belonging to the high stigma out class was not surprising and likely reflects patterns seen in the us and other high income settings where gay men and other msm move to larger cities for social networking opportunities and a more tolerant social climate 6566 screening positive for depression on the phq9 was associated with membership in each of the high stigma classes compared to the low stigma class this is consistent with previous data suggesting that depression is higher among msm as compared with heterosexual men in many parts of the world potentially as a result of stigma and minority stress 13 67 68 69 70 msm interviewed for a qualitative study in eswatini indicated that living with a stigmatized identity led to feelings of depression and selfstigma 19 our findings here further highlight the strong and consistent impact that stigma appears to have on mental health regardless of whether one is open about their sexual behavior unfortunately there is virtually no literature describing effective depression interventions for msm in subsaharan africa 71 72 73 the latent class low stigma showed moderately high levels of disclosure to family and healthcare providers however was not a defining characteristic of the class the context of overall low stigma may provide for a supportive environment for disclosure of sexual behaviors although the low stigma class still showed moderate levels of fear to be in public spaces and verbal harassment and a higher conditional probability for these stigma measures than those in the high stigma not out potential limitations to our study include the use of cross sectional data impeding the inference of causal relationships and the nonrandom selection of study participants which is an assumption of lca however hidden populations such as cismsm and transgender women are difficult to sample through traditional methods given the lack of sampling frame including censuslevel data in eswatini and peerdriven sampling approaches are more appropriate social desirability bias may have affected participant responses for example by causing underreporting of condomless anal sex and stigmatizing experiences although lca leaves open the possibility that one or a few particular stigma items may be driving the associations with risk behaviors we opted to use lca to explore how clusters of stigmaoutness were related to risk behaviors the stigma metrics used in this study were selfreported stigma measures defined as attributable to sexual behavior however for individuals experiencing layered or intersecting stigma the attributable characteristic of stigma may be difficult to identify an additional limitation is that this sample was underpowered to conduct a separate analysis for transgender women without cismsm conclusion even in the context of increasingly available biomedical hiv intervention strategies including oral preexposure prophylaxis the reduction of hivrelated risk practices remains crucial for the prevention of hiv acquisition and transmission in these analyses stigma appears to consistently be associated with increased hivrelated risk practices and risks for depression consequently evidencebased stigma interventions that are able to operate under challenging legal and human rights settings may be key to combating the persistent hiv epidemic for cismsm and transgender women in eswatini abbreviations aic akaike information criterion aor adjusted odds ratio bic bayesian information criterion caic consistent akaike information criterion ci confidence interval hiv human immunodeficiency virus lca latent class analysis msm men who have sex with men phq patient health questionnaire authors contributions ss led the development of analysis and writing of the manuscript cl led the finalization of analyses and manuscript writing and led the revision and submission process ch served as study coordinator contributed to questionnaire development and provided input on the analyses and manuscript development sk created data entry and data management systems for the study contributed to the questionnaire development and provided input for the analysis lvl dk mm bs lm and sm supported conceptualization of the study including data collection methods implementation of the study and interpretation of study results sb conceptualized the study designs monitored study stages and gave guidance on the analysis and was involved throughout manuscript development all authors contributed substantially to either the study design data collection analysis or interpretation of data participated in drafting the article or revising it for intellectual content and approved the final version to be published as outlined by the icmje authorship criteria competing interests the authors declare that they have no competing interests

background men who have sex with men msm and transgender women in subsaharan africa are subjected to high levels of sexual behaviorrelated stigma which may affect mental health and sexual risk behaviors msm and transgender women who are open about or have disclosed their sexual behaviors appear to be most affected by stigma characterizing the mechanism of action of stigma in potentiating hivrisks among these key populations is important to support the development of interventions methods in this study a total of 532 individuals were recruited across eswatini swaziland through chainreferralsampling from october december 2014 including 419 cisgender msm and 109 transgender women participants were surveyed about demographics stigma outness of samesex practices to family members and healthcare workers and mental and sexual health this study used latent class analysis lca to determine latent constructs of stigmaoutness and used multinomial logistic regression to determine associations with underlying constructs and sexual risk behaviors results three latent classes emerged 1 those who reported low probabilities of stigma 55 276502 2 those who reported high probabilities of stigma including physical violence and fearavoidance of healthcare and were not out 11 54502 and 3 those who reported high probabilities of stigma including verbal harassment and stigma from family and friends and were out 34 172502 relative to the low stigma class participants from an urban area adjusted odds ratio aor 278 95 confidence interval ci 153507 and who engaged in condomless anal sex aor 185 95 ci 117291 were more likely to belong to the high stigma out class in contrast those who had a concurrent male or female partner were more likely to belong to the high stigma not out class aor 273 95 ci 105707 depression was associated with membership in both highstigma classes aor 314 95 ci 150655 not out aor 242 95 ci 151387 out conclusions sexual behavior stigma at a community level is associated with individuallevel risk behaviors among msm and transgender women and these associations vary by level of outness about sexual practices achieving sufficient coverage of evidencebased stigma interventions may be key to realizing the potential impact of hiv prevention and treatment interventions for msm and transgender women in eswatini

current biotechnology is characterized by its capacity to generate biological processes and analyze large amounts of information supported by the development of advanced equipments biotechnology has opened up unique potentials for producing new objects by manipulating and transgressing boundaries between domains that were formerly understood as incompatible or by creating completely new materials these new entities are named bioobjects and they are defined as biology innovations produced through processes continuously negotiated in the intersection of science politics and society in this definition bioobjects are approached as temporary categories that are produced in an ongoing bioobjectification process aiming at controlling life in specific time and space when mentioning bioobjects as novel biological entities a special place has to be assigned to the hela cells for their capability to challenge conventional natural cultural scientific and institutional classifications and to generate controversy due to their potential challenging of established order and practices thus under the lenses of bioobject and bioobjectification concepts various remarkable features may be attributed to hela cells and to the controversial bioethical arguments their establishment and use still generate today six decades later the hela cells hela cells are an immortalized line established in the late 1950s from a rare cervix adenocarcinoma of a young woman they were named after her henrietta lacks these cells became and still are one of if not the most important one laboratory model of modern cell biology research since its first establishment in 1959 they were applied to study crucial biological processes of healthy and pathological systems the functions of genes and the development of pioneer omics approaches as also proved by the over 60 000 publications produced according to medline database they were also necessary for relevant research that was awarded with two nobel prizes one for discovering the link between human papilloma virus and cervical cancer and another about the role of telomerase in preventing chromosome degradation recently a first detailed genomic and transcriptomic characterization of a hela cell line relative to the human reference genome and an haplotyperesolved genome and epigenome of the aneuploid hela cancer cell line has been published among the various applications based on hela cells it is worth remembering one of the earliest and important one ie the development of the vaccine against the polio virus hela cell lines are commercially available and also circulate freely within the scientific community the biological characteristics of the hela cells showed to be clinically extraordinary as described by howard w jones who conducted the gynecological examinations and found that the tumor was soft difficult to identify by the bare fingers its color was purple and …general examination was completely negative inspection of the cervix however revealed a lesion … smooth glistening and very purple … its appearance was different from any of the other 1000 or so carcinomas of the cervix i had previously seen it also did not respond to radiotherapy but what was amazing of this tumor was its capability even compared to other cancer cells of rapid propagation and unusual invasiveness and to be durable not only inside henriettas body but also outside in laboratory nowadays we know that the cause of the proliferation capability of these cells is related to an active version of the telomerase which during the cell divisions prevents the incremental shortening of the chromosome telomeres which is implied in aging and eventual cell death because of their persistency contamination of other cell lines by hela cells is frequent thus they have been also referred as laboratory weed aneuploidy is documented in hela cells as result of horizontal gene transfer from human papillomavirus 18 to human cervical cells in culture conditions hela cells divide unlimitedly and may mutate hence from the same tumor cells removed from henrietta many strains of hela cells have been generated estimations of their total number spread in the laboratories and repositories all over the world give amazing quantities which far exceed the total number of cells that were in henriettas body worth stressing hela cells have even been proposed to be regarded as the contemporary establishment of a new species because of their ability to replicate indefinitely their own clonal karyotype their chromosomal incompatibility with humans their ecological niche and their ability to persist and expand the hela cells have been also presented as a paradigmatic example of fraud and prevarication of bioethics since neither henrietta lacks nor her family have been informed about the use of hela cells and anonymity was compromised through the naming of the cellline the hela cells case became popular recently with the publication in 2010 of the book the immortal life of henrietta lacks by journalist rebecca skloot which was winner of several awards and became a bestseller in the last months moreover the sequencing of hela genome was object of a new important case concerning consent and privacy since even though the genomes of the cells used in these studies are not identical to lacks original genome still their sequence may reveal some heritable aspects which would violate descendants privacy because of this fact and also because of the extraordinary scientific and bioethic significance of hela cells in august 2013 an agreement was resolved between the us national institutes of health and henriettas family members accordingly the sequence data were placed in a controlledaccess database ie the nihs database of genotypes and phenotypes which would require researchers to apply to the nih to use the data in a specific study and to agree to terms of use defined by a panel including members of the lacks family this agreement is expected to urge new discussions regarding consent for future use of biospecimens with a goal of fostering true partnerships between researchers and research participants from hela cells to the hela bioobject the concepts of bioobject and bioobjectification have made possible to describe and discuss the hela cells with a consistent set of features that describe the process of how they come into being as biological phenomenon research object and commercial product and how this shift is part of a more complex interaction between biology science technology and society hela cells possess features of a bioobject which seem to be of particular relevance first of all the potentiality to cross barriers in henriettas human body in fact a virus induced dna modifications resulting in their immortalization thus hybridity may be suggested as an outcome of the interaction between different domains while the transformation of henrietta lacks cells by the virus produced a new entity a boundary crawler between humannonhuman some important characteristics of these cells also concern biosocial implications we recognize to the bioobjects principally this tumor raises property issues it was part of henrietta lacks body belonged to her because it was inside her and existed due to her thus being her property on the same time however it may be identified as something separate from her in the form of a parasitic invasive and transgressive biologic material to be dissected outside the body its survival became technologydependent separate from her this medical waste became a precious material to be shared sold and disputed it acquired the identity of a tool to study but also to generate other bioobjects in a circular process where the new knowledge is the starting point of new bioobjectification leading to the production of further bioobjects hela cells can also be described as part of a hermeneutical process where their meaning is produced through a continuous and dynamic process of interpretation they represent a multitude of meanings depending on context and interpretative approach hence they require new policies and communication practices the importance of hela cells raises from the combination of some crucial factors concerning their easy culture their availability through large scale industrial production and distribution their fame in the laboratories all over the world and finally their low cost phenomenology epidemiology and personalized medicine the story of henrietta lacks life is in sharp contrast to the story of the life of her cancer cells as a poor black woman she represents the margin of the society the other her cancer cells on the other hand have characteristics that make them especially valuable for the research they are valuable because they made possible to study essential aspects of what it implies to be human seen in relation to the emphasis on quantitative medical research in todays society henrietta lacks cells underline the value of qualitative research in medicine qualitative method phenomenology and hermeneutics are well known from caring sciences like nursing sciences with direct links or roots in heideggers philosophy this phenomenological method is developed to uncover human concerns and practices that are central for being and dwelling in the world focus is on experiences as a method it helps in identifying contextually bound clusters of themes and it makes interpretation a key issue for scientific analysis as it is essential to understand phenomena as part of processes and context the interpretative process is dynamic and strives to go from the part to the whole in a manner where critical reflection of the process is emphasized aiming at achieving insights of general value in contrast to hela as a single cell line nowadays in the field of molecular biology epidemiological research on common complex diseases is based on large databases not the least biobank data this large scale approach is high on the agendas of academic as well as public and popular debates and of regulatory work at communitarian and national levels in europe in part this reflects how new technology has changed epidemiological research in the last 1015 years and how ethical and legal regulations collide with medical and commercial visions in this field cancer investigations conducted on hela cells represent an interesting contrast with epidemiological research on ccd this latter in fact focuses on groups and is closely linked to the discourse of personalized medicine here large collections of samples are converted into data combining huge demographic databases health record databases and survey collections ie combining quantitative and qualitative materials in personalized medicine representation and categorization are key themes as identification of a group and its representative are crucial in public discourses on epidemiology and personalized medicine on the other hand underrepresentation is a hot topic as medical research is considered not fully reliable for the various groups being conducted mostly only on a restricted population thus neglecting the other groups moreover this fact would reinforce the main social and political categories of the 20th century namely gender race ethnicity and class against this background the modeling based on hela cells is politically and socially interesting and epistemologically and ontologically challenging the scientific value of hela cells which have been generated from a rare cancer of a poor black woman have been applied for creating models to be valuable not only for the specific but also for the general biology if new knowledge can be extracted from research on henrietta lacks tissue does that imply that unicity is an ontological premise for cancer research is there a hierarchical relation between unicity and variety the method used in cancer research based on henrietta lacks cells represents a continuous interpretative process going from the detail to the whole and back again in a circular critical rethinking of contexts and processes according to the phenomenological approach in caring sciences in epidemiological research aiming at personalizing medicine and treatments knowledge on basic biological functions as well as possibility to test and experiment are required the hela cells make possible both being used as experimental model and being tools for assays like in a hermeneutical circuit thus from the hela cells an exceptional phenomenon knowledge has been gained about the general which in turn has been applied for defining personalized medicine and treatments which again generate new knowledge common complex diseases epidemiology and hela cells the importance of cancer in global society and the focus on epidemiological research sheds new lights on the value of the hela cells since according to the official world health organization data cancer is an increasing cause of death globally besides epidemiological research on ccd is a main tool for developing diagnostic identifying causes and individualizing treatments research based on hela cells is not only still important but has been even revaluated epidemiological research on ccd is a quite noteworthy area for society individuals health and wellbeing as well as for economy medical biotechnology has generated new opportunities and also loud ethical and legal debates and a new landscape of directives regulation and law concerns on the draft of eudata protection regulation has been driven by geneticists and ethicists involved in biobank research on ccd the first being critical toward possible research limitations and the second being divided in pro and con fractions toward the use of huge databases of personal data in this framework biobank research appears as a main road for research breakthrough while personalized medicine is regarded as the new area for diagnostics and treatments however focusing this latter on group specific characteristics doubts have raised on their effectiveness in representing populations since the chosen categories could be reproductions of established social categories instead thus not representing the medical relevance required if the basic research developed on the hela cells may not be controversial in itself and thus does not create public controversy when these cells also regard biobank issues conversely some quite problematic questions may rise among them variety and diversity helacells in fact would represent the value of the one while epistemological assumptions in epidemiological research on biobank collections would represent the value of the many accordingly doubts can be raised whether fundamental biology research based on hela cells would represent and produce additional understanding of human constitution health and wellbeing considering epidemiological research and fundamental biology research toward a new paradigm of science in the field of medical biotechnology like in science overall research and society are intimately related and changes of one reflect the other policy is a relevant and often controversial outcome of this interaction as the bioobjectification process points out in the case of biobank research an important context is the new eu draft concerning data protection regulation as well as the establishment of the new european biobank network which concern the use of new qualitative and quantitative materials and methods which create new challenges for researchers clinicians and regulators in this context the draft of eu data protection regulation is object of laud public debates and disputes our social economic setting is organized in private and public spheres in communal and individual ownership the industry and ethical guidelines have so far focused on informed consent anonymity benefit share property and ownership regarding bioeconomy in europe research and commercialization have been split in public and private sectors where information about the individuals has been restricted to the public institutions now the need of cooperation between medical research and pharmacy as well as the use of personal data create new challenges regarding privacy autonomy and governance thus a new challenge is emerging both from society and research concerning the most suitable models for organizing and governing the advancement of biotechnology research while on the same time protecting the citizens the eu data protection regulation draft aims at building up a joint platform for the eu with common rules as well as common interpretations of established rules and centralized control functions this document pushes forward the relevance of informed consent as its key ethical concept at the same time it aims at facilitating unity and cooperation within the eu where materials are meant to be shared overcoming the present national obstacles concerning laws and regulation in addition bbmri has already grown in to a 54member consortium with more than 225 associated organizations from over 30 countries making it one of the largest research infrastructure projects in europe as already pointed out the bbmri has proposed the concept of expert centers in which pharmaceutical research would be conducted outside the industry setting donor material would not move outside biobank infrastructure and industry would not have exclusive rights to data generation with this platform and the draft of eudata protection directive eu aims at strengthening the protection of the individual and at bringing together formerly separated public and private institutions and sectors ie it is starting a change regarding governance and ownership of knowledge and property this approach is expected to make real that new vision of the role of biotechnology and bioindustry in eu and in individual nation states we believe that these changes ie a new perspective of knowledge production and ownership can also be regarded as the starting point of a shift toward a new of paradigm for science where life sciences social sciences and humanities will jointly contribute to the human wellbeing in conclusion in this article we have shed lights on the relation between science society and policy from the angle of the bioobjectification process of the hela cells the highquality of these cells is the result of an odd combination of their unusual features that make them a model cell for biology and medicine with the legal technological and socioeconomic contexts in which they have been produced distributed and used as a result they generate questions about representation significance and value of the single and exceptional and the power to modify and change they can generate thus as expressed with the hermeneutics terminology they appear as a phenomenon process where new meanings and biorealities are created these cells disrupted and undermined the being of henrietta lacks while the life of hela cells is opposed to the being of henrietta lacks so the hela cells and not henrietta lacks have come to represent life seen from the angle of present discourses on biobank research and data protection regulation the bioobjectification process of the hela cells seems to be part of a further societal and political discourse on variety individuality and property belonging to one human being hela cells have represented humanity and emphasized the importance of individual as a core concept of the personalized medicine

the immortal hela cells case is an intriguing example of bioobjectification processes with great scientific social and symbolic impacts these cells generate questions about representation significance and value of the exceptional variety individuality and property of frightening a lethal cancer and emarginated a black poor woman origins with their ability to contaminate cultures and to spread into spaces for becoming of extraordinary value for human knowledge wellbeing and economy advancements hela cells have represented humanity and emphasized the importance of individual as a core concept of the personalized medicine starting from the process leading from hela cells to hela bioobjects we focus on their importance as high quality biospecimen we discuss the tension between phenomenological characteristic of fundamental biological research and the variety of material and methodologies in epidemiology and personalized medicine the emerging methodologies and societal changes reflect present eu policies and lead toward a new paradigm of science

when we say ‛organisation we are operating with a fundamental ambiguity it can mean either the process of organising or the result of that process the ‛organisedness of social action and subsequently a system of organised action trying to eliminate this ambiguity by regulating the language we use would not only be futile because it is far too deeply embedded in languageit would also be unwise a better suggestion would be to grant language a presumption of wisdom and ask why it has so stubbornly preserved this ambiguityand not only in german following this path one soon hits upon that recursiveness of human action which lies in the fact that our action results in the production of precisely those structures that subsequently enable and restrict our further action giddens wanted to preserve this double meaning of producing and product explicitly under the heading of ‛structuration and his conception of the duality of structure dissolves the commonplace dualism of action and structure their mere opposition in the circular figure of recursiveness structures are the medium and the outcome of action even in organisations they are initially only a ‛concomitant resultin the sense that they are an unintended and unreflected side effect of action often enough we create structures without wanting to and without attending to them but when the flash of reflection illuminates structuration as producing and product when we pause and begin to ask questions and to practise structuration in a reflexive way then structuration becomesin nuceorganisation organisation is structuration that has lost its naivety its primordiality its innocence reflexive structuration this reflexive structuration finds its most pointed expression in the formality of modern organisation in formal constitutions and procedures which are of great importance in the coordination of action the organisers not least hope that this will collectively secure and increase individual reflexivity and rationality whether this actually happens and who benefits and who is burdened is a subordinate question markets can also be the object of such organisational effortsresulting for example in strategic business networks finally even those more extensive modes of interorganisational coordination of action that hollingsworth calls governances are partly the result of reflexive structuration however the feature of formal constitutionsuch as rules of formal membershipis much more weakly developed in interorganisational networks than in organisations the concept of organisation is ambiguous also because today it concerns a state of affairs that existed in the most diverse historical epochs and societies when ptahhotep vizier of king isesi recorded the best practices of pyramid building on papyrus scrolls around 2700 bce this was the result of what we would today call reflection on the structuration of pyramid building which resulted in the formulation of rules and regular practices but organisation per se sans phrase is a modern concept that has only emerged in the course of what has been called ‛modernisation in sociologythe detachment of social practice from religion and tradition by means of rationalisation 1 only with this development does talk of ‛organisations as institutionsusually referring to social systems called organisationsgain its historical substrate and somehow these organisations have a conspicuous part in the genesis of capitalism the bearers of this reflection however are no longer just single peoplesubjects personal actors individualsbut recursively enough organised systems of science administration and economy to name but a few or corporative actors in whose structuresrules and resourcesthe cumulative reflexive knowledge of modernity is stored perhaps one could even say ‛inscribed in this latter case we can also follow ritsert in speaking of system reflexivity while subject reflexivity refers to an individuals selfreference in thinking and acting without which reflexive structuration is unthinkable system reflexivity in our context refers to a supraindividual namely organisational reflexivity a movement back into itself beyond individuals and individual thinking and acting in the course of which organisational knowledge is produced and inserted into new recursive loops of organisational action 21 foundations of structuration theory organisation reflexivity and recursiveness in this view organisations conceived as systems of organised action or practices are reproduced as a result of themore or less purposiveactions of competent actors or knowledgeable agents such agents refer in their interactions to structures to sets of rules and resources and to other structural features of their field of action properties that are appended to the field of action by this structured actionrigid departmental boundaries for example or a rigid division of labour a high failure rate in conventional mass production discrimination against employees asymmetrical income distribution to name but a few in drawing on these actors thus reproduce these structures and structural propertiesand entire social systems such as firms and interfirm networks indeed they often do this intentionally though they are neither completely aware of nor able to fully control the consequences of their actions organisations are characterised by organisational practices by recurring forms of action practiced in organisations and not merely by formal structures structural properties or inputoutput relations or by communication or decisionmaking alone organisational structures only exist at all in the actions and practices of actorsand subsequently in their memories and expectations in the form of a virtual order in our view organisations are those social systems within which action is directed and coordinated by means of reflection specifically by means of reflection on their structuration the formulation and establishment of rules and the provision of resources takes place in a reflected way which is to say that when it comes to organisations structuration is the resultalthough an only partially intended oneof reflection striving for expediency for giddens actors always act reflexively this is to say that in their actions they refer more or less deliberately to their own past present and anticipated future behaviour as well as to that of others and to the structures of the field of action yet we speak of organising only when this reflexivity pertains to the shaping of these structures and we speak of organisations in themodernsense of organised social systems only when formalityformal constitution and regulationis present as differentia specifica following giddens actor model even the level of individual action involves the interplay of three layers of action that must always be considered individual3 and organisational forms of reflexive monitoring the rationalization of action because … the conscious or unconscious motivation of action by a desire for wish fulfilment or fear avoidance it is already evident here how familiar discourses in organisational research can dovetail those on steering and control those on organisational ideologies and those on motivation for giddens however actors never fully control the processes of social reproduction much is closed off to them such that in many respects they act as competent actors on the basis of merely ‛practical implicit knowledge they know how it is done or perhaps better they know how to do it they are good at it without being able to explain exactly how and why they do it furthermore they act on unrecognised premises and thereby produce unintended consequences the results especially of collectivefor example organisationalaction often turn out differently than intended in doing what they do competent actors refer recursively to structures perpetuating them through this very actioneven if they are not always left unchanged in the process this is exactly what recursiveness means the iterative application of an operationtransformation to its own resultin this case the operation ‛structuring is applied to the result ‛structure in other words recursiveness means that the output of an operationtransformation is reapplied as a new input to this same operationtransformation which is precisely what happens to the structure reproduced in and by action it is the result of action and enters into further action as its ‛medium 4 structures therefore enable reflexively acting actors to act competently in interaction situations even as they constrain actors possibilities of action given the pervasiveness of views that focus onesidedly on their restrictive character we would like to emphasise this restricting and enabling aspect of socialas well as organisationalstructures we can go even further enabling is based on restriction modern organisations are a special case only insofar as these restricting and enabling structuresrules and resourcesare established reflexively and their fixation is attempted by means of formalisation formality here means first of all formal determination the obligations expectations rights and resources specified in the formal structure referand this is another the primary meaning of formalitynot to concrete contents and situations but to generalisable ‛cases not to concrete persons but to positions departments areas of expertise etc and finally to the corporate entity itself in this sense establishing formal relations between positionsorganisational units organisations but not concrete relations between persons the fact that the latter relations are formalised and formed in this way however points to the power dimension of formal organisation and to the way power can be expanded by its detachment from concrete persons indicated in the formal structure are also modes of attribution that permit one to punctuate the stream of action to make out of the stream of practical intervention in the world delimited acts which is to say actions to break them down into responsibilities of this or that department into causes and effects costs and benefits etc and to constitute the identity and boundaries of an organisation 5 giddens distinguishes between three dimensions of the social that are initially only separable analytically at the level of social structures these dimensions are called signification legitimation and domination when referring to the corresponding action or interaction they are called communication sanction and power as they interact actors mediate the level of action with the level of structure by making the rules and resources under situational conditions into modalities of their action in ways specific to the situation and in accordance with their biographies and competences which is to say in highly particular ways when members of organisations communicate with each other they refer reflexively and recursively to structural formsrules in the sense of generalisable proceduresof signification which they in thisalways situational particularway make into modalities of their action they exercise power in interactions by referring to organisational resources that they bring into the interaction sequence as means of power they sanction by attributing their actions to norms and evaluating and judging the actions of others on the basis of norms that they derive from reflexive recourse to the ways and means of legitimation in organisations for example they might refer to the practices of evaluation used for persons 5 stolz and türk emphasise that in this way incisions are made in the world social interrelationships are severed blanked out desymbolised performance processes buying and selling behaviours and so on and in doing all this the actors produce the organisational structures the structure of signification legitimation and dominationwhich is to say the existing rules and resources let us summarise following giddens the structures of social systems can be broken down analytically into two types of rules and two types of resources 1 rules for the constitution of meaning establish what can be called the cognitive order of a social system or in our case of an organisation for giddens this includes all those aspects related to the interpretation of the world as the foundation for action in organisations this refers for example to interpretative schemes symbols myths and so on even the sensualaesthetic aspects of organisations for instance their architecture or less concretely the attractiveness of actions and objects of action form part of this cognitive order 2 rules for sanctioning social action make up the normative order of an organisation from examining the rise and fall of organisational culture as a possible object of reflexive structurationthat is organisational designit is apparent that feasible cognitive and normative orders are only the tip of the iceberg also in organisations 3 allocative resources enable actors to control material aspects of social situations such as the disposition of factors of production goods produced or money 4 authoritative resources by contrast permit the exercise of power over persons for example by determining workflows schedules and pay we view giddens structuration theory which we have sketched above in outlining a few of its basic lines of reasoning as a kind of sociotheoretical frameworksome even speak of a metatheoryfor social science research this framework needs to be supplemented by building blocks from theory of society and in our case organisational theory to this we will now turn 6 6 in our view however a fullfledged theory of society let alone a theory of modern society does not currently exist nor does giddens offer one we are therefore very cautious in this respect and limit ourselves to sparse references concerning the acquisitive principle in capitalist economies and the enormous expansion of the technical organisational and economic possibilities of spacetime binding as a characteristic of modernity in dealing with organisations as phenomena of modernity however organisational theory itself contributes to a theory of modern society which we are thus helping to construct to a small extent though we are unable to indicate the exact place or significance of organisational theory within it organisation as reflexive structuration 2 organisation as a reflexive form of structuration hardly anyone would deny the enormous relevance of organisations for modern society andaside from the most prominent exceptions of luhmann and colemanhardly any author of ‛grand theory gave the modern organisation the place it thus deserves in his theoretical architecture not parsons7 not habermas not bourdieu not even giddens nonetheless a growing number of authors and publications have been attempting to claim structuration theory for organisational research from the point of view of giddens theory this should come as no surprise since the three concepts whose centrality we have underscored herereflexivity structuration and recursivenesseasily and plausibly converge in the concept of organisation if organisation is defined as reflexive structuration in precisely that double sense of recursive production of a product discussed above in any instance where reflection sheds light on structures and structuration and enters into the practice of structuring as well as into its results we are dealing with organisations reflexivity is institutionalised in organisationsreflection namely on the structuration of collective actionwhich is not to say organisations are a paragon of rationality the labour management and organisational sciences of the twentieth century especially business administration are already forms of the reflection of reflection even if they are also forms of reflection that were halted early on insofar as they long remained restricted to the search for universal or situational one best ways as the twentieth century comes to a close however awareness of contingency has once again sharpened considerably and taken hold of the taylorist paradigm of mass production and beyond that of onebestway thinking in general however applying structuration theory to the ends of organisational research also suggested itself from the point of view of organisational theory first organisational theory was in urgent need of a foundation in social theory and a theory of society an urgency that is only magnified in view of a development that can also be observed elsewherefor example in industrial sociology technology studies and economicstowards an explosively increasing number of theoretical perspectives and paradigms that hardly communicate with each other such that warning about the fragmentation and even dissolution of organisational research is not entirely unjustified our impression is that the dimensions of the social proposed by giddenssignification legitimation and dominationare wellsuited for carefully integrating these diverging theoretical perspectives interpretative culturalist and institutionalist approaches approaches based on theories of power domination or control and economic approaches to organisational research 8second the concept of structuration with its notion of the duality and recursiveness of structure allows for what we find to be a relaxed approach to controversies which as we know are notorious also in organisational theoryand which we should however gradually leave behind we have in mind especially the controversies around the question of ‛action versus structure which in organisational theory has been answered often enough in favour of one side or the otherin favour of action or decision for example by simon and the carnegie mellon school and in favour of structure by the theories of structural contingency for example in which what actors do plays such an underestimated role yet giddens concept of structurewith its dual components rules and resourcesoffers particularly favourable ways of approaching questions of organisational theory while this may be selfevident for the concept of rulesas the relevance of organisational rules certainly seems obviousit requires careful explication by way of precisely defining the concept of rule it applies then also and particularly so to the concept of resources which is indispensable in the framework of political and economic organisational analyses one need only think of the resourcedependence approach of organisational research the resourcebased view of strategic management or of micropolitical or strategic organisational analysis or generally of the view that the enterprise is an institution for the transformation of production factors into products third the concept of recursiveness suggests also considering the relationship of organisations to supraorganisational institutions in its light this means taking account not only of the influence of these institutions on organisations but also of the reverse influence organisations have on the manifold institutional conditions of organisational actiona supplement to new institutionalism that we consider highly significant fourth a peculiarity of giddens concept of structure consists in its emphasis on spacetime binding as a decisive effect an aspect whose relevance is becoming strikingly clear today in view of for example justintime manufacturing in regional and global networks fifth the concept of organisational structures whichexcept in traces of memory and expectationexist only in action and are therefore always under the tension of action permits an unconstrained understanding not only of organisational stability and inertia but also of organisational transformation and it does so with a view both to the individual organisation and its intended changethe keyword here is reorganisationas well as to a possible unintended transformation of an organisation or of the ‛genre of organisation or of particular types of organisations including questions of their origin their genesisthe keyword here is evolution sixth giddens concept of action can connect up with a theoretical description of the relationship between organisation and psyche that allows us to reckon with those dramatis personae who create and change the organisations in the first placeand who are also for their part to some extent creatures of the organisation while these six areas of problems are certainly not the only ones nor ordered here in a perfectly systematic manner they are nevertheless highly significant desiderata of a sociotheoretical foundation for organisational theory we now intend to discuss them in greater detail the dimensions of the social and the role of the economy all organisational action we emphasise once again plays out in all three dimensions of the social at once a certain organisational vocabulary is used repeatedly as a set of interpretative patterns and is reproduced ipso facto as an element of the cognitive order of an organisation the ‛laws of the formal organisation the formal rules evaluation procedures and leadership styles but also the informal standards of what constitutes good work for example are applied followed and thereby reproduced as the organisations order of legitimacy the organisation of labour implies a form of domination over human beings and is reproduced as an authoritative resource through repeated practice knowhow and technology permit domination over nature and matter and are reproduced as allocative resources by recurrent application in general organisational action implies recourse to a set of organisational patterns of interpretation and norms organisational rules and resources derived from an organisational structure which in this wayby application of organisational rules and resourcesis recursively reproduced and in some circumstances modified in the process at first glance figure 1 seems merely to provide an unsatisfying juxtaposition of these dimensions of the social rather it begs the questionand this is in many ways the most exciting question of organisational theory how are the dimensions of cognition legitimation and domination related we all know to put it mildly that they have a bearing on each other our norms depend on our understanding of the world on our patterns of interpretation and vice versa our patterns of interpretation concepts and definitions of situations are established with power and they are conversely powerful means of exercising power and whatever is considered legitimate depends likewise on power relations just as conversely norms function as instruments of power in this ‛horizontal direction in the relationship of the dimensions of the social we thus reckon with recursive relationships of constitution and we indicate these relationships in figure 2 by arrows which set it apart from figure 1 only in emphasising this recursive circularity once again 9 how does the economy come into play in all of this the traditional way of understanding economy as the management of and struggle over scarce resources would be too narrow for giddensscarcity is better understood following commons as institutional production itself institutional scarcity a general social theorybased definition of economy must be conceived more broadly and in giddens this is the case he regards the inherently constitutive role of allocative resources in the reproduction of societal totalities be they entire societies or organisations as differentia specifica of the sphere of the 9 cf ortmann for a similar account and detailed illustrations based on the example of lean production organisation as reflexive structuration economic indeed only in modernity does this sphere experience that institutional differentiation which has become so selfevident to us modern economic institutionsmoney and credit labour markets product and financial markets competition and enterprises all designate institutionalised practices that are historical to the highest degreeare marked by the dominance of the production of allocative resources and for many organisationsenterprises above all of coursethis might be a suitable characterisation we can then speak of economic organisations in the case of capitalist enterprises practices of profitable production even dominate we can take this as a starting point for a structurationist theory of the enterprise that gives economics its due without reducing the enterprise to pure economics the acquisitive principle as gutenberg called it is not an anthropological constant not a psychologically but an institutionally anchored regulative without which the system could not function however this institutional dominance by no means signifies that the other dimensions of the social are insignificant in and for economic practices rather even when it comes to the rules and resources in and of economic organisations we are dealing with that recursiveness between the dimensions of the social indicated in figure 2 economic practices go hand in hand with the reproduction not only of allocative and authoritative resources but also of rules of signification and legitimation this manifests particularly clearly in the maintenance of the cognitive and normative order which is shaped by accounting and bookkeeping systemsan order that recursively ensures that practices are recognised and evaluated as economic or else modified until they roughly conform to that order the extent to which the rules for the constitution of meaning depend on the allocative and authoritative resources of an organisation and vice versa can also be shown for example by the fact that concepts for the organisation of production such as taylorist mass production or lean production never concern only the production technology ‛per seassembly lines computers automation storage areas and technology transport technologybut always the practical handling of it and this immediately implies questions about the domination of human beings questions about legitimation about fairness in dealing with human beings for example and about signification rules cannot be conceptualized apart from resources which refer to the modes whereby transformative relations are actually incorporated into the production and reproduction of social practices structural properties thus express forms of domination and power it has already been indicated above that we can further differentiate the dimension of domination into politics and economy along the lines of the distinction between authoritative and allocative resources as long as we keep in mind that this does not mean economy in a pure sensethat is purified of the other dimensions of the socialbut refers instead to the more or less farreaching institutional differentiation of two spheres one of which is concerned primarily with the domination of human beings and the production of authoritative resources and the other primarily with domination over nature and matter and the production of allocative resources this distinction of practice is quite common also within organisations as thecritically intendedtalk of ‛political decisions in enterprises indicates whenever considerations of power prevail over economic concerns we can then inquire further about the recursive relationship between these two dimensions the use of power resources may increase efficiency andor profit just as conversely economic resources increase power over human beings and we can ask about the relationship of each now separated into politics and economics to the interpretative schemes and norms by means of which we define the is and ought in organisations we will not go into these differentiations in any more detail here but instead conclude by pointing outusing the example of law and politicsthat organisational action stands in a recursive constitutional relationship not only to organisational but also to supraorganisational structuresto the institutional environment as we can say in the language of new institutionalism it is constrained and enabled by the institutional environmentthink of the political and legal regulation of telecommunications or tv markets labour protection and codetermination laws and so onand it has an impact on these supraorganisational structures the latter does not always involve strategic intent but often enough it doesnamely to influence those restricting and enabling structures organisations try to regulate their regulations that is the ones that affect them regulation of regulation recursive regulation ortmann and zimmer call this strategic institutionalisation institutions and institutionalisation it could be shown that this way of wielding influence involves the use of communicative normative political and economic means and that it targets all the abovementioned dimensions of the social seeking to change interpretations and interpretative schemes 10 and influence perceptions of legitimacy and norms 11 as well as political and economic conditions the return of society to organisational theory then also means addressing the enormous influence of organisations and especially of enterprises on the institutionalbut particularly the regulatoryconstitution of society as a whole business administration has always had a certain interest in this topic today the pertinent questions of how environmental protection laws accounting rules capital market laws banking regulations antitrust legislation and so on affect enterprises are handled predominantly by property rights theory transaction cost theories agency theories political economy and public choice theory as one can now learn from the instructive anthology regulation and corporate policy regulierung und unternehmenspolitik by sadowski czap and wächter usually however it is how certain regulations operateespecially their efficiency effectsthat is of interest in business administration the question begins with a regulation that is somehow assumed or alleged to be given in order to trace its effects on enterprises and ‛the economy influence in the opposite direction as obvious as it is is much more seldom discussed 12 from the perspective of structuration theory however institutions and regulations must be analysed from the outset as arestricting and enablingmedium and as a product of action which is to say also as a product of strategic action that calculates and seeks to influence the effects of institutionalisation processes and regulations in light of wellunderstood interests tracing the lines of the giddensian dimensions of the social permits us to distinguish and consider institutional orders that pervade all of societyall of its symbolic political economic and legal institutionsin this recursive constitutional relationship to action and now especially to the action of organisations as corporate actors this ties institutions and institutional orders more closely to action more closely to strategic action and therefore more closely to economic and other interests and thus more closely to power conflict and politics than is often the case in neoinstitutionalism and if we follow giddens in defining institutions as those 11 to stay with the previous example should private television be permitted or banned should advertising on television be permitted banned or subject to time restrictions 12 cf in the abovementioned anthology by sadowski czap and wächter however wengers revelatory polemical contribution which draws on public choice theory and the theory of rentseeking and walzs contribution to the same volume which is somewhat similar but more moderately argued on the pertinent theoretical foundations see the introduction by sadowski ibid cf also the impressive work of hutter who combines transaction cost theory and systems theory into a selfreferential theory of the economy and of the production of law richard nelson discusses pathways of such recursive regulation that can sometimes lead entire industries into a lockin of their status quo all these theoretical approaches can enrich and complement each other societally imposed regular practices that have the greatest distanciation in time and space within societal totalities then perhaps this is also a sufficient response to concerns voiced for example by türk and nelson that the concept of institution is too vague to be truly fertile societally imposed practicesthis definition however requires further clarification of the concept of rule it contains rules resources and modalities giddens defines rulesthose of the constitution of meaning as well as those of legitimationquite simply as generalisable procedures of practice as generalisable procedures applied in the enactmentreproduction of social practices they are inherent in the actions of the actors and nowhere else verbally formulated rules such as those found in legal codes or organisational instructions job descriptions etc that is in the blueprints of formal organisations are not rules in this sense but codified interpretations of rules games in organisations to which we will return below are based largely on rules in the sense of practised procedures that are not codified what we get from all of this are some not very obvious yet very important distinctions for which the usual terminology of organisational theory often has no equivalent 1 a regular praxis made up of organisational practices in which 2 rules understood as generalisable procedures are inherent these 3 can be formulated as codified interpretations of rules and finally 4 beyond rules the additional structural properties of social systems that are produced reproduced and altered by that regular praxis but are themselves neither rules nor resources for example the division of labour hierarchy the spatiotemporal interrelatedness of interactions or centralisationin short everything that is usually called structure in organisational theory but is not structure in the narrower sense of rules and resources that we have given it here the strange thing about rules of all kinds is that they cannot themselves govern the way they are applied and therefore strictly speaking it is only in this situational application that their meaning is fully decidedalso and especially their meaning for what happens in organisations this is of particular significance when it comes to formalexplicitly formulated‛rules which traditionally play such a prominent role in organisational theory application which only appears to be secondary because it is derived from the formal ‛rule is in reality organisation as reflexive structuration eminently constitutive for the meaning of this ‛rule and the concept of informal organisation points to how this supposedly so marginal application is of the utmost importance for the functioning of any organisation even and especially when that application consists in a deviation an underminingindeed even when it consists in the violation of the formal set of ‛rules 13 as alfred schutz has said in this set of ‛rules is a certain emptiness that needs to be filled in and by application this is as true for rules of constituting meaning as it is for rules of legitimation which can only be filled supplementedreplaced in situational contextual circumstances equipped with the indices of the here and noweven as they are stripped in concrete action of their typicality giddens term modalities refers to the rules and resources that are filled in this way deployed hic et nunc by someone with a specific biography and competency according to this interpretation14 they designate the place of mediation between action and structure and therefore giddens reception of schutz is on this reading of some significance for the notoriously controversial question of whether giddens succeeded in this mediation 15 if we have continuously cited the example of the constitution of meaning by use of interpretative schemes and the concomitant production of a cognitive order as its corresponding structural dimension all this applies equally to the constitution of legitimacy by use of norms and the concomitant production of an order of legitimationand to every practical intervention in the world by use of facilities and the concomitant production of an order of domination the latter proceeds with recourse to resources made available by an existing order of domination and every disposition under situational circumstances implies an analogous movement from an emptinessthe somehow still empty generality of resources as means to typical but not concretely defined endsto the fullness of the now here and in this way which the user only imparts to it in praxis 16 as explained above we consider it a great advantage that giddens concept of structure in this way includes specific resources especially with a view to organisations and especially enterprises note that this concept of resources avoids the opposition between the material and the immaterial even if it sometimes seems otherwise some forms of allocative resources might seem to have a real existence in a way which i have claimed that structural properties as a whole do not but their materiality does not affect the fact that such phenomena become resources in the manner in which i apply that term here only when incorporated within processes of structuration that we first must make resources into resources that we have to generate them in recursive loops of organisational praxis associally significantresources before we can use them as such this is an insight that is thoroughly incorporated in the resourcedependence approach of organisational research as well as in the resourcebased view of strategic management where as one can see it has considerable consequences for the praxis of organisation and management the binding of time and space in giddens terminology structuresthat is rules and resources‛bind time and space 17 ‛instantiated in situated practices they provide the latter with temporospatial extension institutionalisation and a globalisation that can be supplemented replaced offset or corrected by certain forms of localisation and regionalisation technologies of storage irrigation conservation transport and as of recently especially data storage and processing as well as communication provide the enormous possibilities of timespace extension that we are confronted with today organisations are the medium and result of the development of precisely such technologies they enable or promote 16 schutz has also shown this perhaps surprisingly for the case of the ‛tool a product that is used in further recursive loops of human praxis for the purpose of producing on the recursivity of ends and means thus created cf ortmann it is not simply that means are derived from ends and measured against them rather ends are also seen anew rediscovered reposited in the light of new means this recursivity underminesdeconstructsany affirmation of economy that has to operate with fixed needs orders of preference and ends as ortmann has attempted to show on the basis of the relationship between ‛recursivity productivity and viability 17 on time binding cf luhmann 125 221224 who with reference to korzybski likewise traces time binding to structure formation organisation as reflexive structuration technology development which in turn massively accelerates the development proliferation and power of organisations in society with ‛storage giddenswith a view to modernityhas in mind also and above all the storage of authoritative resources in memory in the form of writing and today by means of computer technology but he also has in mind the form of organisation which considerably increases the possibilities for storage the origin of this special nuance in a tradition which from husserl via schutz and heidegger to derrida 18 has made the temporality and spatiality of human existence a prominent object of reflection may have impededand may continue to impedeits reception in germany however this will change in times when dichotomies such as globallocal indicate spatially the distance and the rending tension contained therein the small dairy cooperative in east frisia whose dried milk is enjoyed by children in southern africa is a standard example of what giddens calls timespace distanciationthe globalisation of modernity a globalisation that initially occurs naturally and only later becomes an object of reflection which is also to say an object of reflection on the structuration of global enterprises and enterprise networks the fact that organisation is always about spatiotemporal organisationabout production schedules time worked and time lost operating hours justintime production night work and overtime cycle times target times setup times break times and about production spaces reworking and storage spaces transport routes and communication channels outsourcing regional and global networksrequires no explanation modernity has given rise to enterprises that on the one hand have nearly disappeared from viewthat are ‛hollow ‛virtualand on the other hand operate worldwide enterprises that are detached‛disembeddedfrom their local contexts and reembedded only via organisation information technology and communication technology the close attention giddens social theory pays to time space and regionalisation his concept of structure and structuration especially tailored to this and his keen eye for the fact that the concept of spacetime distanciation is directly related to the theory of power in other words that spacetime extension by way of organisation is of fundamental significance for the extension of power this too contributes to the attraction his theory holds for research on organisational theory 18 especially giddens definition of structure as an intersection of presence and absence a virtual order involved in the reproduction of situated practices in time and space originates in heidegger and derrida rules and resources are in this sense outside of time and space except in their instantiations in action and in their coordination as memory traces in this respect they are characterised by an absence of the subjectjust as language is without a subject it is in action however that they have their actual existencethey receive it by means of that filling supplementation and replacement discussed above with reference to schutz on giddens reception of derrida cf ortmann organisational change organisational change may be more or less intentional or unintentional in the former case we will speak of reorganisation in the latter of evolution evolution may refer to individual organisations 19 but above all to the genres here populations of organisations of course they are interrelated evolution also takes place through reorganisation the factual consequences of which are incidentally never entirely intended but evolution proceeds also by way of change that is unplanned from the outset as well as by selection evolution as we use the term does not imply any sort of advancement however defined in the case of reorganisation the intentionality of change means that it is intended but not that it is realised as intended in opposition to rationalist textbook versions of reorganisation we have borrowed levistrauss image of bricolage tinkering a productive action that works on an unfinished task with a limited supply of meansa tinker box bounded rationality goals that change depending on opportunitiesthink of the opportunities created by new technologiesand toollike means for tasks of a type only partly defined by ends these are the most important features of tinkering as well as of reorganisation which makes changes to the structure of organisations to their rules and resources in a political process that ultimately outstrips the metaphor of the lonely tinkerer reorganisation is the conscious reflexive restructuration of ‛organisation as a field of action a restructuration that aims to change an organisations rules and resources while playing out in every dimension of the social as an attempt to change established structures of signification legitimation and domination this is subject like all organisational action to the recursiveness of structure reorganisationas well as resistance to changemust therefore make use of the very means of power made available by the given organisational structure disputes about restructurings are often so fierce because they regulate how power will be distributed in the future rounds of organisational games we therefore follow giddens as well as crozier andfriedberg in interpreting resistance to reorganisations not as an expression of the irrationality stupidity and inertia of human nature but on the contrary as an organisationally induced phenomenon the usually thoroughly rational behaviour 20 of players in an established game of routine who have become comfortable and proven themselves within its structures its game rules and distribution of resources and now in the face of a game of innovation that impacts on and may destroy the old game structures and should at the very least change them they react by deferring putting on the brakes or resistingnot seldom by the way while citing reasons that are good even from an organisational point of view this view of things deprives reorganisation processes of much of that wellordered rationality that textbooks often attest to them and which is frequently expressed not only in unaffected endsmeans hierarchies and correspondingly ‛rational step sequences and phase schemes but also in the more or less unshattered belief that the results of reorganisation processes are also properly understood as the results of intentional action even after abandoning such a picture of rational and controlled reorganisation the rationality that is threatened in this way can rescue itself by means of everrationalist social darwinist conceptions of evolution then it is not rational reorganisers but rather environment selection andor adaptation that ensure the survival of rational perhaps even optimal forms of organisation we can here leave aside the critique of these ideas as handed down from veblen via the population ecology approach to some variants of new institutionalism because this has been done conclusively elsewhere for example by kieser and by nelson we would just like to point out that giddens strongly rejects this kind of evolutionism in the social sciences as well as any theory of social transformation understood in this way his primary reasons are twofold people do not make their history just as they please but in knowledge of this very history as reflexive beings and they change this history depending on their knowledge the same by the way could be said of organisations neither ‛societies nor ‛organisations are fit to serve as those clearly definable basic evolutionary units that are independent of the course of history itself but whose very evolution should be the issue at stake here representations of organisational change also require a completely different form and in short must operate with concepts such as episode coincidence and critical threshold of change they must reckon with contingency necessity and chance which can force change into certain courses and trajectories path dependency is an important concept in this context because it allows us to grasp fairly well the peculiar mixture of chance and necessity that brings about the ‛evolution of organisation in specific directions 21 it is not the heroes of a universal principle of efficiency‛survival of the 21 cf arthur david north ortmann path dependence means that the direction of processes depends on their course and on ‛small events with each step being determined by the one before so to speak and not from the beginningfor example by the compass bearing ‛efficiency organisational solutions do not necessarily gain acceptance because they are efficient but they can be efficient because they have gained acceptance consistent with this view cf the noneconomistic portrayals of the triumph of computer technology and the genesis of systemic rationalisation and lean production in ortmann for a general discussion of the relationship between contingency chance and necessity in connection with the development of forms of production with reference to stephen jay gould cf ortmann fittestwho are victorious according to this account but lucky winners who could just as easily have become losers but who now having won have at their disposal the means to build on their victory to oust the others from the market permanently to gradually ensure their own efficiency and last but not least to rewrite the criteria for success and history itself in such a way that their victory appears as a heroic act of efficiency winner takes all it is not by chance then that path dependency runs like a golden thread through nelsons contribution finally structuration means structuredness and structuring in principle stability and change are on equal footing here this is perhaps the greatest advantage of which a giddensinspired organisational theory can boast that it allows us to think both the sometimes so rapid changes and the sometimes sheer despairing inertia of organisationsas well as the complication that change without stability is not even possible for both of course structuration theory provides only a theoretical framework within which the rigidity and conservatism of organisational structuresor indeed their changeabilitybecome theoretically workable it does not provide this theorisation for particular empirical casesit cannot and does not intend to at its level of generality yet it renders stability inertia encrustation blockage and immobility issues that can be addressed theoretically because they are deciphered as results of recursive reproductionas results of constant movement organisation and psyche at least since barnard it has been clear that organisations consist of actions not persons this is a consensus that would not deny that persons are ‛important for organisations but would like to insist that no organisation subsumes the whole person with all his or her activities that it is precisely theirorganisationalactivities that are organised and in turn produce the organisations and not for example the character traits of persons their hopes doubts aversion to garlic secret thoughts or vices and virtues and that all organisational activities are understood as elements of organisations but how then are we to grasp theoretically thatand howpersons are ‛important for organisationsand nota bene vice versa psyche motives performance readiness anxiety likes and dislikesthat is the needs 22 of the acting persons to use 22 mccloskey does not hesitate to speak of desire the economy depends today on the promises made yesterday in view of the expectations about tomorrow … a correct economics … is historical and philosophical a virtual psychoanalysis of the economy adjusting our desires to the organisation as reflexive structuration the concept under which economic theory subsumes all this without dealing with ithow can they feature in our socialand organisationaltheoretical outline the fact that it does not suffice for the more precise definitions that are required here to imagine adding in psychoanalysis as the competent discipline as it wereafter all psychoanalysis portrays the individual in his or her unmistakable identity in his or her lifesituational and lifehistorical individuality is due to the circumstance that the object of psychoanalysis is not real interactions and object relations but the interpersonal relations that are embedded in personality or to put it more drastically the inner world of fantasy scenes psychoanalysis is concerned with schemes of eventsassensed not the investigation of eventsassuch 23 interactions however as an element of the social are events psychoanalysis cannot immediately connect up with this hope for mediation is nourished only by the insight that the figures of experience derive genetically from real interaction the foundational interaction forms are always the inner precipitation of interactions and furthermore the forms of interaction are functionally related to real interaction as drafts of behaviour and action interpersonal relations in personality is thus supposed to mean from the collective social structures we get past the mediating figures of the interaction game and into the individual in the following way the … interplay in the motherchild dyad influences the childs organism calibrates its behavioural reactions that is it is precipitated in the childs organism … interaction is laid down as an interaction engram to then be instrumentalised as a design of behaviour themselves the result of interactions these drafts of behaviour determine subsequent interactions genetically as well as functionally they are related to interactions they are specified by interactions in order to determine further interactions but as regulated regulators they are internal to the individual reality principle the fact that this term desire tends in specialist jargon to be immediately replaced by less dangerous onestaste need preferences utility functionspermits needs to be kept outside exogenous and subsequently dispensed withhow disconcerting in view of mccloskeys quoted definition structuration theory as the following will showthey are almost verbatim excerpts from ortmann suggests an endogenising of needs the recursive production of needs through production and consumption the fact that orthodoxy cannot admit this or can do so only at its margins does not detract at all from the unheardof importance of this recursivity unheardof is perhaps the wrong expression concerning this insight marx veblen and keynes for example were not given a hearingin fact it went in one ear and out the other 23 on this and on the role of psychoanalysis in social research see also leithäuser and volmerg as internal regulators they clearly do not belong to the observable level of interaction phenomena rather they are building blocks of the essence of personality in its societally specified form these drafts of behaviour embedded in the personality which constitute the personality in its essence have been called specified interaction forms 24 the specified forms of interaction are the societal relations in the concrete individual as we can see they are the results of a recursive process of production emerging from interaction processes they enter into new interactions in important ways and are fixed as interaction engrams in order to then be related in the form of interaction designs to actionwhich recursively stabilises that fixation lorenzers ‛specified interaction forms designate the level of mediation between action and personality structure thanks to lorenzers reformulation of psychoanalytical concepts in terms of forms of interactionnota bene this somewhat misleading choice of words refers to interaction designs or patterns in individuals not to forms of real interactionwe can offer a sketch of the individual that can be meaningfully linked to social and organisational theory a schematic version of which looks something like figure 3 25 the interaction forms interaction designs the authors can only appear in interactions be they imagined or really occurring scenes the psychoanalytic achievement however is still the reconstruction of eventsaspereceived not of events behavior interaction specified interaction form interaction engram personality structure 24 here lorenzer quotes his own work symbol interaktion praxis 25 lorenzer opts for a somewhat different much more complex form of representation organisation as reflexive structuration to speak of interaction engrams and personality structure as we do here and as lorenzer does in his work is also to imply something like a cognitive structure that is not however central to the framework of psychoanalysis desires and fears on the one hand and something like reason on the otherboth sides are accounted for in giddens model of action which distinguishes between three levels of consciousness in actors discursive consciousness practical consciousness unconscious motivescognition it also considers both reflexive monitoring and rationalisation as well as the motivation of action i distinguish the reflexive monitoring and rationalization of action from its motivation if reasons refer to the grounds of action motives refer to the wants which prompt it however motivation is not as directly bound up with the continuity of action as are its reflexive monitoring or rationalisation motivation refers to potential for action rather than to the mode in which action is chronically carried on by the agent … for the most part motives supply overall plans or programmesprojects in schutzs termwithin which a range of conduct is enacted much of our daytoday conduct is not directly motivated with the help of lorenzer we can understand this more precisely that is in terms of recursiveness and structuration theory as the relationship between an interaction engram which refers only indirectly to interaction scenes and specified interaction designs which refer to them directly but we need psychological access not only to desires fears and motives but also to cognition including its unconscious parts for a combination of cognitive psychology and symbolic interactionism which are linked to jakob and thure von uexkülls recursively constructed models of the ‛function circle and the ‛situation circle we have taken hints from the instructive work of brauner with its structurationtheoretical designrecursiveness of interaction and cognitive structure brauners dynamic circular model of interaction represents a cognitivepsychological elaboration of the basic idea we would like to present here connections to anthony giddens concept of action are unmistakable especially the proximity of mental control of action mentale handlungskontrolle to giddens reflexive monitoring of action brauners model makes clearand it is no coincidence that it shares this with giddens actor modelthat we produce and change our individual cognitive maps of the world in iterative and recursive loops of practicethat is in the practical application and reflection of these cognitive maps both therefore offer possible links to the most promising approaches of cognitive psychology that are not rationalistically preoccupied such as neissers perceptual cycle and its reworking by karl weick both fine examples of thinking in terms of recursivityin this case between perceiving and acting neissers perceptual schemata are the results of a perceptual learning that enter into new acts of perception as active informationseeking structures and are thereby recursively reproduced and possibly modified connections to questions of organisational learning are obvious and weick elaborates them we include not only lorenzers interaction designs but also these neisserian cognitive structures in the personality structure of acting persons and we are now prepared to connect these two descriptions of social and individual structuration we will then see that the place of mediation between the individual and societyor organisationis interaction 26 26 in the sense of social action which as in max weber finds meaningful orientation in the past present or expected future behaviour of others for more precise definitions and for deviations from weber see ortmann if we replace the upper half of figure 4 with scotts layer model we can see that our model is compatible with a version of sociological neoinstitutionalism focused on societywide institutions and governance structures as well as organisational fields into which the social structure represented in our scheme develops organisation as reflexive structuration every interaction is simultaneously individual and social action and the perception of events and eventassuch the puttingintoaction of interaction designs and the occurring of social praxis in the medium of social structures that every interaction is both at the same time does not imply that both are the same thing nor does the fact that each is something very different imply that they are not related in a comprehensible and specifiable way on the contrary there is no specific form of interaction in lorenzers sense that can be realised in interaction wholly outside the medium of social structures nor any social practice that is not somehow the realisation of individual drafts of interaction furthermore every interaction implies on the side of social structures production and institutionalisation and on the side of the individual socialisation and internalisation although we cannot reckon a priori with successful or even mutually harmonious processes of socialisation internalisation on the one hand or of reproductioninstitutionalisation on the other interactions these central sites of mediation between the individual and society are therefore not to be characterised merely as agencies of socialisation but always simultaneously with a view to society as sites of production of social structures and institutions27 critique and outlook despite the considerable spread of structurationtheoretical research in organisational theory in particular the reception of giddens is marked by noticeable deficits leaving important room for improvement especially in the germanspeaking world this is due not only to the fact that the field he tills is occupied in this country by habermas and his students who have hardly ever spoken of organisations but giddens himself has abetted this trend in a certain sense it is not merely that he has written well over 20 books to date making it difficult even for benevolent readers to follow the developments of his thought rather it is precisely the reader who is still unfamiliar with giddens work who is left with the impression that bernstein has described as follows one sometimes feels that giddens is not always in control of the material he is discussing where one expects detailed explication and justification too often there is repetition and eloquent variation temperamentally giddens is foxlike in his approach to issues although his systematic ambitions require him to be like the hedgehog given the sheer variety of topics themes and thinkers he treats one can understand why he tells us about his book constitution of society this was not a particularly easy book to write and proved in some part refractory to the normal ordering of chapters inaccuracies and inconsistencies concerning terminology and conceptualisation have rightly been pointed out and not only by critics such as archer and stinchcombe the germanlanguage edition of giddens magnum opus the constitution of society with its grave translation deficiencies did not improve the situation yet even in the original english edition the glossary of this work contains strange terminological deviations from the body of the text there are categorical inconsistencies in giddens definitions of authoritative and allocative resources for examplea meaningful distinction which he however sometimes seems to confound with the distinctions materialimmaterial resources and technologicalorganisational resources bernstein has bemoaned deficits in how the theory deals with the justification of norms and in terms of its critical quality gerstenberger has found the validity of historical claims lacking a criticism whose relevance for the socialtheoretical core of structuration theory would need to be discussed separately it is thus not surprising that giddens writings have received a great deal of attention but at the same time have triggered vehement controversies many critiques revolve around different ways of reading the basic theorem about the duality of structure archer for example charges that giddens concept of structuration oscillates between two divergent images on one side there is the hyperactivity of agency which contributes innately to the volatility of society on the other side the structural properties of society exhibit a rigid coherence so that the aspect of stability is exaggerated outhwaite has objected that archer reads into giddens texts the very opposition between action and structure that giddens is so intent on eliminating kieβling refers to a ‛standard critique that accuses giddens of subjectivist reductionism but himself comes to the opposite conclusion that giddens theoretical apparatus suffers from an objectivist surplus discussion of the mediation of action and structure continues it is rather surprising that the theoretical debates have lacked any specific discussion of the mechanisms of mediation and in particular that the significant question of modalities in giddens theorem of the duality of structure has garnered little attention although our remarks on this will not be the last word either we believe we have at least suggested the way forward for discussion of this concept in section 22 in our view further clarification of the mediation of action and structure could be fruitful for the interplay of theory development and empirical researchif expectations are kept in check the concepts of structuration theory as with any competing theoretical perspective should for many research purposes be regarded as sensitizing devices nothing more that is to say they may be useful for thinking about research problems and the interpretation of research results a look at the landscape of current empirical organisational and network research shows how much it stands to gain from theoretical inspiration giddens structuration theory provides just such an inspiring theoretical frameworkprovided we do not limit ourselves to trying to fill it with empiricism but instead keep in mind the constitutive role of this ‛filling for that framework and the considerable opportunities to absorb and productively work with the insights of other theoretical traditions and the established concepts of organisation theory this then also opens up opportunities for communication between supposedly incommensurable discoursesone need only think of interpretative organisational research economic and sociological neoinstitutionalism or even distinctly structuralist or actiontheoretical approaches as well as the classical organisation theory of business administration it then becomes only natural that in the course of its fulfilment such a framework should also be supplemented perhaps even replacedin a process of principally interminable critique

our beacons of organizational sociology series makes available through firsttime translations texts that have shaped debates in organizational sociology in nonenglishspeaking countries or presents reflections on such debates by established scholars the first text in this series is a shortened english translation of the german article organisation als reflexive strukturation by günther ortmann jörg sydow and arnold windeler published in 1997 in the highly influential book theorien der organisation die rückkehr der gesellschaft theories of organization the return of society the article applies giddens social theory to organizational research in elaborating on the principle of reflexive organization the text provides a socialtheoretically informed concept of organization that is of continuing relevance for organization research today the publication can be classified as one of the decisive writings by the authors contributing to establishing organizational research based on structuration theory in the germanspeaking world informing many studies eg on new organizational forms innovation and interorganizational relations the concise overview of the various existing studies in organization research using a structuration perspective at that time in the original manuscript is not part of this translation

introduction in high income countries there is concern about the consequences of excessive alcohol consumption 1 especially in youth when these behaviours are common 1 2 3 4 and may track into adulthood 56 there is evidence of a dramatic rise in alcohol consumption in young people in the west of scotland and in the uk more broadly 7 the reduction of alcohol use and binge drinking in particular are priorities for the british government 3 this reflects concerns about public drunkenness and antisocial behaviour on the one hand and the longer term health effects of excessive drinking such as increased mortality in heavy drinkers 8 there is also evidence from scotland of an increase in the lifetime prevalence of illicit drugs in recent decades with everuse of cannabis by young adulthood being much more common than everuse of other drugs 9 cannabis use in young people is associated with psychotic symptoms and dependence on other illicit drugs 1011 although there is debate over its health consequences 12 among young adults who have been longterm drug users there is evidence of poor selfrated health and increased mortality 1314 this evidence on increasing substance use in adolescents and young adults together with the lack of effective treatment for substance dependence 15 raises questions about which factors facilitate the uptake of excessive alcohol and drug use media portrayals are one potential influence shaping young peoples views of various behaviours however it has been demonstrated that portrayals of substance use in films are often unrealistic as has been well documented for smoking 16 17 18 they often glamourise smoking and make smoking appear to be more prevalent than contemporary figures support thus despite the dramatic fall in adult smoking in the uk and usa since the 1950s it has been suggested that smoking in films was as common in 2002 as in 1950 19 smoking imagery declined in top us box office hits between 1996 and 2004 but not within films intended for youth audiences 20 similar findings have been reported for the most popular films in the uk showing that despite a substantial fall between 1989 and 2008 overall tobacco imagery appeared in 70 of all films and predominantly in films categorised as suitable for children and young people 21 this has alerted health professionals and policymakers to the potential of media images to shape substance use in young people 22 evidence is now building to suggest a causal link between viewing images of smoking in films and young peoples initiation of smoking 22 23 24 25 26 to date little attention has been paid to the influence of film images of other behaviours such as alcohol and illicit drug use on young peoples own use of these substances alcohol consumption is also very commonly portrayed in films including in grated 27 and animated 28 films a content analysis of 100 of the top grossing us films between 1986 and 1994 reported that 96 had references that supported alcohol use and 79 included at least one character who used alcohol whilst incidents of alcohol use were common portrayals of the hazards of drinking were not reflected 29 similarly a study of the most popular us film rentals from 19967 found 93 included alcohol use and 22 illicit drug use in 12 of films one or more of the major characters used drugs and 65 of adult characters used alcohol and in 43 of films alcohol use was portrayed as a positive experience 30 a content analysis of the top grossing us films from 19992001 found 15 of teen characters used illicit drugs and again were unlikely to be shown as suffering any consequences of their drug use 31 in very recent years a few studies have reported an association between exposure to alcohol images in films and young peoples own alcohol consumption 32 33 34 35 these studies followed earlier ones which had demonstrated an effect of exposure to alcohol advertising marketing and portrayals on young peoples subsequent drinking behaviours 36 thus in the usa a strong relationship was seen between film alcohol exposure and onset of drinking in 3577 1014 year olds who were never drinkers at baseline 32 crosssectional associations between film alcohol exposure and drinking were observed in 5581 13year olds from 27 schools in germany after adjustment the odds ratios were 147 212 and 295 for drinking without parental knowledge and 142 184 and 259 for binge drinking 33 to our knowledge no studies have reported on exposure to images of illicit drug use and own drug use here we report a crosssectional analysis which investigates the association between exposure to images of a alcohol and b drugs in films and a current drinking and b ever use of drugs in young adults living in the uk we have previously reported a lack of association between exposure to smoking in films and smoking in these young adults 37 as a number of factors may confound any relationship between film exposure and substance use 36 we adjust for gender background characteristics personal characteristics friends substance use and time spent watching television videos or dvds methods sample data are from the west of scotland 11 to 1616 study a longitudinal study of health and lifestyles in a single year cohort 38 respondents were recruited in 19945 during their final year of primary schooling and resurveyed at ages 13 and 15 and at age 19 after leaving school at 11 parental questionnaires were completed for 86 of the sample the study received approval from the university of glasgow ethics committee for nonclinical research involving human subjects and participating education authorities and schools respondents were invited to take part via letters with information sheets detailing the survey procedures prior to participation they signed a consent form confirming that they had read the information sheet had the study explained to them and understood what it involved that the information they would provide was confidential and would be identifiable only by an id number and that they could choose not to answer any questions they wished because of the schoolbased nature of the sample the sampling scheme involved several elements to ensure representativeness at both the primary and secondary school stages as reported elsewhere 7 in brief the survey used a reversesampling procedure which randomly selected the 43 secondary schools stratified by level of deprivation and religious denomination with a separate stratum for independent and staterun schools these schools were used to select a random sample of feeder primary schools together with primaries making a high number of parental placing requests within these 135 primary schools classes were randomly selected with all pupils in selected classes eligible to participate of the 2793 pupils who attended the targeted secondary schools 2586 participated in the baseline survey 85 in the survey at age 13 and 79 in the survey at age 15 as expected losses to followup increased in the postschool period reducing the sample size to 1256 at age 19 full details of the sampling strategy are available elsewhere 39 the baseline sample was representative of 11 year olds in the study area in respect of sex and socioeconomic status 40 differential attrition made subsequent waves less representative for example attrition was higher among lower ses groups school truants early school leavers and smokers probabilistic weights have been derived at each wave to compensate for nonresponse 4041 adopting the system of weighting proposed by little and david 42 as these factors could be related to alcohol and drug use we report results based on weighted data at age 19 unweighted analyses are available on request each schoolbased survey included selfcompletion questionnaires administered in examtype conditions at age 19 respondents were interviewed by nurses using computer aided personal interviews measures exposure to alcohol and drugtaking in films to estimate the amount of alcohol and illicit drug use that the respondents had seen in films we aimed to replicate methods developed by sargent and colleagues 23 24 25 43 as closely as possible at age 19 respondents were asked to indicate in a selfcompletion questionnaire whether they had seen each of a unique list of 50 films randomly selected from a sample of 601 films released between 1988 and 1999 hence each respondents list of 50 was different the 601 films included the usas 25 top boxoffice hits from 1988 to 1995 the top 100 boxoffice hits in 1996 1997 and 1998 the top 50 boxoffice hits from the first half of 1999 and 51 additional films which featured stars popular amongst adolescents 25 trained coders have recorded the number of seconds of alcohol and drug use in each film as described elsewhere 32 alcohol use was defined as consumption of a beverage that was clearly alcoholic implied possession of such a beverage or purchasing alcohol excluded were occasions when a character had an empty alcoholic beverage container or when alcoholic beverage containers were displayed but were not implied as being consumed drug use included actual or implied use or specific preparation for use as well as drug dealing it also included use of drugs prescribed for another person but not use or misuse of a persons own prescription drug an index of film alcohol use was calculated by summing the seconds of alcohol use in the films that each respondent had seen from hisher list of 50 films this number was divided by the seconds of alcohol use they would have viewed if they had seen all 50 films on their list this proportion was multiplied by the seconds of alcohol use in the full sample of 601 films to provide an estimated exposure to alcohol in all 601 films given their viewing habits a separate index of film drug use was calculated in an analogous fashion the total estimated exposures for each respondent were translated into minutes one case who did not complete a film list and two who reported having seen all 50 films on their list were excluded the estimated film exposure variables were then classified into quartiles cut offs for the film drinking exposure were 04476 minutes for the lowest 477691 for the 2 nd 692931 for the 3 rd and 9312017 for the highest quartile those for the film drugs exposure were 07 minutes 830 minutes 3070 minutes and 70175 minutes alcohol at age 19 current drinkers reported the quantity of a range of alcoholic drinks consumed each day over the past week this was summed over the last week never and exdrinkers were assumed to have consumed 0 units dichotomous measures were derived we followed the uk royal college of psychiatrists guidelines to define binge drinking heavy weekly drinkers were those exceeding current guidelines 144 drug use respondents indicated which drugs they had ever used from a list which included common street names because of the differing social characteristics of people who have only ever used cannabis vs other drugs 9 we report here two separate outcomes ever use of cannabis and ever use of hard drugs defined following recommendation by the prevention working group of the uk advisory council on the misuse of drugs 9 as temazepam tranquillisers heroin methadone temgesic cocaine crack and morphine or opium parental social class occupational data from parents at age 11 were used to derive a head of household classification where no parental data were available information from the young person on current parental occupation was utilised the reliability of these data is high 45 social class data were collapsed into four categories nonmanual occupations skilled manual semiskilled and unskilled manual and missing parental structure at age 15 respondents reported which parental figure they lived with or other relatives the very few cases with no parent were excluded because information on parental carecontrol and household variables could not be consistently evaluated by the respondents parental bonding inventory at 15 respondents completed the brief parental bonding instrument 47 which provides scores for parental care and control ranging from 08 each scale was collapsed into three categories for crosstabulations but used as a continuous variable in the logistic regressions attitudes to risk and rulebreaking at 15 respondents rated themselves in relation to risktaking and rulebreaking with response categories very true true untrue and very untrue qualifications by age 19 respondents were dichotomised into those who had obtained any highers at school vs none friends alcohol and drug use at 19 respondents reported how many of their friends engaged in various activities with seven categories ranging from none to all two dichotomous measures were derived for the crosstabulations whether half or more of their friends drank and used cannabis tv video and dvd use at 19 respondents reported how many hours each week and weekend day they usually spent watching television videos or dvds the total hours per week were categorised as 09 1019 2029 3039 and 40 hours for crosstabulations analysis crosstabulations were used to compare the proportions for the four outcomes at age 19 according to quartiles of alcohol and drug exposure and potential confounders a series of logistic regression models was then run for each outcome multivariate models were built sequentially first the unadjusted relationship with the relevant film exposure was assessed subsequent models adjusted for gender then additionally for background variables personal characteristics friends drinking or drug use and finally for hours per week watching television videos or dvds we present weighted data but analyses using unweighted data produced similar results crosstabulations and logistic regression analyses excluded respondents who had missing data on any of the potential confounders in the final multivariate model results basic descriptive characteristics of the sample are shown in table 1 substance use was common a third of the young adults were classed as heavy drinkers and half as binge drinkers over half reported ever use of cannabis but many fewer reported ever use of one or more of the hard drugs listed almost all reported that half or more of their friends drank alcohol respondents had seen a mean of 190 of the 50 films presented to them mean film alcohol and drug exposures were 726 minutes and 45 minutes respectively the mean number of films was higher for males than females and males film alcohol and drug exposures were higher there were no social class differences for films seen or film alcohol exposure but film drug exposure was higher in those from higher social class backgrounds there was a positive correlation between the film alcohol and drug exposure measures table 2 reports the percentage of heavy and binge drinkers by quartile of film alcohol exposure and the percentage of ever users of cannabis and ever users of hard drugs by film drug exposure the p values reported in the table relate to heterogeneity within the groups but we also tested for linear trends in the crosstabulations the tests for linear trends in the percentage of heavy drinkers and binge drinkers by film alcohol exposure quartiles were statistically significant similarly there was an increase in the percent who had ever used cannabis with each quartile of film drugs exposure the percentage who had used hard drugs was also highest in the highest quartile of film drug exposure but with less evidence of a stepwise increase male gender and perceiving oneself as a risktaker and rulebreaker were associated with all four substance use measures and having no highers at 19 with all except binge drinking respondents from manual class backgrounds were more likely to have used hard drugs and those reporting lower parental care were more likely to have ever used both cannabis and hard drugs friends drinking and cannabis use were strongly associated with own drinking and drug status respectively there were no associations between the substance use measures and parental structure parental control or hours per week watching television videos or dvds table 3 shows the results of the logistic regression models for each outcome both before and after adjusting for potential confounding or mediating variables we consider the alcohol outcomes first in the unadjusted model those in the highest quartile of film alcohol exposure were more likely to be classed as both heavy and binge drinkers and 159 respectively compared with the lowest quartile on the basis of their reported alcohol consumption the previous week adjustment for gender reduced the associations but further adjustment for background characteristics returned the odds ratios for the drinking measures to the unadjusted levels adjusting for risktaking rulebreaking and qualifications and particularly for friends drinking status reduced the odds ratios but further adjustment for hours watching television videos or dvds made no difference to the associations in this final model only gender for heavy drinking and 064 for binge drinking and friends drinking status for heavy drinking and 154 for binge drinking had odds ratios which did not include unity ie film alcohol exposure was no longer significantly associated with heavy or binge drinking we turn now to consider the relationship between exposure to film images of illicit drug use and everuse of cannabis and hard drugs in the unadjusted model ever use of cannabis showed a stepped association with film drug exposure and 180 adjustment for gender attenuated the association whereas adjusting additionally for family background made little difference the or was further attenuated after adjusting for personal characteristics friends reported cannabis use and then tvdvdvideo watching in the final model having any highers seeing oneself as a rulebreaker and reporting that half or more of ones friends used cannabis were the only ors in the model with 95 confidence intervals that did not include unity for hard drug use the confidence intervals for the unadjusted ors in third and highest quartiles overlapped with unity although the odds were greatest in the highest film drug exposure quartile in each of the models for ever use of hard drugs none of the associations reached conventional levels of significance even in the unadjusted model in the final model hard drug use was significantly inversely associated with having any highers and positively associated with seeing oneself as a rulebreaker and reporting that half or more of ones friends used cannabis discussion in this crosssectional analysis we have demonstrated an association between film exposure to alcohol and both binge and heavy drinking in young adults and to our knowledge for the first time an association between film exposure to illicit drugs and ever use of cannabis these associations persisted after adjusting for gender social class family structure and levels of parental control but not after adjusting for other variables including personal characteristics such as risktaking rulebreaking and achievement of school qualifications and in particular friends substance use it is somewhat difficult to know how to interpret these attenuations in the associations particularly in this crosssectional analysis it is likely for example that young people who drink heavily or take drugs are not only more inclined to do this in the company of likeminded friends but they may also share or develop similar tastes in cultural representations of substance use with them which may in turn determine the kinds of films they choose to watch on the other hand portrayals of substance use could directly influence an individuals uptake of drinking and drug use which could itself influence the friendship groups that they choose to maintain or develop the crosssectional nature of the analysis thus means that it is not possible to establish the direction of causality even before concerning ourselves with the impact of potential mediating or confounding factors we cannot distinguish here between two plausible but competing explanations either that film images of substance use may influence behaviours or that people who have already adopted particular patterns of substance use may choose to watch films that reflect similar lifestyles and values furthermore it is important to acknowledge that images of substance use in films occur within a wider media context in which a vast array of different images are portrayed over time from a variety of sources a few other studies one including prospective data 32 have reported an association between film alcohol exposure and drinking in younger adolescents using similar methods a german study obtained much stronger associations between film alcohol exposure and measures of drinking before and after adjustment for a comparable set of potential confounders 33 our findings of some association between exposure to film images of alcohol and illicit drugs and young peoples own substance use in this crosssectional analysis are of interest particularly because in contrast to other studies which have reported to date we did not see any association in this study population between exposure to smoking in films and young peoples own smoking at age 19 37 we speculated that this lack of association with smoking may be attributable to several factors these factors could also explain the smaller association we observe in this uk study between film alcohol exposure and drinking in comparison with the usa and germany first there are methodological issues one of which relates to respondent age our study differs from previous research studies which have focussed on adolescent experimentation with smoking and drinking it is plausible that by age 19 other influences could have had such a strong effect that the impact of exposure to these behaviours in films is swamped young adults may also have a more sophisticated and critical reading of media images which makes them more resistant to their effects a second methodological issue relates to the timing of the film exposure we used coding of substance use in films completed by our american colleagues at the time of our fieldwork at this point coding was only available on films up to and including 1999 hence we missed exposures to more contemporaneously released films our second group of potential explanations for a lack of an association between smoking in films and own smoking in these young people 37 related to the cultural environment and the prevalence and social prominence of the behaviours in question although the mass film industry is increasingly globalised it is plausible that scottish viewers empathise less with hollywood film stars or are distanced from american culture fictional or reallife visual portrayals of substance use in tv programmes popular with young people in the uk may be more salient in the scottish context another potential difference lies in the prevalence of substance use in the various countries which have been studied scotland is commonly described as having an alcohol culture compared with most other european countries where levels have remained static or fallen 48 against such a background any impact of the portrayal of substance use in films may be diminished additional caveats that we raised in our previous paper on smoking 37 are also relevant here we have no measure of how accurate young adults recall of the films they had seen was and we did not record whether films had been viewed once or repeatedly also alcohol and drug use were selfreported in the study although our interviewers went to some lengths to ensure confidentiality and privacy whilst reporting on substance use furthermore alcohol use measures were based on reports of consumption in the last week and this may not have been representative of the usual pattern and frequency of drinking in every individual other limitations that we have raised earlier in this paper are important to rehearse there was considerable and differential attrition between the first wave of the study and the wave of data collection at age 19 years although we selected a weighting system designed to address differential attrition it is possible that some residual attrition bias remains for the alcohol variables we were able to use current measures of consumption as our outcome whilst for the drug use variables we were only able to analyse everuse in the latter case we cannot know when this drug use took place or for how long it was a feature of the young persons life our measures of film exposure are comparable to those reported previously for example a study of american 1014 year olds based on the same parent film sample reported that respondents had seen a median of 16 of the 50 films on their unique list which translated into a median exposure to alcohol use of 83 hours in the sample of 601 films the relatively higher alcohol exposure would be expected given the nature of films likely to have been watched by the older adolescents in our study conclusion our finding of an association between estimated exposure to film images of alcohol use and young peoples current use of alcohol from this crosssectional study is consistent with findings from other recent studies the association we report for exposure to film images of illicit drugs and ever use of cannabis suggests that this may be an important relationship to explore in future welldesigned longitudinal studies which are able to examine whether exposure to images of drugs in films is related to the initiation of illicit drugs use such studies could also explore whether the types of images affect different groups of young people in different ways competing interests the authors declare that they have no competing interests authors contributions kh js and hs specified the analyses to be undertaken and led on interpretation of the findings all drafts of the paper were written by kh with input from all coauthors hs pw and rw oversaw the design and data collection for the 11 to 1616 study hl and hs undertook the statistical analyses js oversaw the coding of images of drinking alcohol and drug use in the films all authors read and approved the final manuscript

background as the promotion of alcohol and tobacco to young people through direct advertising has become increasingly restricted there has been greater interest in whether images of certain behaviours in films are associated with uptake of those behaviours in young people associations have been reported between exposure to smoking images in films and smoking initiation and between exposure to film alcohol images and initiation of alcohol consumption in younger adolescents in the usa and germany to date no studies have reported on film images of recreational drug use and young peoples own drug use methods cross sectional multivariable logistic regression analysis of data collected at age 19 20024 from a cohort of young people 502 boys 500 girls previously surveyed at ages 11 in 19945 13 and 15 in schools in the west of scotland outcome measures at age 19 were exceeding the sensible drinking guidelines heavy drinkers and binge drinking based on alcohol consumption reported in last week and ever use of cannabis and of hard drugs the principle predictor variables were an estimate of exposure to images of alcohol and of drug use in films controlling for factors related to the uptake of substance use in young people results a third of these young adults 33 were classed as heavy drinkers and half 47 as binge drinkers on the basis of their previous weeks consumption over half 56 reported ever use of cannabis and 13 ever use of one or more of the hard drugs listed there were linear trends in the percentage of heavy drinkers p 018 and binge drinkers p 0012 by film alcohol exposure quartiles and for ever use of cannabis by film drug exposure p 000 and for ever use of hard drugs p 033 the odds ratios for heavy drinking 156 95 ci 106229 comparing highest with lowest quartile of film alcohol exposure and binge drinking 159 95 ci 110230 were attenuated by adjustment for gender social class family background parental structure parental care and parental control attitudes to risktaking and rulebreaking and qualifications or heavy drinking 142 95 ci 095213 and binge drinking 149 95 ci 101219 and further so when adjusting for friends drinking status when the odds ratios were no longer significant a similar pattern was seen for ever use of cannabis and hard drugs unadjusted or 180 95 ci 124262 and 157 95 ci 091269 respectively fully adjusted or 141 090222 and 128 066247 respectively conclusions despite some limitations which are discussed these crosssectional results add to a body of work which suggests that it is important to design good longitudinal studies which can determine whether exposure to images of potentially healthdamaging behaviours lead to uptake of these behaviours during adolescence and early adulthood and to examine factors that might mediate this relationship

introduction population aging is a rapidly growing global challenge according to the report from the united nations in 2019 the number of individuals worldwide aged 65 or older will increase by almost 80 over the next three decades 1 in europe and north america major industrialized parts of the world with low crude mortality and low fertility rates more than 25 of the population is projected to be aged 65 or older by 2050 1 among developed nations south korea is facing a particularly swift problem of population aging by the year 2030 the percentage of older individuals is projected to be near 25 in south korea which is higher than the proportions estimated in countries like england the united states and china 2 similar to the cases of other western 3 and asian countries 4 population aging is a more prominent concern in rural areas of south korea because many younger people migrate to urban areas for education or employment but rarely return to their home town leaving the remaining population disproportionately older 5 in the context of this global trend toward extended lifespans promoting healthy aging is becoming more important than ever that is maintaining wellbeing in older age by developing and maintaining functional ability 6 in older people declining physical function associated with biological aging may be a natural and irreversible process 7 given this biological challenge it is particularly important for older people to optimize their healthrelated quality of life 89 healthrelated quality of life is a broad valueladen concept that reflects how individuals perceive the impact of physical andor mental wellbeing on their ability to fulfill daily functioning and interactions with others 10 a number of factors including socioeconomic status 1112 health behaviors 13 and living arrangements 14 are related to the promotion of healthy aging among these participation in social activities has been reported as an important determinant of healthrelated quality of life among older adults 415 as they age many older people experience changes in their participation in social activities due to major life transitions such as retirement the death of close family or friends or declining physical functions studies have reported that the reduction in social networks common among older people can increase social isolation and loneliness which have been identified as public health concerns due to their negative impact on physical and mental health 16 17 18 according to previous studies 19 20 21 the contribution of participating in social activities improved the physical and mental health of older people for understanding social activities and health status in older people it is important to address variations in the living environment such as access to transportation local safety neighborhood stability social and local climate and so on due to their influence on active and healthy aging 22 in general living in a rural area often limits a persons access to resources that are critical to health such as education jobs or clinics and hospital facilities 2324 moreover rural areas in many countries experience more pronounced population ageing and are likely to have higher rates of poverty and greater rates of chronic diseases than urban areas 324 thus rural health for promoting safety and a healthy life would be vital among the rural population characterized by the ageing farming population 422 in south korea despite the contribution of economic advancement to reducing ruralurban disparities in public services and welfare programs health inequality among rural older adults remains a major public health issue 25 however findings from previous studies that have examined ruralurban differences in social activities have been inconsistent 26 27 28 29 this may result from a number of factors such as rapidly changing ruralurban boundaries especially in developing countries as well as increasing diversity in social determinants of health within the older adult population while healthrelated quality of life has been the main outcome of interest in research targeting the older population few studies have longitudinally explored quality of life during the senior years examining its association with changes to inperson social activity among communitydwelling older adult populations in rural areas 30 31 32 33 therefore the main purpose of this study was to describe longitudinal changes of participation in social activities and healthrelated quality of life and to explore the associations between changes in inperson social activities and health related quality of life among rural older adults over four years materials and methods study design and participants this study is a part of the korean social life health and aging project project which was a communitybased longitudinal study the kshap aimed to understand current health status trends and determinants of health and social network characteristics among older koreans dwelling in a rural community township k gangwhagun incheon south korea 34 more than 42 of residents in gangwhagun engage in agriculture and about 40 of the area is farmland 34 township k is a typical rural korean community in which most residents live by farming 35 in 2013 the total population of township k was 1864 individuals from 871 families the kshap study targeted the entire older adult population aged 60 years or older as well as their spouses the age criterion was based upon the standard of an older age pensioner set by the national pensions act 35 detailed information on the kshap has been provided elsewhere 34 the survey questionnaires included questions on general sociodemographic characteristics health history social network characteristics healthrelated quality of life and other physical and psychosocial functions 34 measurements sociodemographic and health characteristics variables related to sociodemographic characteristics included age gender work status marital status religion and education gender was dichotomized by either male or female age was calculated by subtracting the participants birth year from the year of survey work status was categorized as yes or no marital status was categorized as living with spouse separated widowed divorced or never married religion was categorized as no religion protestant catholic buddhist or other education was categorized as no education elementary school middle school high school or college or higher variables related to health characteristics included body mass index smoking status drinking habit medical comorbid conditions gait speed mental status bmi was calculated using height and weight and then categorized according to the geriatric bmi groups with underweight being a bmi 225 kgm 2 normal being a bmi 225 kgm 2 to 249 kgm 2 and overweightobese being a bmi ≥ 25 kgm 2 36 smoking status was categorized as past and current smoker past smoker but not now have never smoked or recently started smoking drinking habit was categorized as never rarely or once a week or more regarding medical comorbid conditions selfreported diagnosis of hypertension hyperlipidemia arthritis or osteoporosis was included cognitive status data was obtained using the minimental status examination for dementia screening korean version 37 to measure gait speed timed up and go was obtained by a trained data collector 38 healthrelated quality of life healthrelated quality of life was measured using the short form health survey 12item version 39 participants were asked to rate each item on a fivepoint likert scale 1 2 3 4 or 5 35 the sf12 consists of the physical component summary and the mental component summary the pcs and the mcs are standardized 10 for each of the eight domains the items are summed and then converted to a 0100 scale higher scores indicate better physical and mental healthrelated quality of life social activities inperson social activities in the kshap study 34 inperson social activities were defined as official or unofficial participation in social activities outside of activities related to earning income in this analysis we included four activity types volunteering religious activities hobbies and meeting with friends in the wave 1 survey participants were asked to respond either yes or no to each item in the wave 4 survey participants were asked to rate the frequency in which they participated in each activity over the prior year by choosing one of the following options 1 2 3 4 5 6 or 7 for the present analysis we recoded response options used for wave 4 into two categories yes and no social networks social networks were measured by network size and network density network size refers to the number of individuals with whom participants can discuss the important topics in their lives in the parent study each participant was asked to list the names of a maximum of five discussion network members with whom they had interacted during the last 12 months when the individuals spouse was included the maximum number of discussion networks could be six network density refers to the number of actual relationships that existed among the members of an individual participants social network out of the total possible number of relationships 40 for evaluation participants were asked to indicate the frequency of their interactions with each discussion network member based on an eightpoint scale that ranged from every day to less than once per year in the parent study if the participant reported that they have spoken to each other at least once per week a relationship is assumed to exist between the two network members network density can range from 0 to 1 a higher score indicates better social connectedness among members within the network ethical considerations and data collection this study was approved by the institutional review board of yonsei university and conducted following the declaration of helsinki guidelines all participants had the opportunity to ask questions after a full review of the study protocol with a data collector and signed a written informed consent before their participation trained data collectors conducted surveys via facetoface interviews in the participants homes or at the local community center completing the survey took an average of 48 min data analysis the data were analyzed using ibm spss statistics for windows version 25 descriptive statistics were reported for all variables comparisons were made between wave 1 and wave 4 using a paired sample ttest for continuous variables and chisquare test for categorical variables comparisons between wave 1 and wave 4 were also made within each gender category using the same analysis individuals participation in each social activity from wave 1 to wave 4 was summarized by four change categories answered yes in both wave 1 and wave 4 answered yes in wave 1 but no in wave 4 answered no in wave 1 but yes in wave 4 and answered no in both wave 1 and wave 4 oneway anova and the bonferroni posthoc tests were used to compare the changes in quality of life from wave 1 to wave 4 by the change categories in social activities we conducted further analysis to compare gender differences in social activities with statistically significant differences in healthrelated quality of life statistical significance was set a priori as p 005 results sample characteristics as shown in table 1 the average age of the participants was 712 and 751 the majority of the participants were women and did not finish high school the mean bmi was 2418 kgm 2 and about 64 of the participants were either overweight or obese from wave 1 to wave 4 the proportion of participants who reported living with a spouse significantly decreased the proportion of participants who reported working showed a significant increase from wave 1 to wave 2 participants reported smoking and drinking less in wave 4 compared with wave 1 their gait speed measured by the timed up and go test decreased from 128 to 132 s however the test result was above the normative reference of their age group and below the cutoff point for high risk of falls over half of participants reported hypertension the proportion of participants with major chronic conditions increased from wave 1 to wave 4 with the exception of those with osteoporosis both men and women showed similar trends of change in these characteristics from wave 1 to wave 4 as shown in table 2 the proportion of inperson social activity participation was higher in wave 4 than in wave 1 for all activities volunteering religious activities meeting friends and hobbies these trends were consistent in both men and women with the exception of volunteering in which more women reported participation in wave 4 whereas men reported no change additionally the number of participants in each change category by social activity type is summarized in figure 1 in all four social activities the majority of participants showed no change in participation from wave 1 to wave 4 this trend was consistent in both men and women regarding social networks there was a significant increase in discussion network size from wave 1 to wave 4 this increasing trend was consistent in both men and women however there was no significant change in network density from wave 1 to wave 4 men and women showed different trends in the change of network density in men the mean network density significantly decreased from wave 1 to wave 4 while no significant change was seen in women regarding healthrelated quality of life participants pcs scores significantly decreased from wave 1 to wave 4 in contrast mcs scores significantly increased from wave 1 to wave 4 these patterns of change were consistent in both men and women changes in healthrelated quality of life according to changes in inperson social activities we compared the changes in pcs and mcs scores from wave 1 to wave 4 among the four change categories in each social activity type in the category of meeting friends there was a significant difference in the changes in pcs and mcs scores f 4275 p 0005 f 2813 and p 0039 respectively those who had previously participated but had currently stopped participating in meeting friends showed the highest reduction in pcs scores among the four categories and this reduction was significantly higher than that of all other groups there were no other significant differences in the changes of pcs and mcs scores among the change categories for other types of inperson social activity in order to identify the differences in the changes in pcs and mcs scores by the change categories in meeting friends posthoc comparisons were performed using the bonferroni adjustment regarding the pcs the participants who reported yes yes reported a significantly greater increase than the participants in the yes no category participants who reported yes no reported a significantly greater decrease in pcs scores than the participants in the no yes category moreover participants who reported no no reported a significantly greater increase in pcs score than the participants who in the yes no category regarding the mcs participants who reported yes no reported a significantly greater decrease than the participants in the no no category to further explore whether there was any gender difference in the effects of meeting friends we compared the changes in pcs and mcs scores from wave 1 to wave 4 in men and women in women there was a significant difference in the changes in pcs and mcs scores among the change categories f 3997 p 0008 f 2808 p 0040 respectively the results of the posthoc comparison revealed a significantly greater decrease in pcs scores among female participants who reported yes no compared with those who reported no yes and no no the mean mcs score decreased in female participants who reported yes no whereas the score increased in all other categories there was a significant difference in the mcs score in the yes no category and those in the no no category among female participants discussion an important indicator of healthy aging in older people is the preservation of good physical and mental health while living in a familiar environment 41 in developed countries rapid industrialization has led to economic development and improved housing educational opportunities and public health access in urban areas 42 simultaneously however a rapid decline in the rural population has not only affected the agricultural labor force but also the typical family structure such as nuclear family configurations which may increase the risk of isolation and poorer healthrelated quality of life among rural older adults 42 this study provided insights into the longitudinal change of healthrelated quality of life and healthrelated quality of life among older adults living in a rural village in south korea longitudinal changes in healthrelated quality of life regarding the longitudinal change of sf12 scores in our sample both female and male older adults reported a significant change over four years participants reported a decrease in pcs scores and improvement in mcs scores comparing our findings on healthrelated quality of life with previous studies is challenging because of geographic diversity across the studies moreover relatively few studies have exclusively focused on rural older adults we tried to compare our findings with studies targeting communitydwelling or rural older adults in various regions our findings were similar to those of one study of communitydwelling older adults in korea by kim et al that reported a moderate average active aging score the authors also reported on the three subdomain scores of active aging scores on safety were the highest followed by health and participation scores 43 in contrast with our findings henchoz et al found that the score of all domains of quality of life including social and cultural life health and mobility and esteem and recognition decreased in communitydwelling older adults 30 further our results are not consistent with the findings of another previous study that reported that rural older adults might feel more loneliness and need for emotional support as indicated by reporting worse emotional wellbeing compared with the selfreport scores of urban participants 44 these discrepancies may arise from several sources for example living arrangements may vary due to both cultural norms regarding filial responsibility and differences in community services across the selected countries and contexts reflecting variations in the availability cost and quality of institutional care for older adults 43 future research should investigate the differences in healthrelated quality of life in older men and women between urban and rural areas with respect to the components of physical and mental health the average pcs score in our sample is slightly higher than that obtained in previous research 4546 while the mcs is similar to the average value for six european countries obtained using the sf12 46 this higher pcs score in our sample may be due to participants younger age and lower prevalence of obesity compared with the samples in prior studies obesity in the elderly can lead to chronic diseases and can affect daily life 47 further studies are needed to compare the impact of obesity on healthrelated quality of life across regions at the global level concerning gender differences our findings supported previous studies which reported a poorer healthrelated quality of life among women than among men 48 49 50 in the present study male older adults were more often currently employed and living with a spouse than female older adults in addition female older adults had a higher prevalence of chronic diseases such as hypertension hyperlipidemia arthritis and osteoporosis compared with male older adults working status living arrangement and multimorbidities may be associated with physical performance or mobility 51 mobility impairments might have decreased participants opportunities to participate in diverse social activities to better understand these results further investigation may be necessary to identify needs ongoing behavior patterns and barriers to mobility in rural older adults changes in pcs and mcs scores by types of inperson social activities importantly we compared the changes in pcs and mcs scores of sf12 for four years by types of inperson social activities in our sample meeting friends was the only social activity significantly associated with changes to physical and mental healthrelated quality of life ceasing to meet friends in wave 4 was significantly associated with the largest decrease in pcs score and a small increase in mcs scores this finding was in line with the result of a previous study which found that only informal social activities with friends were associated with increases or maintenance of life satisfaction 52 our result also aligns with a previous finding on the positive relationship between informal strong ties and subjective wellbeing 53 in addition this finding may support the results of previous studies which show that having multiple group memberships may lower the risk of functional disability and contribute toward maintaining mental health 54 55 56 interestingly our finding revealed a greater decrease in pcs score among female participants who reported yes no compared with those who reported no yes or no no furthermore the mean mcs score decreased in female participants who reported yes no while the score increased in all other categories there is a significant difference in the mcs score in the yes no category and the no no category among female participants however in men beginning to participate in meeting friends in wave 4 seemed to play a positive role in improving mcs scores but this improvement was not statistically significant lam et al argued that participation in multiple organizations is a psychosocial resource that protects older people from threats to their health due to changes in their social identity 57 a decline in an individuals social role due to advancing agewhich is one of the main changes in social identity later in lifemay lead to isolation therefore formal or informal social activities may contribute to improving an individuals healthrelated quality of life future studies are needed to investigate the gender differences in longitudinal changes of quality of life according to living arrangements and types of social activities in the present study over four years overall participation in social activities increased across all activity categoriesvolunteering religious activities meeting friends and hobbiesas did the social network sizes for both men and women this result was inconsistent with a prior study using national data in china which compared rural and urban older adults in that study urban older adults had better social activity support and reported better health status than rural older adults 58 moreover these findings are in line with the argument that engaging in informal social activities is resource demanding older adults are on average not only less healthy than middleaged adults but also have fewer cognitive and motivational resources that may enable them to get involved in activities which require major effort 59 recently one study reported that strong informal ties might increase subjective wellbeing among rural individuals 60 that is rural older adults may benefit more from informal strong ties such as visits with friends neighbors or relatives than urban older adults this may explain why rural older adults differ from urban older adults and younger adults with particular respect to engaging in informal social activities with friends 52 with this in mind it is important to take into account the advantages and disadvantages of living in rural or urban areas when studying the social interactions of older adults limitations our findings must be interpreted cautiously because we explored associations between change in healthrelated quality of life scores and change in selfreported social activity rather than examining any causal relationship between social activity and quality of life change four years may not be long enough to observe major change in healthrelated quality of life and social activities because of relatively less variability in population migration industry and lifestyle in the rural area further longitudinal studies with older adults with diverse age groups will help answer this question in addition regarding the questions asking about inperson social activity participation different answer options were used between wave 1 and wave 4 to resolve this difference collapsing categories were necessary for wave 4 data therefore interpreting our results needs careful consideration on the potential contribution from the different answer options in particular it is possible that older adult participants underreported or were unaware of memory problems which could lead to a measurement error in the longitudinal analyses because the selection characteristics of the participants in the followup interviews were clearly biased toward higherfunctioning individuals the relationships of primary interest were likely to have been attenuated selfreported data are subject to possible social desirability and recall bias and solely relying on such responses might exaggerate potential relationships lastly our data were from participants recruited from a single rural village in south korea and therefore could not represent the entire older adult population in rural south korea or older adults in urban areas conclusions our findings revealed that rural older adults who stop participating in social activities over the course of four years report a worsening quality of life compared with those who have never joined in social activities those people least likely to engage in social participation are likely to be the most vulnerable those with low income or who are frail the oldest among the elderly and those in poor health face the most barriers to social participation thus in rural areas health professionals should be more vigilant in watching changes in living arrangements and health in older people particularly considering the physical distance between health facilities and households in most rural communities for rural older adults who are able to participate in social activities investing in a rideshare program including going to the grocery store and the doctors office would be beneficial in addition the social aspects of sharing meals would be beneficial for rural older adults who live alone mobile and wireless technologies may offer the potential of increasing connectedness for rural older adults by overcoming social participation challenges future research is needed to explore the lived experience of aging among rural older adults to identify practical approaches to promote physical and social activity which may lead to improved overall health outcomes

during later life inadequate social interactions may be associated with worse quality of life in older adults rural older adults are prone to developing unhealthy lifestyles related to social activities which can lead to a poorer quality of life than that enjoyed by older adults living in urban areas this study aimed to describe longitudinal changes in social activity participation and healthrelated quality of life among rural older adults exploring potential associations with changes to inperson social activity over four years we used prospective communitybased cohort data from the korean social life health and aging project kshap collected between december 2011 and january 2016 the sample included 525 older adults who completed the measure of healthrelated quality of life our results showed a significant change in healthrelated quality of life according to changes in participation in meeting with friends even though an individuals participation in other social activities did not show significant differences in healthrelated quality of life our findings imply that inperson social activities may be an important resource to encourage participation in physical activities and to develop other positive outcomes such as a sense of belonging or satisfaction with later life among rural older adults

introduction cover photographs of mobilities books tend to depict shiny cars trains and planes or people in fast movement yet on the cover of after the car there is a rusty and defective car abandoned in a field seemingly discarded or forgotten it captures a future state where the system of cars has collapsed and cars will rust away and haunt western cities as vacant factories do in former industrial hotspots such as detroit and manchester rust and immobility here symbolize the fading power and allure of cars a more mundane and less futureoriented reading of dennis and urrys cover could accentuate the changing materiality and life cycle of all mobility designs while cars enter the streets as shiny and functioning design objects they will over time due to use and the weather become objects of wear and tear this process is speeded up if they are poorly maintained and parked outside such designs consist of materials that are in processof rusting decaying falling apart and becoming waste or of being repaired or conserved as edensor and strebel discuss with regards to buildings and gregson et al concerning domestic objects this is not necessarily a sign of system failure but of productivity and presence on the street a predictable byproduct of any successful mobility system is the wearing down of oncedesired fashionable shiny and useful objects as well as repair attempts to mitigate this process yet we argue that mobilities scholars have largely ignored the organic materials that constitute such designs how they break down and become waste especially if they are not subject to repair work and maintenance work finally the covers stillness intrigues us mobility designs have mainly been analyzed as designs that mobilize people and cities mobilities book covers as noted depict movement a partial exception is the new routledge handbook of mobilities with its empty train wagon seemingly garaged it looks newly cleaned or perhaps it awaits repair and yet none of the twentyfive chapters in the handbook explores parking maintenance or repair in particular cars and bicycles routinely spend far more time mooredparked and spatially fixedthan on the move the spaces and politics of parking and waiting are strangely neglected in the mobilities literature and beyond the mobilities literature is not blind to stillness it has eyes for erratic turbulences such as abnormal weather conditions flooding hurricanes and heavy snow disrupt the ordered flows of mobilities causing delays accidents and disruptions major turbulences include hurricane katrina in new orleans in 2005 the icelandic ash clouds in 2010 that for a week or so shut european airspace and sent disruption rippling worldwide see special issue of mobilities 6 and the storm off the south coast of england in 2007 that grounded a container ship on the beach less discussed are those smaller turbulences that recurrently affect everyday mobilities cars and bikes from time to time run less smoothly and break down because of rusty chains flat tires defunct motors and so on they are immobilized and await repair work thus we argue that the material life and stillness of mobilities need to be analyzed in a previous article one of us has explored designs and practices of parking bicycles in copenhagen amsterdam and new york two striking features of that fieldwork were firstly the sheer number of parked bikes on pavements and secondly that many of them were rusting broken stripped and vandalized in the present paper we document and analyze ethnographically such unstable neglected and halfdead bikes in copenhagen as we encounter them in racks on the pavement and when the municipality attempts to clear them out we are inspired by aldred and jungnikels observation regarding english cites a common theme was concern about the bicycle when not in use bicycles at rest were perceived as threatened or threatening risky or atrisk affected by theft vandalism the weather official and familial disapproval based on our field study in procycling copenhagen we add that parked bicycles are endangered by and become waste because of a lack of and interest in professional and diy repair and maintenance as much as theft and vandalism this is a general problem in copenhagen although it is most apparent in densely populated neighborhoods with many smaller flats and younger people in doing so this paper offers new insights about the unstable materials and lives of bicycles as everyday objects cycling is normally conceived of as a sustainable and environmentally friendly practice but this study shows that many bikes are ill treated and quickly become waste and matter out place on the pavements in what follows we begin by discussing relevant research about the lives of consumer objects waste and maintenance work this informs our ethnographic vignettes from copenhagen on its many mistreated vandalized and seemingly forgotten bicycles so this paper largely excludes wellmaintained and expensive bikes parked inside flats and basements see bradtberg and larsen for an account of such bicycles in copenhagen the lives of consumer objects we are theoretically informed by ideas that see consumer objects as becoming and having a social and material life beyond their initial production and sale they have a social life as and when people invest identity and emotions in them over time especially when they are bought used regularly and later discarded some discarded objects gain a new lease of life if recycled passed on to friends or sold at charity shops at flea markets or on the internet they have a material life as they break down and stop working they are unstable and aging prone to scratches general deterioration and becoming obsolete crang calls this the negative unbecoming of things design objects are not things but a complex assemblage of many separate materials skilfully assemblaged as a unified design bicycles for example are made from numerous materials including plastic iron and steel and rubber and consist of countless components such as frames saddles wheels seat posts handlebar grips head tubes brakes spokes hubs rims tires seat stays chains front derailleurs chain rings chains pedals crank arms cogsets rear derailleurs mudguards baskets locks lights and much more however when living rough on the street the materials of assemblages are constantly becoming as elements are broken or stolen this reading of objects as assemblages implies that over time design objects such as bikes can mutate and become something else when for instance existing parts are broken or replaced assemblages as edensor points out are never stable closed and secure black boxes although the constituent elements of a heterogeneous assemblage are enrolled to stabilize and order space and materiality they are susceptible to entropy and disordering this unbecoming is also seen when waste is discarded and the very materials of things are scrapped and recycled such a theoretical framework allows us to take bicycles seriously as material objects and explore their complex lifebiographies as energyintensive and polluting consumer objects that are designed in the west and produced in china or elsewhere shipped to the west and sold as shiny commodities in local shops as everyday objects that are used maintained and repaired but also subject to wear and tear neglect vandalism and theft as discarded rubbished and stripped objects living neglected lives in racks and streets as disorderly wasteobjects that require costly removal by municipality maintenance staff and later scraping as secondhand gifts passed on to friends and family or charity or sold cheaply at carboot sales and charity shops or expensively at highend secondhand shops and markets as stolen goods when bikes or parts of bikes are stolen for private use resale or in the assemblage of new bikes as discarded and deassemblaged materials that are scrapped and reused in the production of new designs waste the above list highlights ways in which objects can become discarded and wasted research increasingly highlights how mobilities are great producers of pollution and waste this can be illustrated with virtual mobilities eg emails and photo callsthat are not as sustainable as first imagined electronic waste as graham and thrift write is the fastest growing segment of the overall waste stream mobile phones computers etc are resource intensive to produce and many kilos of hidden resources go into their production they depend upon scarce minerals located in conflictridden countries like the congo where they have fuelled war crimes and violations of human rights they are producedlike most other consumer objectsin distant places in the east and their transportation depends upon massive container ships which consume a great deal of fuel the internet and gadgets consume electricity and generate mountains of ewaste which again consume energy information technology is responsible for roughly the same amount of global co2 emissions as all the aircraft companies combined namely around 2 to make things worse they are used only for short durationsless than a year for mobiles consumer objects are increasingly designed to have short lives so that new designs can be purchased they break easily foreclose repair and update poorly while a constant stream of new models makes existing ones appear outdated and unfashionable almost overnight this is planned obsolescence and is linked to the intensified production of consumer desires of a speededup capitalist postmodernity where we are victims of the morbid cycle of repetition novelty and death as bauman writes the society of consumers devalues durability equating the old with being outdated unfit for further use and destined for the rubbish tip it is by the high rate of waste and by shortening the time distance between the sprouting and the fading of desire that subjectivity fetishism is kept alive and credible despite the endless series of disappointments that it causes the society of consumers is unthinkable without a thriving wastedisposable industry consumers are not expected to swear loyalty to the objects they obtain with the intention to consume what bauman calls wastedisposable industry is discussed by geographers such as moore davies crang and gregson et al they explore the material and economic afterlife of waste across different spatialities waste is not necessarily final and fixed for instance gregson et al follow ethnographically endoflife containerships that are sailed to beaches in bangladesh where they are disassembled or unmade things deemed valuable are recycled in local furniture businesses while the ships themselves are scrapped and sold as steel scrap this is part of a wider offshoring where waste is both a burden and an economic resource even the abandoned car discussed in the introduction will probably be scrapped to extract the steel and aluminum and be recycled in new objects see moore for a general review of different geographical approaches to understanding waste however discarded or unwanted western consumer goods also gain new economic vitality and lease of life when they are passed on to friends and family members or sold as secondhand goods in charity or vintage shops studies of secondhand cultures show how things can move in and out of a commodity state through their lives contrary to the idea of a throwaway society many things are recycled and kept as throwing out useful things is considered at least by some as amoral and wasteful and it can be heart breaking to discard objects or home possessions of affection no matter how outdated in their research gregson et al find that whilst people certainly did get rid of consumer objects via the waste stream they also went to considerable lengths to pass things on hand them around and sell them and just as often quietly forgot about them letting them linger around in backstage areas such as garages lofts sheds and cellars as well as in cupboards and drawers so many outdated objects are not properly binned but live halfforgotten and semiwasted lives backstage yet they may be rescued from binning by lingering backstage this may be the case with large vinyl collections and photo albums that are out of place in many digital family homes people are not only throwing out waste but also living with their own and especially with other household members semidiscarded objects that cause clutter and dust maintenance work another wastedisposable industry is maintenance work graham and thrift critique social theory for focusing upon systems that work maintenance and mending are equally crucial because systems and things decay break and fail all infrastructural systems are prone to error and neglect and breakage and failure whether as a result of erosion or decay or vandalism or even sabotage indeed many such systems are premised on a certain degree of error or neglect or breakage or failure as a normal condition of their existence graham and thrift note in particular how things and cities day in and day out decay a little being exposed to all sorts of human and nonhuman practices pollution wildlife and weather things are always becoming and in the process of decaying if unmaintained they will sooner or later become waste as edensor shows with regards to industrial ruins so graham and thrift argue that the world is involved in a continuous dying that can only be fended off by constant repair and maintenance edensor notes how a building with reference to an old church is simultaneously destroyed and altered by numerous agencies and stabilised by repair and replacement building material the church is constantly in a process as various humans and nonhuman agentsfor instance the weather and insectsact upon its stony fabric without careful and meticulous maintenance and repair the church would deterioratelike the much younger industrial sites and the car in the field while set in stone a church requires nursing to remain alive maintenance and repair work are thus part of an ordering project aimed at maintaining designs at their peak and clearing them off when deemed waste once defined as waste designs become matter out of place that undermine order decaying industrial sites are when seen through the prism of order disorderly ruins social spatial and material order requires continual maintenance so far we have discussed maintenance and repair of big designs what about everyday designs professional repair is in decline because of high labor costs the cost of repair sometimes exceeds the price of a new objectmodel diy repair is probably also declining because many designs foreclose repair yet gregson et al argue that in a very real sense object maintenance drives the consumer world much as graham and thrift have argued that it constitutes the city they examine the repair and especially maintenance work that individuals perform when dusting vacuuming and cleaning cherished home possessions these practices endeavor either to keep consumer objects in or return them to their pristine state to freeze the physical life of things at the point of acquisition and to mask the trace of consumption in the object maintenance and repair work can also be a source of improvization and innovation this is seen when people or professionals upgrade designs or restore vintage designs such diy repair requires competences and interest in doing such work inspired by the discussions above in what follows we explore the social and material life of bikes in copenhagen in other words how are parked bikes treated in this iconic cycling city we are particularly interested in examining how copenhageners treat their own and others bikes by attending directly to the very materials of bikes and their assemblages as well as their constant becomings and unbecomings our analysis is based on a twelvemonth ethnographic study comprised of observations visual documentation and interviews with cyclists and municipality staff the study took place in vesterbro a gentrified residential neighborhood where cycling is very common and also where the central main train station is situated we focused our study on bicycle parking areas located just outside the main train station as well as on eight smaller residential streets some of which have smaller shops and supermarkets in two different parts of the neighborhood on each of these streets we observed filmed and photographed bicycles and in particular their vital parts and materials oiled and driedout chains rock hard and flat tires rusty parts and broken and missing bits these observations are complemented by thirtyfive short interviews with ordinary cyclists at parking racks at the main train station and a nearby supermarket the interviewees were recruited on the streets as they parked their bikes and were offered anonymity as part of their participation the interviews revolved around bike ownership emotional attachment to bikes and practices and competences of maintenance and repair following this discussion is a vignette that illustrates how the municipality of copenhagen regards the many halfdead bikes as disorderly waste and undertakes laborious maintenance work to remove them inspired by ethnographies of thingsasmaterials and waste disposable industries we follow bikes as the municipality removes them from the streets of vesterbro this takes us down the value chain to the scrap sites where most of these bikes end their lives as scrap metal and up the value chain or waste hierarchy at police auctions where the most valuable bikes are auctioned we have interviewed and exchanged emails with the municipality officers in charge of this operation and have on two occasions traveled along with the municipality team as they taped removed and disposed of bikes from the streets of copenhagen the municipality has provided us with statistics about how many bikes they collected recycled and scrapped from 2008 to 2012 bikes in copenhagen small bike shops selling and repairing bikes are everywhere in copenhagen with less than 150 m between them in one particular neighborhood many larger supermarkets sell cheap bicycles they all sell a mix of danish and international brands but they all have considerable carbon footprints a mere 2800 bikes were produced in denmark 2012 this compares with 105 000 in 2007 which reflects a global trend with most bikes being produced in china or other lowwage countries there are no available statistics about the average price of bikes sold in copenhagen but they seem to cost between £350 and £600 less in supermarkets and more in racer cycle shops by danish standards this is not a fortune especially compared with cars that easily cost around twenty to thirty times as much there is a striking contrast between observingespecially parkedbicycles in bike shops and out on the streets of copenhagen their shiny newness of polished surfaces and intact pieces evaporate and mutate into rust scratches dirt and missing parts this deassembling even characterizes newishlooking bikes premature ageing haunts surprisingly many parked bikes in copenhagen they look generally speaking neglected compared with the neighboring cars so neatly parked and maintained many bikes have ingrained dirt driedout or sloppy chains rusty parts scratches semiflat tires and missing broken or bent parts passersby use bike baskets especially on trashy bikes as garbage dumps if cigarette packets cans and greasy junk food paper are not removed immediately the bike will soon mutate into a garbage tip few seem to care much about their own or others bikes this woeful state of bikes in copenhagen is partly the result of cheap materials that easily rust and break but they are also systematically mistreated and vandalized by various human and nonhuman agencies that act upon the very materials of bicycle assemblages one such agency is insufficient and poor parking cycle racks are designed to produce an orderly space with rows of bikes neatly placed next to each other yet every so often chaos reigns one inherent design problem with grid racks is insufficient wheel attachment and support this causes turbulence with bikes falling when touched by the wind or a parking cyclist this triggers further turbulencea domino effectwhere one falling bike takes down several others a notorious shortage of grid racks in copenhagen only aggravates this problem bikes are bent broken and scratched the widespread use of stand props also causes turbulence they conveniently provide ubiquitous parking without leaning against or being supported by a rack or street furniture right at the destination the downside is that they are easily tilted and knocked over walking often implies avoiding fallen bikes for more on this see larsen the weather is another destructive nonhuman agency rain and snow cause rust and both weather conditions prevail in copenhagen visible rust outbreaks are seen on most metal parts of parked bikes eating them from outside in especially in all the scratches theft is a negative human agency stripped bikes without pedals or gears or wheels or handlebars or even frames haunt most bicycle racks and they are always at the mercy of a new round of bike vultures locks and wheels are likely to be damaged during theft and a bike is thrown somewhere when the opportunistic thief no longer needs it or feels remorse bike theft is much more common than car theft and almost all the interviewees had experienced it indeed this was the major reason for buying their present bike their old bikes were not worn out or needing replacement the risk of theft discouragesd the interviewees from investing in highquality bikes and maintaining and becoming attached to their present bikes another destructive human agency is that of treating pavements and racks as spaces of storage and refuse garbage is never placed on the pavements in denmark in contrast to many cities for instance melbourne where there are weekly kerbside collections from bins garbage belongs in designated backstage areas out of sight and smell yet many parked bikes seem to be forgotten or misplaced by their owners literally in the process of decaying and becoming waste perhaps people are not quite ready to bin their bike or they cannot be bothered to throw it away properly they linger on the street similar to as pointed out by gregson et al semiforgotten things in garages lofts sheds and cellars arguably however the major destructive agency is lack of maintenance routines and skills our interviewees put hardly any effort or pride into bike maintenance several said that maintenance would only make theft more attractive see similar findings by aldred and jungnickel the interviewees did not talk about practices of polishing and washing bikes or diy and craft skills as watson and shove noticed in relation to home improvement and there are no systems for bike maintenance such as car washes at petrol stations nor compulsory mot tests for ageing cars few talked about having basic diy bike repair skills most visit a bike shop around the corner for smaller repairs such as a flat tire given the high cost of such repair work few invest much in repair in a cheap shabby bike when a new bike is only marginally more expensive however according to interviewees the lure is not the latest version but a rather a new version of the same or a similar bike bikes are in this respect less victims to planned obsolescence than are mobiles and laptops as one middleaged woman said when she was asked what was wrong with her old bike since she had bought a new one it got stolen i had the same model before but it got stolen so i replaced with the same model many interviewees have detached relationships with their bikes which are just bikes that might be wounded or even gone by tomorrow little money emotion and maintenance are invested in such ordinary bikes as one woman said i have a bicycle from kvickly a danish supermarket because i got tired of having bikes stolen all the time they were much nicer another stated that she had bought her present bike because it was cheap so that it wouldnt get stolen they are means of transport and have little identity or lifestyle value because the wider environment makes it difficult to develop such a relationship this is in contrast with many home possessions that are much easier to protect and therefore develop affection for over time all these agents in combination cause an ongoing stream of smallscale turbulences and spatial disorder that produce abandoned immobile and ownerless bicycle in great numbers moreover they illuminate their unstable nature these agencies destabilize and mutate bicycle into discrete materialseven before they are scrapped observing such notyetendoflife bicycles show that they are not just singular objects but simultaneously multiple heterogeneous things and materials the 650000 bicycles in copenhagen means that a great deal of parking space is needed and streets and racks brimming with bikes are the reality today this overcrowding represents a practical planning problem of waste and matter out of place abandoned immobile and ownerless bikes disturb the smooth running of things the copenhagen municipality estimates conservatively that 40 000 bicycles are abandoned every year on the streets courtyards and racks the bikes also to some degree become objects of irritation amongst cyclists and pedestrians blocking pavements and exits bikes also mobilize irritation because they ruin the clean image of both cycling and copenhagen abandoned bikes may not smell and be a health hazard but they look trashy and disorderly trashy bikes on pavements are simultaneously in place and out of placesimilar to say outofdate food in a fridge they are wasting loudly on their own frontstage abandoned bikes are a waste problem and a space problem calling forth maintenance work according to the municipality this reflects more broadly that waste is political and a becoming process between matteroutofplace and matterinplace we turn now to how the municipality collects dead bikes in practice the process is similar to the manner in which bikes are collected in train stations and from below by private flat owners in the communal spaces of apartment buildings in short everyone must follow the police guidelines surrounding the collection of abandoned bicycles for another study of collective clearing out from below see pikner and jauhiainen maintenance work the municipality spends according to the municipality officer responsible some £240000 annually on a special bike refuse unit which is separated from other garbage and maintenance duties between 2008 and 2012 the municipality has collected some 6426 bicycles yearly on average according to its own spreadsheets in addition to the municipality the train company dsb and the police collect 16 000 bikes a year there is thus a steady flow of new bike waste the municipality estimates that 1012 of all bikes found in public are abandoned yet the cultural and legal status of the bike in copenhagen makes this maintenance work difficult time consuming and ineffective first as argued many bikes in copenhagen are marked by wear and tear lacking repair and maintenance it is difficult to detect whether a bike is abandoned or not the bikes do not reveal their social biography second by law bikes are untouchable it is illegal for shop owners and others to remove bikes even if they block shop windows or façades not even the municipality is allowed to remove a flyparked bike from say the pavement to a nearby rack or to bin a rusty bike however from march 2013 it was permitted on a trial basis for authorized municipality personnel to remove bikes to a nearby place if the bikes were blocking emergency routes and passages yet the municipality is still obliged to inform the owners where they can pick up their bikes bikes are largely protected and freeriding objects on the pavement this is unlike most other abandoned objects that are subject to immediate removal not even cars have the same protection as bikes car parking is strictly regulated through payment time zones parking signs parking meters traffic wardens and rules about parking and fines cars with no or invalid tickets will be fined and eventually clamped the owner can be tracked down due to the personalized registration of cars in contrast cycle parking is unregulated and free of charge and bike ownership is not registered although by law all bikes sold in denmark have to have a unique serial number engraved into the frame the bike is not registered with the authorities a bike cannot be traced to the owner how then does the municipality go about cleaningout and recycling dead bikes analytically we divide the work into preparation identification separation removal and afterlife preparation maintenance work involves planning the renovation teams longterm planning involves ensuring that they systematically clear exposed locations such as train stations every few months and different neighborhoods yearly or every second year in between it does more ad hoc collections at notorious spots we focus here on the planned systematic clearance detailed maps divide neighborhoods into manageable areas of some twenty streets these units are then given a timeframe of five weeks to be cleared when an area is next on the schedule an employee cycles to the area and hangs posters on all the doorways these inform residents that this street will be cleaned of dumped bikes and the remains of bikes copenhagen municipality would like to make an effort so that your neighborhood appears at its bestas a cosy and tidy place therefore we will clear out bikes in the area marked on the map the poster describes how all bikes will be taped with yellow tape from a specific date residents are asked to remove the tape from theiror their holidaying neighboursbike if still in use the municipality promises residents that the maintenance work will have a positive outcome for their neighborhood it will become a cosy and tidy ordered place however the poster says nothing about recycling and it is evident that such bikes are not regarded as a potential resource we also see that the municipality distinguishes between and targets different bike assemblages as part of the garbage work namely dumped bikes and bike remains the former can in principle be a new and working bike which does not look like trash yet it makes sense to include the former because as discussed above many working consumer objects are prematurely discarded moreover many stolen bikes are not sold but dumped when no longer needed this procedure reflects the fact that the law states that everyone needs to give four weeks notice before they can legally remove bikes it also reflects a concern within the municipality we are told by refuse collectors that disposing of bikes that are still being used and valued by the rightful owners jeopardizes the legitimacy of the project it would so to say turn the municipality into a thief the posters and tape minimize that risk identification the employee indiscriminately fastens yellow tape around every single bike one after another a 200300 m long street can easily hold several hundred bikes and to tape each of them takes hours staff bend a little forward and tape together one of the wheels and mudguard with some narrow yellow tapes with the municipalitys logo this is a clever design that automatically unseals when used independently of whether the owner notices it or not if the tape is broken the bike will be regarded as in use whereas intact tape is the indicator of bikestobewasted this is taken as a sign that it is either immobile orand ownerless the waste status of these bikes is a spatialtemporal one they are still in the same place for more than four weeks this challenges ideas that disposal and waste are purely spatial categories the inbetween period slowly during the four weeks there are fewer and fewer taped bikes in the streets this is according to the script if they are released through use however the tape can break against the script some may remove the tape from their stationary nonworking bikes because they plan to repair them one day youngsters may remove the tape as a prank therefore immobile bikes will most likely still occupy soughtafter space after clearing at the end of the period a taped bike may encourage theft especially those bikes that are already unlocked due to recent theft some may find such theft legitimate since the bike is going to be scrapped anyway in fact they keep the bike alive by stealing it or some vital organs one of us for example fell in love with a beautiful 1970s european racer that with a good dose of repair and some new parts could become a real vintage beauty having been taped for four weeks it was destined for scrapping the night before clearance it disappeared this reflects the fact that vintage bikes from the 1970s and 1980s are fashionable amongst cool young people clearly this was not the only soontobediscarded bike that was scavenged during those four weeks this is despite the fact that it is illegal and might be stolen property lanes study of hard rubbish collections on pavements in melbourne showed that 35 of stuff was scavenged prior to collection by the municipality however while the melbourne residents were a little unsure if the practice was actually legal or not pavements and nature strips are regarded a legitimate place to acquire stuff during the announced period and there was no fear of acquiring stolen property or committing a crime on the announced day of the actual clearing five weeks after the notice most tapes will have been unsealed to our surprise the tape had disappeared on many many poor and even scrapworthy looking bikes separation and removal after five weeks the actual disposable work can begin this phase can be further divided into a recycle and scrapping phase based on our observations as we traveled with the refuse team one of us wrote first employees trained in bike mechanics walk the streets assess and pick those bikes with the recycle exchange potential of making at least £60 at a later auction these selected bikes are registered manually in a digital tablet system only functioning and intact bikes are selected while valuable and functioning parts are overlooked we are told that it is not worth picking less valuable bikes or parts due to the expenses involved in handling them most bikes are not worth around £60 after living rough on the streets of copenhagen we observed that most bikes to be scrapped were inexpensive supermarket bikes or middlerange brands victims of what appeared like a few years of wear and tear even fairly new supermarket bikes were snubbed not deemed worthy of moving up the value chain unless in perfect condition moreover many functioning parts that could easily become vital cogs in a new bike assemblage are relentlessly overlooked and head to the scrap graveyard the chosen few deemed fit for reuse are then driven to a storage facility where are they are immobilized for another four weeks of waiting all the remaining bikes are indiscriminately destined for scrapping we were initially surprised to realise that the vast majority are considered nothing but waste clearly many of them are in very poor condition but equally many are little or no worse than many inuse bikes with a little maintenance and repair many would even be in a better state than most other streetresiding bikes furthermore our observations suggest that few of these bikes are unlocked or appear to have been stolen based on the state of their olocks the common lock in copenhagen this suggests that many abandoned bikes are neglected and forgotten rather than stolen goods then an employee registers all the taped bikes in a tablet this is partly to keep track of the overall work and partly to organize the forthcoming removal then the renovation team arrives on one of the following days with a lorry to pick up the many registered bikes taking one street after another the diary extract below gives a sense of how clearing takes place at a small residential street where most bikes are parked with stand props or by leaning against house façades the tablet states that on the next street there are a handful of bikes awaiting removal just enough to fill the load the driver navigates the oneway streets turns the corner and scouts after bright yellow tape signalling us to stop five bikes stacked together are spotted this is a few less than the tablet says they must have gone missing they are loaded onto the back of the lorry in a matter of minutes and this is despite the fact that they are all locked the many bikes with olocks are simply lifted by the back wheel and rolled onto the lorry these locks are so easily undone by a human hand the few bikes that are moored to something with quality ulocks or chains it turns out are almost equally impotent when facing a professional bolt cutter they are lifted within seconds i count twentyfive bikes on the lorry now then we inspect the whole street by foot to make sure that we do not miss some another four bikes are found and they are squashed in together with twentyfive other bikes the pickup request is cancelled on the tablet and it is updated with the number of bikes collected we leave the street and drive directly to the scrapyard clearly this work has some cleansing effect when we inspected the streets some days later the pavements look less messy crowded and haunted by trashy bikes although it has not entirely eradicated the problem interestingly there was less general garbage as the municipalities sweeping machines could better traverse these streets afterlife as mentioned the collected bikes destiny is recycling or scrapping the unlucky ones are driven directly to the scrapyard on the outskirts of copenhagen where they are brutally smashed together with cars and other metal waste brutally as they are not examined for valuable and reusable parts these bikes end their lives as mixed scrap that is shipped abroad and remelted in countries such as turkey vietnam and india the head of the scrapyard tells us the payment that the municipality receives in returnaround £12000is symbolic and covers only of 45 of the expenses connected with the clearance this is despite the fact that 975 of the collected bikes are turned to scrap metal and only 25 are reused the tobe recycled bikes have to wait another four weeks before they can be sold at the police auction this is in case a rightful owner calls for his or her bike and to check whether any has been reported stolen if a bike has been stolen it is reunited with its owner or handed over to the insurance company if the insurance payout has already been made the unstolen and unclaimed bikes are then sent to popular police auctions open to members of the public hunting for a good bargain secondhand cultures are often driven by thrift by more rather than less consumption at the auction we attended a few hundred bikes were sold at an average price of £88 bought by private buyers for their usevalue and by bike shop owners for their exchangevalue after a bit of repair work the bikes will be resold and thereby reinjected into another cycle of exchange and use on the very streets from which they had previously been removed conclusion the copenhagen bicycle system is applauded worldwide for highquality elevated cycling lanes this procycling city has more kilometers of cycling lanes than any other big city moreover they are well maintained and not plagued by potholes and vanishing painted lines as is common in new york and london yet as graham and thrift argue even wellfunctioning systems are prone to errors and neglect in this paper we have argued that the bicycle system in copenhagen because of its many neglected halfdead abandoned and wasted bikes is no exception we argue that generally speaking many bikes in copenhagen are treated as inferior and disposable objects that live rough on the streets consumer objects are always unstable and unbecoming yet this process is speeded up in copenhagen with regards to bicycles this is caused by a combination of inadequate urban design lack of maintenance and repair weather conditions and cheap bikes with poor materials a vicious combination of poor parking design and theft discourages investment in quality bikes and becoming attached to them this means less cycling neglected bikes do not afford a smooth fast or long ride this in part explains why longer commuter journeys to and from copenhagen are rare cycling more usually applauded as a sustainable form of transport can also cause co2 emissions clutter in the streets and waste this we have argued is not because bikes are victims of the whims of fashion and planned obsolescence but rather because many people ride cheap bikes that are insufficiently maintained and repaired and often replaced with a new cheap model within a few years we have paid particular attention to the municipalitys attempted ordering of the perceived disorder and waste around bikes this maintenance work is slow challenging and expensive order is never maintained for long stolen and halfdead bikes quickly haunt the stands againthese are bikes that are going nowhere and are woefully heading towards the garbage tip as edensor says more generally systems of disposal are rarely perfect and matter is often more difficult to eradicate than is imagined very few of the collected bikes or bike parts are recycled there is more concern with getting rid of dead bikes than with giving first aid and saving functioning organs this is in part because the law prevents people from scavenging unclaimed bikes and the municipality from giving away the collected bikes we end by proposing that a truly cyclingsupportive and sustainable city should not only be known for its cyclingfriendly environment but also by adequate parking little bike theft goodquality bikes secondhand and vintage bike cultures diy repair and maintenance skills and affectionate bike owners who treat their own and each others bikes with respect in this light copenhagen is not yet a truly great cycling city

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introduction one thing that has an important role in communication is language and with language one can communicate with one another people use language to communicate either directly or indirectly nowadays people can not only communicate directly or face to face with other people they communicate with but can also communicate in cyberspace or through social media such as whatsapp instagram twitter facebook line etc according to erza the way of communication through social networks has become a phenomenon recently and one of the most popular social networks is instagram instagram provides various kinds of features that can allow users to post their uploads and provide comments on other users uploads according to blair and serafini instagram is a social network based around sharing pictures and fifteensecond second videos which can be posted to other social media sites with instagram reels users could upload longer videos in commenting on uploads to an account instagram users can use language freely either polite or impolite language because instagram has no feature that can filter comments given by its users even though today users could set a warning message in their post for other people to use proper language when commenting instagram users commonly follow accounts according to their interests through this social media they can exchange information posting pictures and short videos following celebrities or influencers promoting products sharing informative or education contents and many others followers commonly give comments to express their admiration like dislike and disappointment towards an account they follow sometimes they find mistakes and take out their frustration on instagram accounts through comments however not all expressions used by instragram users are appropriately polite they leave inappropriate comments on the account that is impoliteness this study distinguised between rudeness and impoliteness the former is the use of offensive language that is unacceptable in a particular social contexts the latter is a language phenomenon that commonly contains a negative meaning because it is intentionally used to attack the targeted person or institution the study of impoliteness was pioneered by culpeper in 1996 in which he examined impoliteness used to attack army recruits culpeper proposed impoliteness strategies as the opposite direction to brown and levinsons politeness in another study culpeper defines impoliteness as a mental attitude held by a participant that is comprised of negative evaluative beliefs about specific behaviour in a specific social context as well as the activation of that attitude by those specific social in context behaviour according to culpeper impoliteness is a disapproving attitude toward particular actions taking place in particular circumstances expectations goals andor beliefs about social organization namely how one persons or a groups identities are mediated by others through interaction serve as the foundation of impoliteness disrespectful behaviour like impoliteness is supported by expectations desires and or beliefs about certain values in foreign language learning impoliteness has been studied in its forms and strategies one of the studies examining impoliteness in foreign language learning is impoliteness in efl for example impoliteness in foreign language learners complaining behaviours across social distance and status levels in addition to foreign language learning impoliteness is examined in film such as research conducted by yusniati entitled impoliteness strategies found in akeelah and the bee movie impoliteness is also examined on various of social media such as impoliteness on instagram used by haters of lady gaga impoliteness strategies used in a politicians facebook by halim on youtube impoliteness was studied by arrasyd and hamzah entitled impoliteness strategies in you tube comment section found in indonesian presidential debate 2019 the purpose of the current research is to continue the research conducted by apriliani but with a different focus and research questions in the previous research the researcher only focused on the types of impoliteness strategies used by haters while in the current research researchers did not only focus on the types of impoliteness strategies but also explored emotions expressed via impoliteness by haters the researchers studied the impoliteness used by haters through comments on the fifa instagram account there are several reasons the researchers studied the impoliteness used by haters on this instagram account first instagram is one of the most popular social media and almost everyone uses instagram second there are many comments using impolite language that haters use on instagram as a form of their disappointment third fifa currently has become a trending topic on instagram among football fans because of its controversial decisions many people are disappointed as fifa did not put sanction to israel when israeli soldiers fired tear gas at a football match in palestine haters has assessed fifa of having a double standard against israel the impoliteness used by haters on fifas instagram comments was examined the following is an example of a comment from a hater using impoliteness on the fifa instagram fsssaaammm double standard when two different parties make the same mistakes the treatment they get is also different the excerpt above shows that a hater used impoliteness to express his disappointment with fifas decision that is considered to have double standards against the israel football team this is because fifa gave a different treatment to israel in the 2022 world cup the russian football team was banned from competing because the russian government attacked ukraine while israel was still able to take part in the 2023 u20 world cup even though the israel army attacked palestine during the football event in palestine this made the haters furious because they felt that fifa made an unfair decision literature review pragmatics impoliteness is a language phenomena that relates to the use of a language as intended by its users commonly studied under pragmatics according to mey pragmatics studies how language is used in interpersonal communication which is influenced by social norms according to yule pragmatics is the study of the relationships between linguistic forms and the users of those forms only pragmatics allows humans into the analysis in this threepart distinction meanwhile according to levinson the study of pragmatics focuses on how language interacts with the context in which it is used to express meanings by language users in short pragmatics is a branch of linguistics that studies the relationship between the external context of language and the meaning of language through the interpretation of the situation in which the language is used by its users in other words pragmatics is a branch of linguistics that studies speakers meanings or intentions based on the context of the situation at the time of the speech occur in the present study the intention of speakers was examined under the use of impoliteness impoliteness in a simple definition impoliteness is the opposite of politeness and it is intentionally conducted expressions that are included in the politeness generally support the face meanwhile the impoliteness strategy is against it according to bousfield impoliteness constitutes the communication intentionally gratuitous and conflictive verbal face threatening acts which are purposefully delivered unmitigated in context where mitigation is required andor with deliberate aggression that is with the face threat exacerbated boosted or maximized in some way to heighten the face damage inflicted culpeper stated that impoliteness strategies refer to the approach to attack face want whereas politeness strategies refer to the way to assist or redress face want impoliteness appears as a form of emotional outburst against hatred expressions of impoliteness also emerges because of the urge to vent frustration culpeper has classified five types of impoliteness strategies namely bald on record impoliteness positive impoliteness negative impoliteness sarcasm or mock politeness and withhold politeness the following is a detailed explanation of the types of impoliteness strategy based on culpeper bald on record impoliteness this strategy is used to attack someone directly without considering the interlocutors face culpeper states that ftas are conducted in a direct clear and facethreatening manner in an unambiguous and concise manner this strategy occurs because the speaker deliberately does not want to maintain good relations with the interlocutor an example of bald on record impoliteness is shut up you dumb this sentence is said directly and frankly in an unambiguous way that makes the sentence considered as bald on record impoliteness positive impoliteness this strategy is designed to be destructive to the desire of the positive face of the interlocutor the purpose of this positive face is the desire of each individual to be respected valued and also needed by others several substrategies in positive impoliteness include ignoring others rejecting disassociating from others being disinterested unconcerned making others uncomfortable an example of positive impoliteness is no keep away go home we dont want you this utterance is a speakers rejecting of the interlocutor so that the sentence is considered as positive impoliteness negative impoliteness the use of this strategy is to destroy the desires of the interlocutor negative face or attack the interlocutor negative face several substrategies or outputs on negative impoliteness include frighten condescend scorn or ridicule be contemptuous do not treat the other seriously be little the other invade the others space explicitly associate the other with a negative an example of negative impoliteness is babyish isnt it the term babyish is used to express scorn at someone so it is considered as a negative impoliteness sarcasm or mock politeness sarcasm can be used to contrast the meaning of someones feelings towards something the intended meaning is in contrast to the polite intention through this strategy the speaker use politeness language but with impolite purposes in other words via this strategy politeness is used by speakers to generate impolite meanings this is included in the impoliteness strategy because the speakers are not really sincere with what they say an example of an utterance with sarcasm is when someone talks to the interlocutor if today is a good day but in reality that the day is a bad day in case of impoliteness the sarcastic utterance is to attack other interlocutors withhold politeness withholds politeness occurs when the speaker does not carry out the politeness strategy desired by the listener or is silent in other words it is situation that a speaker has to show politeness as commonly required but in fact heshe does not provide it this is considered as intentional impoliteness for example when someone has been helped by another person but the person being helped deliberately does not express gratitude it is considered as withhold politeness therefore being silent and failing to thank are the realization of this strategy impoliteness can be induced by some factors culpeper reported that unequal social power intimacy and a conflict of interest could provoke impoliteness people with more social powerful tend to use impoliteness to those with no social power those who have close relationship also tend to do impoliteness conflict of interest is the commonest trigger of impoliteness by which each party is trying to defend their own interest a study by bousfield found that offensive situations could trigger impoliteness spenceroatey stated that negative emotions can regulate linguistic behaviour including impoliteness some studies found that emotions and impoliteness go together for example kienpointner reported that specific negative emotions can provoke the use of impoliteness wijayanto et al concluded that negative emotions such as anger annoyance and hatret could provoke impoliteness they explained that expectation hopes and right that are not acceptable to speakers listeners can induce negative emotions these negative emotions provoke the use of impoliteness emotion knowledge emotions are reactions carried out by the body as an effect of a certain situation and condition and they are aspects that determine a persons attitude they are represented as common because they play an important role in social interactions emotions interact with information about the situation and its norms and all that information is represented in emotional schemas in memory emotions are classified into two types namely positive emotions and negative emotions in positive emotions feelings of happiness cheerfulness peace and joy will usually arise meanwhile negative emotions are the opposite of positive emotions negative emotions will cause feelings of anger disappointment sadness and hatred in the expression impolite the emotions that are caused are negative emotions according to shaver et al negative emotions are classified into 3 types namely anger sadness and fear anger anger is a form of emotional expression that is used to express anger and hatred towards certain situations there are several subordinates in anger expressions including torment envy jealousy discussed revulsion contempt rage outrage fury wrath hostility ferocity bitterness hate loathing scorn spite vengefulness dislike resentment exasperation frustration aggravation irritation agitation annoyance grouchiness and grumpiness sadness sadness is an expression used to describe sad feelings there are several types of subordinates included in the sadness group including pity sympathy alienation isolation neglect loneliness rejection homesickness defeat ejection insecurity embarrassment humiliation insult guilt shame regret remorse dismay disappointment displeasure depression despair hopelessness gloom glumness sadness unhappiness grief sorrow misery melancholy agony suffering hurt anguish fear fear is an emotion that arises because of feelings of fear this emotion will develop into anxiety there are several subordinates included in fear including anxiety nervousness tenseness uneasiness apprehension worry distress dread alarm shock fear fright horror terror panic hysteria mortification pity sympathy method this study used a qualitative approach which described and explored the use of impoliteness and emotional expressions involved in the impoliteness the qualitative research was conducted to observe social phenomena and human problems and to explore and understand meaning thoughts of a person or society towards the phenomenon itself the type of the qualitative research employed was descriptive research that was conducted by taking data form of words or pictures rather than the numbers that the result contains quotes from data to illustrate and strengthen presentations bodgan and biklen also stated that if the research data were verbal or social behavior needs to be analyzed descriptively and researchers need to use qualitative methods the present research used the theory from culpeper to describe the types of impoliteness strategy and the theory of emotion knowledge by shaver et al to explore the emotional expressions the object of this research was expressions of impoliteness the research data was comments written by haters that contained impoliteness researchers took data sources from social media namely comments from social media users on the instagram account fifa the techniques used to collect data are observation and documentation there were several steps taken to collect data 1 researchers observed the fifa instagram account 2 selected data that can be categorized as an expression of impoliteness 3 screenshot comments that contain impoliteness 4 paid attention to the expressions of impoliteness made by haters to do data analysis we carried out the following steps the first step was describing the expressions of impoliteness found among instagram users on the fifa instagram account using culpepers impoliteness theory and then identified the emotional expressions of haters on the fifa instagram account using the emotional knowledge theory by shaver et al and the last was drawing conclusions results fifa is a football federation throughout the world all matters related to football are covered by fifa when the u20 world cup championship was about to be held fifa made a decision which was considered unfair because it allowed the israeli football team to take part in the world cup championship this made haters disappointed because fifa should have banned israel from participating in the world cup as a form of sanction against israel because israeli soldiers had attacked a football match in palestine previously fifa had banned russia from participating in the world cup as a form of sanction against russia which had attacked ukraine but in the same condition israel had attacked palestine but fifa still allowed israel to compete in the world cup championship this made haters disappointed and felt that fifa was unfair in making decisions giving rise to negative responses from haters which were expressed in comments on the fifa instagram account the present research observed the use of impoliteness by haters found in the comments of the fifa instagram account first the present research analysed the types of impoliteness strategies used by haters and secondly the present research observed the emotions of haters expresses via the impoliteness to analyse the first research question the present research used the impoliteness strategies by culpeper and to analyse the second research question we used the emotional knowledge theory from shaver et al types of impoliteness strategy on instagram fifa bald on record impoliteness this strategy is used to attack someone directly without considering the face of the person they are talking to culpeper stated that ftas are carried out in a direct clear and facethreatening manner in an unambiguous and concise manner this strategy occurs because the speaker deliberately does not want to maintain a good relationship with the person he is talking to in the data that has been collected researchers found 38 data in the forms of bald impoliteness strategies due to space limit we only provided 3 data for analysis the following are the data taking the form of bald on record impoliteness strategy datum 01igfifa31032023pnj29 open your eyes the data is a comment uploaded by the haters account pjn29 addressed to fifa via the instagram account fifa the short utterance used by hater implied that the hater felt disappointment with the decisions taken by fifa because they are considered more proisrael this is because fifa continues to give permission to israel to take part in the world cup even though the israeli army has caused chaos in a football match in palestine while fifa has not given permission to russia to take part in the world cup because russia has caused chaos in ukraine the language style used by haters is informal from the comment of the haters the haters stated that fifa should open its eyes so that it is fair in making decisions from this data it can be seen that haters attacked the interlocutor namely fifa firmly directly and without ambiguity according to culpeper if someone attacks the interlocutor firmly directly and without ambiguity then that is a form of bald on record impoliteness datum 11igfifa31032023fsssaaammm double standard when two different parties make the same mistakes the treatment they get also different the data is a comment uploaded by the fsssaaammm account addressed to fifa via the fifa instagram account based on the utterance used by the hater it can be seen that the hater underestimates fifas performance because fifa is unfair in making decisions and fifa continues to give permission to israel to take part in the world cup even though the israeli army has created chaos in football matches in palestine while fifa has not given permission to russia to take part in the world cup because russia has caused chaos in ukraine double standard is a sentence written by the hater that attacks the interlocutor directly and without ambiguity the language style used by haters is informal according to culpeper if someone attacks the interlocutor directly and without ambiguity then it is a form of bald on record impoliteness datum 32igfifa31032023msophiann banned israel the data is a comment uploaded by the msophiann account addressed to fifa via the fifa instagram account the haters comment shows that heshe is protesting against the decision taken by fifa which allows israel to take part in the world cup the sentence ban israel is written by the hater who attacked the interlocutor firmly directly and unambiguously who asked fifa to ban israeli football from participating in the world cup championship the language style used by haters is informal according to culpeper if someone attacks the interlocutor directly firmly and without ambiguity then it is a form of bald on record impoliteness culpeper stated that this strategy is designed to destroy the positive face of the interlocutors the meaning of this positive face is the desire of each individual to be respected appreciated and also needed by other people some substrategies in positive impoliteness include ignore snub the other disassociate from the other be disinterested unconcerned unsympathetic use inappropriate identity markers use obscure or secretive language and seek disagreement we found 13 data in the form of the positive impoliteness strategies in this section we only present 3 data positive impoliteness datum 19igfifa31032023zalan21 swine fifa has no pride russia is banned but israel is still roaming the sphere of football barbaric fifa is not fit to be the parent of an organization to hell with fifa the data is a comment uploaded by the zalan21 account addressed to fifa via the instagram account fifa the data demonstrtes that the hater feel disappointed with fifas performance heshe thinks that fifa is unfair in making decisions because it gives different treatment to each country the language style used by the hater is informal regarding the use of words in this comment the hater uses an abusive and profane language according to culpeper if someone attacks the interlocutor by applying abusive or profane language then this is a form of positive impoliteness with the sub strategy of swearing or using abusive or profane language datum 31igfifa31032023idepst fifa is a pet of israel the data is a comment uploaded by the idepst account addressed to fifa via the fifa instagram account the hater wrote that fifa is pet of israel the data implies that that there is anger expressed by the hater because of the decision taken by fifa is considered to be more proisrael this anger was caused by fifas decision to continue to give permission to israel to take part in the world cup even though the israeli army had caused chaos in a football match in palestine while fifa had not given permission to russia to take part in the world cup because russia had caused chaos in ukraine the language style used by haters is informal the hatercomment attacks the positive face of the interlocutor by using call the other names by the word identity pet according to culpeper if someone attacks the interlocutor using another name then this is a form of positive impoliteness with the sub strategy call the other names datum 24igfifa31032023mystoganskuy fifa double standard you fifa baggers and under wears you all like pig and dog the data is a comment uploaded by the mystoganskuy account addressed to fifa via the fifa instagram account the hater wrote that fifa is like pig and dog based on the data it can be analysed that there is a feeling of dissatisfaction expressed by the hater because the decisions taken by fifa is considered more proisrael this is due to fifas decision to continue to give permission to israel to take part in the world cup even though the israeli army has caused chaos in a football match in palestine while fifa has not given permission to russia to take part in the world cup because russia has caused chaos in ukraine the language style used by haters is informal based on the comment written by the hater that heshe used word association of fifa with other names like pig and dog according to culpeper if someone attacks the interlocutor using another name then this is a form of positive impoliteness with a substrategy of calling the other names negative impoliteness the use of this strategy is designed to destroy the desires of the interlocutor negative face and also attack the interlocutor negative face several substrategies or outputs on negative impoliteness include frighten condescend scorn or ridicule be contemptuous do not treat the other seriously be little the other invade the others space explicitly associate the other with a negative in the data that has been collected researchers found 25 data which is a form of the negative impoliteness strategy however in chapter iv researcher will only analyze 3 data the following are several of data found by researchers that are a form of the negative impoliteness strategy datum 15igfifa31032023msidikaja fifa stupid bunch of fools the data is a comment uploaded by the msidikaja account addressed to fifa via the fifa instagram account based on the comment written by haters it can be seen that the hater got disappointed with fifa this is because fifa applies different treatments to each country so haters think that fifa is unfair the language style used by haters is informal based on the comment it can be seen that haters use words that ridicule and insult the interlocutor according to culpaper if someone attacks the interlocutor by using words that are ridicule and insulting then this is a form of negative impoliteness with the sub strategy condescend scorn or ridicule datum 30igfifa31032023muhammadazmann shame on you the data is a comment uploaded by the muhammadazmann account addressed to fifa via the fifa instagram account based on comment written by haters it can be inferred that the hater got angery as he is disappointed with fifa which is to be more proisrael the hater is disappointed because fifa still gives permission to israel to take part in the world cup even though the israeli army had caused chaos in a football match in palestine while fifa had not given permission to russia to take part in the world cup because russia had caused chaos in ukraine the language style used by haters is informal based on this comment it can be seen that the haters use derogatory words according to culpaper if someone attacks the interlocutor by using derogatory words then it is included in negative impoliteness with sub strategy condescend scorn or ridicule datum 17igfifa31032023edomlia990 hey fifa dont involve to israel or moses will kill you and your family one by onebravo israel the data is a comment uploaded by the edomlia990 account addressed to fifa via the fifa instagram account based on the comment written by haters it appears that the hater is protesting against the decisions made by fifa this is because fifa continues to give permission to israel to take part in the world cup even though the israeli army has caused chaos in a football match in palestine while fifa has not given permission to russia to take part in the world cup because russia has caused chaos in ukraine the language style used by haters is informal based on the sentence in the comment it can be seen that haters use frightening words to attack the interlocutor according to culpeper if someone attacks the interlocutor by frightening then that is a form of negative impoliteness with a frighten sub strategy sarcasm or mock politeness sarcasm can be used to contrast the meaning of someones feelings towards something else the intended meaning of mock politenee is in contrast with what the speaker wants to express but with politeness words to attack others implicitly in this strategy politeness is used but the meaning is not this is included in the impoliteness strategy because the speaker is not really sincere with what he says the researchers found 2 data which in the form of sarcasm or mock politeness strategy the following are the data of the sarcasm or mock politeness strategy datum 02igfifa31032023astrophiliamon are you sick fifa the data is a comment uploaded by the astrophiliamon account addressed to fifa via the fifa instagram account based on this comment it can be seen that the haters are satirizing the interlocutor namely fifa this was a form of protest from the hater who was disappointed with fifas decision which was considered unfair because it gave different treatment to each country the language style used by the hater is informal based on the comments written by haters it can be seen that the comment has another meaning the sentence are you sick is not an expression that actually asks about the addressees health condition but is an expression of ridicule according to culpeper if someone attacks the interlocutor by using words that have no real meaning then this is a form of sarcasm or mock politeness strategy datum 45igfifa31032023islamicelevenofficial sorry our eyes are blind when we see israel but our eyes are sharp when its russia… so lets continue regardless of the damage done by israel the data is a comment uploaded by the islamicelevenofficial account addressed to fifa via the fifa instagram account based on comment written by haters it can be understood that the hater felt disappointed with the decisions taken by fifa the reason is that fifa is considered to provide different treatment to each country fifa has given permission to israel to take part in the world cup even though the israeli army has caused chaos in a football match in palestine while fifa has not given permission to russia to take part in the world cup because russia has caused chaos in ukraine the language style used by haters is informal the sentence from the haters comment sorry our eyes are blind when we see israel but our eyes are sharp when we see russia is an allusion to fifa whose eyes seem blind when they see israel but sharp when they see russia according to culpeper if someone attacks the interlocutor by using words that have no real meaning then this is a form of sarcasm or mock politeness strategy withhold politeness culpeper defines withholds politeness occurs when the speaker does not carry out the politeness strategy desired by the listener or is silent it is a strategy that is used by people to expect politeness things because the polite things are not used being silent and failing to thank are the realization of this strategy the meaning of politeness that is expected in a certain situation but is left out for some reason this is considered as intentional impoliteness in this study researchers did not find data that included a withhold politeness strategy the emotional expressions in impolite comment from hater on instagram fifa anger datum 08igfifa31032023arif12h thus is stupid federation forza the data was a comment uploaded by the account arif12h addressed to fifa via the instagram account fifa based on the sentences written by the hater it can be perceived that the hater felt angry and scorned the interlocutor this is because fifa carries out different treatment between israel and russia this made the hater angry and the hater thought that fifa was unfair in making decisions and was considered to be more proisrael based on this the haters emotional expression is anger with subordinate scorn datum 15igfifa31032023msidikaja fifa stupid bunch of fools the data was a comment uploaded by the msidikaja account addressed to fifa via the fifa instagram account based on the sentences written by the hater it can be understood that the hater is feeling angry and scornibg the interlocutor this is because fifas decision is considered to be more proisrael fifa continues to give permission to israel to take part in the world cup even though the israeli army has caused chaos in a football match in palestine while fifa has not given permission to russia to take part in the world cup because russia has caused chaos in ukraine based on this the haters emotional expression is anger with subordinate scorn datum 22igfifa31032023catatangame fifa is slave for israel the data was a comment uploaded by the notangame account addressed to fifa via the fifa instagram account in the comment was written by the hater there is the word slave which can be interpreted as an insult this was an expression of anger from haters who protested against the decision that fifa had made hater thinks that fifa is afraid of israel and does not dare to impose strict sanctions against israel so it continues to give permission for israel to take part in the world cup based on this a haters emotional expression is an angry expression with a subordinate type of contempt sadness datum 28igfifa31032023antorenz please fifa must react to the israel armys attack on the match in palestine dont stay silent you must be fair the data was a comment uploaded by the antorenz account addressed to fifa via the fifa instagram account based on the comment was written by the hater the hater felt disappointed because the hater thought fifa was unfair in making decisions apart from that hater think that fifa is just silent about the incident that occurred between israel and palestine based on this it can be concluded that the haters emotional expression is sadness with a subordinate type of disappointment the data was a comment uploaded by the anangtyantoo account addressed to fifa via the fifa instagram account the comment was written by hater showing the feelings of disappointment regarding the decision that fifa has taken because it is considered to be more proisrael this is because fifa continues to give permission for israel to take part in the world cup even though the israeli army has made a mess of a football match in palestine while fifa has not given permission for russia to take part in the world cup because russia has made a mess in ukraine based on this the emotional expression of the hater is anger with a subordinate type of disappointment datum 52igfifa31032023gilangg01 israel attacks the palestine national team where are you fifa loser the data was a comment uploaded by gilangg01 account addressed to fifa via the fifa instagram account based on the comment written by the hater it can be seen that the hater was feeling disappointed with fifa which was considered unfair the comment was written by hater showing the feelings of disappointment felt by haters regarding the decision that fifa has taken because it was considered to be more proisrael this is because fifa continues to give permission for israel to take part in the world cup even though the israeli army has made a mess of a football match in palestine while fifa has not given permission for russia to take part in the world cup because russia has made a mess in ukraine based on this the emotional expression of the hater is sadness with subordinate disappointment discussion the researchers analysed the types of impoliteness and emotional expression from haters comments on fifa instagram posts we collected and analysed 78 data we found 38 data included as bald on record impoliteness 13 data were positive impoliteness 26 data were negative impoliteness and 2 data were sarcasms or mock politeness meanwhile we did not find any data included as withhold politeness we found that bald on record impoliteness was the most dominant type of impoliteness apart from this we also analysed the emotional expressions involved in the impoliteness based on the emotional knowledge proposed by shaver et al the study analysed 74 data relating to emotions we found 44 data that were included as anger and 30 data were included as sadness emotional expressions meanwhile fear emotional expression was not found we found that anger was the most dominant of emotional expression in line with bousfield the impoliteness used by the haters contained gratuitous and conflictive verbal face threatening acts which were purposefully delivered to attack viva the findings of this study confirm fatimah and arifin in which haters used impoliteness because what they expected and desired from the organisation was against their values justice or fairness expectation and wants nevertheless the findngs of this study are also differentt from those of some previous research for example yusniati did not find impoliteness in the form of sarcasm or mock politeness this could be because the data of her study was taken from films whereas this research collected data from haters reactions in social media comments in which sarcasm are commonly used unlike the findings of krisdayanti the present study could not find out the purposes or intentions of using impoliteness in addition while the present study could find negative emotions involved in the impoliteness the previous research did not nevertheless in line with wijayanto et al our findings confirm that negative emotions can become triggers of impoliteness the findings also agree with spenceroatey who argued that negative emotions can regulate linguistic behaviour such as impoliteness which is confirmed by our data for example many haters got very angry and disappointed with viva and the emotions trigerred them to use impolite language this could be because emotions and impoliteness could go together as a communication mode conclusion based on the data analysis that has been carried out it can be understood that fifas decision to continue to allow israel to take part in the world cup football match has reaped many objections from haters in the comments column on the fifa instagram account many haters protested fifas decision the researchers found some impoliteness strategies in hater comments including bald on record impoliteness positive impoliteness negative impoliteness and sarcasm or mock politeness of these types the most dominant strategy was bald on record impoliteness regarding emotional expressions we found two emotional expressions based on shavers emotional knowledge theory in which anger was most dominant emotional expression found hopefully the present research could contribute to the development of research of impoliteness in cyber communication apart from that the researchers would like to make this simple research as a starting point to develop further research or it can be used as a reference for further research of impoliteness in social media with different methods and aspects

this research describes the types of impoliteness strategies and emotional expressions in impoliteness used by haters in commenting on instagram social media many impolite stattements were deployed by haters of fifa because this football association is considered unfair in making decisions and treating israel and russia differently descriptive qualitative method was employed to analyze the research data the present research took data from haters comments in the comment column of the fifa instagram account the data analysis included identifying and describing the use of impoliteness strategies and emotional expressions involved the impoliteness the research has revealed that some types of impoliteness strategies were used by the haters with bald on record impoliteness being the most dominant strategy and anger was the most dominant emotional expression involved in the impoliteness

introduction over 35 million children are living outside their country of birth including 71 million refugee children with many facing disruptions in their education and struggles to access quality schooling as global migration has continued there is no doubt that interest in diversity and inclusion within school systems has grown exponentially over the last three decades while migration is nothing new and is of ongoing concern within the sphere of education with the rise of social media and rolling news societies have become increasingly sensitised to world events that may previously have appeared to be at a distance added to this are significant movements of people within and away from regions of the world affected by intractable conflict environmental and food emergencies wars poverty and struggling economies and infrastructure as host countries of migrant people are formally bound by national and international law to provide educational opportunities to migrant children such movements have inevitably led to a wider range of children with complex backgrounds and needs entering schools meanwhile as societies become more sensitised and as schools grapple with increased intakes and the seemingly intensified challenges so too have preservice teacher education programmes been faced with the challenge of addressing the needs of teachers as they enter such diverse classroom environments with a subsequent gradual increase in the amount of diversityrelated content in teacher education programmes the role of teachers in the education of migrant learners is held to be crucial equally preservice teacher education is generally considered to be essential in equipping trainee teachers to teach diverse groups of learners ultimately creating equal educational opportunities for all regardless of background however while there has been a proinclusive turn involving a recognition that education must be inclusive of learners multiple identities and much reform in teacher education over the last three decades some scholars have been disappointed by how little progress has been made as ryan et al have argued the crucial priority of preparing teachers for increasingly diverse classrooms has not been addressed there is a small but growing body of work that focuses specifically on preservice and inservice teacher education for working with migrant learners evidenced by the articles in this review as well as by online training courses available and by chapters in larger collections on teacher education however given that the migrant identity can be subsumed within wider talk of diversity there are other subfields that are relevant here for example the longstanding area of multicultural education as well as work on migrant learners and their teachers experiences there is also instructive work on teacher identities and teacher beliefs particularly concerning diversity recognising as it does the links between identities beliefs and practice and especially how these identities and beliefs manifest themselves in how empathetically a teacher might behave in diverse classrooms despite the growing scholarship mentioned above there remains a particular gap when it comes to preservice teacher education for teaching new or recent migrant learners in compulsory education this gap occurs despite the fact that migration continues to be a global phenomenon with migrant learners and their teachers facing challenges that go beyond dealing with cultural difference xenophobia and racism to include the possibility of trauma from the upheaval of migration caused by war poverty and political unrest resulting in interrupted education and disrupted family life it should also be acknowledged however that such children do indeed hold multiple identities aspects of which increase and decrease in salience to them and their education at different points in their lives although there is not adequate space to address these other aspects of identity in this review article therefore this article argues that learning to teach migrant learners deserves particular attention and aims to contribute to knowledge in this area by offering a critical qualitative review of articles published between 2002 and 2021 on preservice teacher education that report on a variety of research and teacher education initiatives in preparing trainee teachers to work with migrant learners in compulsory education it focuses on the following interwoven questions 1 what are the beliefs of preservice teachers about teaching migrant learners 2 what role do preservice teachers migration identities and empathy have on their beliefs about teaching migrant learners 3 what role can and should preservice teacher education play in shaping these beliefs and identities a presentation and synthesis now follow the current literature relevant to the field they reveal two important and interrelated themes trainee teachers beliefs in the context of societal diversity and teacher identities and empathy which after a presentation of the scope of the research review are then used to analyse the articles selected the ensuing discussion of the findings problematises the development of empathy as an aim as well as the role of critical selfreflection in mediating the attitudes of trainee teachers the article ends by proposing increased critical researcherteacher collaboration in future research multicultural teacher education multicultural education can be understood in many different ways however its essence may be expressed as the view that education should create equal educational opportunities for both minorities and the majority in societies with an emphasis on adapting the school to reflect social diversity and to respect diverse backgrounds through pedagogies that are relevant and responsive to a diversity of cultural backgrounds therefore it is argued preservice teacher education should be directed towards this purpose given its essential role in equipping trainee teachers to enable all children and young people to access learning opportunities while this review was motivated by the challenge that the author faced in finding scholarship on preservice teacher education that has a very particular focus on learning to teach migrant learners the area of multicultural teacher education appears to most easily encompass concerns about migrant learners given its interest in respecting the diverse backgrounds of learners therefore it is this scholarship that was chosen as the foundation for this review there has been longterm academic engagement in the field of multicultural education and multicultural teacher education key publications have included the handbook of research on multicultural education the routledge international companion to multicultural education and developing multicultural teacher education curricula in addition there are chapters on teacher education and diversity in collections focusing on teacher education more broadly while the field has undoubtedly been dominated by scholars from the usa there are also contributions from a range of other countries including australia the uk thailand and south africa additionally there is a growing body of work on migrant learners and their teachers in terms of specialist work focused on teacher education and migrant learners there are some publications of note in addition to the articles that will be discussed in this review springers companion to research in teacher education has a chapter on teacher education research and migrant children and there are several chapters in the handbook of research on teacher education that include migration in their considerations of diversity there are also key journals that periodically devote space to the topic such as teacher educators 2018 special issue on immigration and teacher education and editorials in journals such as the european journal of teacher education that focus on wider inclusion issues nevertheless it remains rare to find consideration of multicultural teacher education and migrant education in the same review therefore this review aims to bridge this gap synthesising these strands of scholarship some shared concerns emerge first there is often a focus on language learning and attainment and the perception that migrant learners underperform this can sometimes lead to a deficit model that focuses on what the child is lacking rather than the knowledge that the child may hold and neglects the nonhomogeneous nature of migrant children however goodwin has noted that there has also been a growing appreciation of cultural issues particularly noting the ideas of cultural disorientation and being caught between cultures second there is continued recognition that while specific training is required to work effectively with migrant learners provision for such training has not improved indeed in some cases it has been reduced along with reduced funding and time for teacher education in general in addition to fear of diversity and reluctance to deal with racism held by trainees despite efforts to promote critical reflection among trainees finally there is a shared frustration that research in migration and education in general and teacher education in particular continues to be lacking this is despite the apparent rise in practicebased research and many and varied attempts to engage teachers in research and encourage researchers to collaborate with practitioners this is surely a reminder that the challenge of preparing teachers to teach migrant learners is as significant as it ever was aspects of these three areas of concern will reemerge later in the findings of this review teacher beliefs and identities research on teacher beliefs and identities is also relevant here scholarship on teacher beliefs makes a strong case for the links between beliefs identities and practice not least when it comes to teacher beliefs about diversity influenced by teachers backgrounds experiences and identities and how these beliefs manifest themselves in how a teacher behaves in diverse classrooms studies in this area highlight not only the risk of negative or stereotypical beliefs among student teachers detrimentally impacting on learners but also the value of exploring the underlying contextually based influences on teachers identities as well as their biographies in terms of migration which it has been argued should be discussed within teacher education programmes inevitably then the role of teacher education in developing and influencing teachers beliefs is a focus in scholarship identifying teacher educators as holding the potential to help or hinder student teachers to develop through their openness towards learning and highlighting the importance of the teacher practicum experience inschool mentoring and opportunities for critical reflection on teaching practice closely related to teacher beliefs are teacher identities given the strong potential for the former to be influenced by the latter in their review of the literature on teacher identity beauchamp and thomas highlight the centrality as well as the complexity of identity in teacher development with day et al adding that it is a concept that is constantly evolving during the preservice stage and on into teachers professional lives in this sense preservice teacher education is seen not merely as involving onetime input but as the beginning of a longterm process of development of teacher competencies and identities contexts and power relations unsurprisingly then beauchamp and thomas argue that a greater understanding of teacher identities is essential in order to design effective teacher education programmes shifting the focus towards the interest of this review multicultural teacher educationalists would propose that understanding of teachers cultural identities and particularly enabling trainee teachers themselves to understand their own and others identities through critical reflection is crucial to preservice teacher education while the areas of teacher beliefs and identities and the apparent influence of these two aspects on practice are undeniably important to consider in preservice teacher education for teaching migrant learners what this review will reveal is that the connections are complex and sometimes problematic this is not least the case when it comes to trainees beliefs about and experiences of migration and assumptions that might be made about the level of empathy those with migrant backgrounds do or should show towards their learners i will return to these concepts later scope of this review and search strategy this research review is a critical qualitative review focused on published articles that present research reviews of teaching interventions and curriculumpractice reviews on preservice teacher education for teaching migrant learners in compulsory education the qualitative narrative approach was selected to allow space for analysis of themes that are insignificant numerically but significant in terms of themes of concern or interest without generalisation as an aim a critical lens was applied to research in terms of using a selective purposive sample of articles with a significant focus on thematic analysis that goes beyond description towards highlighting the crucial issues in preservice teacher education for migrant learners the common threads of identities and beliefs emerged during the review process the review is based on articles in englishlanguage journals only as this is the only language in which i am fully fluent the search strategy loosely followed the stages outlined by newman and gough i did an initial general search based on google and google scholar looking for teacher education and migrant education to find the key search terms i then turned to academic databases beginning with scopus i did a boolean search of titles abstracts and keywords with my search terms refined to teacher education or teacher preparation or teacher training or teacher instruction and migrant or immigrant or asylum seeker or refugee i also limited the search to research articles and excluded books and book chapters i limited neither the time period nor the country focus this generated a list of 142 articles once i had skimread the titles of these articles i limited the disciplines to arts and humanities and social sciences i also excluded articles that mainly focused on learners who are secondgeneration immigrants who were born in the country where the study was conducted as this would have broadened the scope beyond what could be achieved usefully in this article i also excluded articles that focused solely on continuing teacher education although i included those that referred to both or where it appeared that inservice teachers may not have previously taken part in a programme of initial teacher education i decided to include some other articles that mentioned diversity but not migrantimmigrantrefugeeasylumseeker learners in the title as once i had read them in more depth i discovered that they nevertheless included a discussion of migrant learners i also used the references in the selected relevant articles to find articles that did not appear on scopus finally i searched taylor and francis wiley and elsevier journal websites as well as the digital library eric to fill in any remaining gaps such inclusions and exclusions are indicative of how challenging it was to unearth the right articles given that migration issues can sometimes be somewhat buried in discussions around diversity more broadly and definitions of migrant immigrant and ethnic minority among many other terms can differ overlap and diverge in different ways in different countries the findings were synthesised and presented in narrative form employing thematic analysis to identify and report on key themes two themes emerged inductively and are explored in the findings and synthesis section supported by the wider literature in teacher education to enhance the subsequent discussion findings and synthesis this review found 26 relevant journal articles published in english between 2002 and 2021 the list of papers included in this review can be found in table 1 while the majority were based in countries in the global north where the english language dominates there was also a small number of studies from a range of nonanglophone european countries as well as 1 study in africa and 2 in asia the country focuses and the number of articles were as follows usa sweden australia cyprus canada finland hong kong ireland kenya northern ireland portugal thailand and spain the studies were a mixture of qualitative or quantitative research projects and reports evaluations and supportive accounts of specialist training initiatives and practice two themes emerged from the review and are considered in turn below trainee teachers beliefs in the context of societal diversity and teacher identities and empathy trainee teachers beliefs in the context of societal diversity the role of teachers in the education of migrant learners is generally held to be crucial however teaching and teacher education do not exist in a bubble but are influenced by many personal historical political and institutional factors as well as by dominant societal attitudes such as racism and xenophobia teachers also hold their own beliefs shaped over time through life experiences and cultural backgrounds and sometimes altering during their training and practicum experiences therefore it was unsurprising to discover that the research articles reported a mixture of attitudes held by preservice teachers towards migrant learners chan and gao explored the views of preservice teachers in hong kong towards newcomer children from mainland china in their study student teachers expressed a range of views on teaching such children with the majority viewing them from a deficit standpoint and as presenting a serious professional challenge this revealed the influence of prevalent negative societal stereotypes of mainland chinese people transmitted through the media while in some contexts this might translate as racism given that both hong kong chinese and mainland chinese share an ethnicity in this case it could be more accurately described as xenophobia or cultural discrimination more positive attitudes were reported by níkleva and ortegamartín in the context of a study on undergraduate education students on an undergraduate teacher education programme in spain a country which at the time of the research had already culturally diversified in a significant way therefore the authors regarded this as having had a positive impact on students attitudes the experience of having had immigrant classmates is viewed as culturally enriching which vastly facilitates their encounters with multicultural students in their future profession in the context of ireland a country which in the 2000s was considered to be relatively new to immigration leavy indicated that student teachers were inexperienced with cultural diversity due to lack of exposure despite this lack of exposure the study reported high levels of tolerance and support expressed towards religious cultural sexual and language diversity evidenced by trainees taking on the role of advocate for language diversity in the classroom thus the lack of exposure to diversity in this regard did not seem to negatively influence student teachers views overall then the studies in this review demonstrate a range of beliefs and a range of suggested explanations for such attitudes societal diversity was less of a determinant of positive attitudes towards migrant learners than might be expected xenophobia can at least in some cases be a factor and anxiety over lack of training was a bigger barrier to trainees positive beliefs about migrant learners the finding that preservice teachers hold negative beliefs about migrant learners is nothing new from a sociological and political perspective schools and universities represent sites of socialisation of children and adults into the kind of people that society deems acceptable if a countrys diversity and its media reporting on this topic do not unfailingly determine trainee teachers beliefs about migrant learners this leaves space for consideration of the role that teacher education can play in influencing such beliefs indeed if one assumes that teachers beliefs about migrants impact on practice which can then have a significant impact on how migrants feel in class then it is understandable that teacher education is looked to as the vehicle by which to effect change in this area however how exactly to do this what policies pedagogies curricula and training are needed is not agreed upon teacher identities and empathy it is often suggested that teachers as a workforce do not reflect the diversity of identities held by their students and that this is problematic for being able to empathise with students in this research review empathy understood as stepping into the shoes of another person in order to better understand them was overwhelmingly recommended as a significant resource for preservice teachers to draw upon and it was argued that this practice was facilitated when trainees had migrant backgrounds and experiences themselves ginsberg et als research in the usa with student teachers and teacher educators focused on a preservice teacher education programme which involved migrant trainee teachers working with hispanic learners the authors claimed that trainees ability to understand the experiences of migrant learners made them more empathetic and therefore effective in supporting such learners as they were able to better use a pedagogy of recognition whereby the student teachers actively sought through their teaching approach to recognise and relate to the learners backgrounds and to offer a deeper sense of respect for them empathy was also deemed useful when extended to experiences of discrimination and it was cited as a motivator for migrant teachers in their work significant here however was not only the fact that the teachers were migrants themselves but that they shared a specific hispanic background similarly in naidoos analysis of an afterschool homework club for refugees in australia they reported that trainees decided to take part in this intervention precisely due to personal experience of racism and its deleterious impact on learning unsurprisingly then these and several other studies called for increased support and in some cases recruitment of migrant teachers so that teachers could offer this level of empathy and recognition to migrant learners such as in the case of burmese teachers teaching the burmese curriculum to students from myanmar in migrant learning centres in thailand indeed taking the need for empathy further it is for some the knowledge of migration that underlies this empathy that should also result in action on the programmatic level in vellanki and princes interesting collaborative autoethnography based in the usa the authors themselves from migrant backgrounds reflected on a global teacher education course on which one of them studied and one of them taught and argued that such expertise should be taken into account when designing and modifying such courses thus again the importance of personal identities and experiences in informing a teachers beliefs on migration diversity is underlined however several authors argued that where trainee teachers were not from a migrant background they could develop empathy through preservice teacher education programmes in their narrative study on the experiences of three teacher educatorsleaders in canada in the context of attempting to integrate syrian refugee learners gagné et al suggested developing culturally relevant pedagogy as part of culturally relevant education through engaging trainees in the power of sharing stories from refugee learners and a deeper understanding of the learners lives similarly outside the university or college setting it was argued that empathy could be achieved through a teaching practicum or inschool placement often a compulsory part of preservice teacher education and seen as crucial to the broader development of teachers wellman and beys article on an art education intervention that involved trainee teachers argued that this kind of initiative was essential to enabling preservice art teachers to encounter and learn to work more effectively with refugee students tilleylubbs studied a servicelearning project in an immigrant community in the usa that placed students with spanishspeaking families focusing on the experiences of student teachers they concluded that a servicelearning project can be transformative for the teachers offering an effective pedagogy to develop an awareness of students worlds away from school critically however while the majority spoke with unwavering positivity about the importance and potential of developing empathy among student teachers not all studies agree that teaching migrant learners in teacher practicum experiences or even being a migrant themselves would automatically lead to the development of empathy or compassion among trainees particularly when their migration cultural and ethnic backgrounds differed so widely anttila et als study in finland involved collecting the views of preservice physical education teachers after facilitating workshops for asylum seekers with some participants concluding that after this experience they had no desire to repeat it not least because they did not see why culturally diverse content and pedagogy might be relevant to a school subject such as physical education racism and xenophobia may also have been a factor here given that many of the migrant learners that the student cohort worked with were asylum seekers from iraq and afghanistan mendenhall et als study of a teacher training programme on approaches to school discipline in kakuma refugee camp in kenya showed how even when teachers empathised with students sharing with them their refugee background they still sometimes used corporal punishment due to the extreme challenges of working in such a resourceconstrained environment thus even where empathy is encouraged and expected due to an aspect of shared identity it may simply be out of reach for teachers under pressure indeed a short teacher practicum may at best be simply a starting point especially if it is not accompanied by other aspects of preservice teacher education such as inschool mentoring and opportunities for critical reflection on practice nevertheless as day et al remind us the complexity of teacher identities means that they may be considered constantly evolving and under construction throughout the preservice period and beyond influenced by people contexts and power relations therefore perhaps there still remains the potential for empathy and its positive impact on practice discussion empathy critical selfreflection and the role of preservice teacher education the findings that emerged from this research review speak to broader critical issues within preservice teacher education and migrant education and the most appropriate role for teacher educators the first theme revealed that in terms of trainee teacher beliefs negative views and anxieties appear to dominate the articles included in the review these beliefs include a deficit approach that views migrant learners as lacking ability racist or xenophobic stereotyping and viewing working with migrant learners as much more challenging that working with nonmigrants this leads in some of the articles to trainee teachers being reluctant to work with migrant learners again after their first experience during the preservice period a number of the studies underline the risk of negative or stereotypical beliefs among trainee teachers detrimentally impacting on learners many articles attribute such beliefs to a lack of knowledge and training in teaching diverse learners some link these beliefs to the level of nationalmigratory diversity in a country however this does not seem to be a decisive factor the second theme relates to preservice teacher background and empathy here the review reveals a strong emphasis on the value of empathy in learning to teach migrant learners many articles foreground the apparent advantage of being a migrant teacher oneself both to being able to empathise and to being equipped to develop teacher education curricula while several studies also highlight that being a migrant oneself is not essential to developing empathy with migrant learners and that this is a skill that can be developed through the teaching practicum nevertheless other articles complicate this narrative highlighting that even holding shared experiences with migrant learners does not necessarily lead to empathy or a desire to teach migrant learners in the future as mentioned earlier while preservice teachers hold varying beliefs and have had varying experiences concerning migrant learners influenced by many factors both inside and outside the school environment it is widely accepted that teacher education can influence such beliefs and student teachers understanding of their experiences it was also argued that this matters because of the link between teachers beliefs and pedagogical approaches and how migrant learners feel in class nevertheless as goodwin and allman and slavin confirm teacher education that directly focuses on migration issues is not consistently in place worldwide therefore they call for compulsory input mandated on the national and institutional level on migration issues in teacher education and coursework the teaching of culturally relevant pedagogies and for training for teachers to become advocates for migrant learners the implication here is that the lack of a deliberate approach can have a detrimental effect on trainees leaving them either unprepared or disengaged from the process of learning to teach and support migrant learners due to being disengaged from their own potentially stereotypical views on such learners and from their own cultural identities however it was also highlighted that schools and universities represent sites of socialisation of children and adults into the kind of people society deems acceptable this understanding is key to considerations of migrant learners and the education of their teachers because it poses two challenges in terms of the agency of teachers educators and teachers to what extent are teacher educators able to control the potentially negative impact of negative societal views on trainee teachers and to what extent are these teachers when they arrive in classrooms with migrant learners able to control the potentially negative impact of these views on their learners just as teacher identities are impacted by multiple factors and are often in flux so too are the identities and beliefs of those who are tasked with educating these student teachers teacher educators are also part of this socialisation project and may themselves be uncomfortable with encouraging critical reflection on identities or problematic societal beliefs thus the challenge arises rather than working for the socialisation of and acceptance by students into the status quo can schools educate students to make changes in their society and can teacher education and educators facilitate this on this tuomi is hopeful the ability to adapt to societal transitions is a skill that needs to be developed in teachers rather than working for socialization into the status quo schools can foster proactive agents of social change the idea of school as a site for social transformation is a powerful and attractive one the findings also lead us to ask bigger questions about the role of empathy troubling the notion not only of its achievability whether that be through drawing on ones own identities and experiences of migration or discrimination or learning it from scratch through inschool teaching experiences but also of its desirability as a goal within preservice teacher education as cushner and mahons focus on the importance of teachers engagement with diversity implies particularly for those trainees from nonmigrant backgrounds who cannot realistically empathise with migrants from experience a short teacher practicum cannot be more than one part of a much longer term perhaps even lifelong commitment to developing as a culturally responsive educator critical selfreflection was a skill that often appeared to be mentioned as complementing empathy in the articles in this review and is often cited as part of culturally relevant education scorgie highlights that critical selfreflection involves transformation including the disorienting dilemma that requires learners to confront and evaluate their underlying beliefs and assumptions using both personal reflection and reflective discourse with others leading to empathy such an approach may require in zembylas and papamichaels view the use of pedagogies of discomfort within multicultural teacher education whereby the discomfort of student teachers when dealing with challenging topics might be harnessed in order to challenge dominant beliefs habits and normative practices that sustain stereotypes and social injustice thereby creating openings for empathy and transformation this may be especially important where trainees lack intercultural or multicultural experience in terms of migrant learners wider scholarship has highlighted the importance of learning to reflect in a personal way on diversity racism and internalised notions such as colourblindness however as dorner et al have highlighted students often struggle to appreciate the complexity of identities even their own and some show resistance to being challenged as was seen in the findings in this article and elsewhere in the literature this can stem from many aspects of a preservice teachers institutional environment and their professional and personal life and beliefs not least the beliefs they have about themselves as a good person or a good teacher and it is a particular concern within antiracist and multicultural education given these beliefs attitudes and identities further questions emerge about how they are shaped and the role that teacher education can and should play in shaping trainee teachers ball suggests that teacher educators must assist teachers in replacing their feelings of insecurity discomfort and inadequacy with feelings of agency advocacy and efficacy gay and kirkland among many others also propose that critical selfreflection in addition to cultural critical consciousness is crucial going beyond regurgitation of course materials towards an analysis of their own beliefs and biases critical reflection also links to identity as beauchamp and thomas note reflection is recognized as a key means by which teachers can become more in tune with their sense of self and with a deep understanding of how this self fits into a larger context which involves others in other words reflection is a factor in the shaping of identity indeed several articles in this review also recommend critical selfreflection as an essential part of teacher education as a way of helping trainee teachers learn how to effectively engage with migrant learners however the resistance towards teaching migrant learners that surfaced in some of the studies in this review presents a challenge to critical selfreflection as a failsafe strategy while it can be facilitated by a sense of empathy with migrant learners one cannot assume that empathy will be achieved and one cannot even expect a teacher educator to empathise with trainees when trainees hold views that teacher educators may find abhorrent so if a teacher educator is not modelling such empathy then surely the potential of preservice teacher education to develop such skills in a student teacher may be limited perhaps where the value of empathy might be under question what is more important is the way preservice teacher education approaches empathy it may be sufficient for teacher educators to offer in the spirit of openness and honesty the modelling of critical selfanalysis harnessing the power of storytelling and applying this pedagogy of discomfort to themselves if indeed critical selfanalysis is so essential to critical multicultural teacher education for teachers of migrant learners then surely this could be the first step summary and conclusion this article has offered a critical qualitative review of 26 englishlanguage journal articles from a diverse range of countries that focus on research and practice among preservice teachers and their beliefs about and experiences of teaching migrant learners two themes have emerged first the review revealed that student teachers were more likely to hold negative beliefs and anxieties about teaching migrant learners while the diversity of the country in which the students are working did not seem to be a strong determinant of such beliefs articles suggested that such beliefs were more often linked to lack of knowledge and training second a strong belief in the value of empathy in learning to teach migrant learners emerged with the caveat that having a migrant background did not necessarily lead to a more empathetic student teacher the wider discussion problematised empathy as a goal and highlighted the challenges inherent in encouraging the development of critical selfreflection among preservice teachers several issues regarding preservice teacher education for teaching migrant learners remain undoubtedly more research that focuses on teacher education specifically for learning to teach migrant learners as well as reflections on the future of teacher education for this task are required ryan et al have reported the rise in practicebased research and many and varied attempts to engage teachers in research and link researchers with practitioners similarly cheng and lis recent article calls for more effective practitioner research as part of teacher professional development and some of the articles included in this review illustrate that teacher educatorsteacher education researchers and trainee teacher partnerships in both research and writing may offer a step in the right direction particularly when some of the researcherspractitionersauthors have experienced migration themselves it would be enlightening both to see more of these collaborations and also to read a more critical reflection on the experiences of such collaborations not least as it may shed light on the issue that was the motivation for this review in the first place why there is so little research on teacher education and migrant learners two decades into this century another age of migration looks set to continue ferfolja has argued that in a world increasingly globalised knowledge of diversity and understanding the extent of differences encountered in schools is pivotal to enable new teachers to effectively address students sociocultural and learning needs and to provide an equitable and more informed classroom environment if as ryan et al hope the crucial priority of preparing teachers for increasingly diverse classrooms is to be addressed then resources need to be funnelled towards this end we should not in a few years time find ourselves saying as goodwin did in 2017 when reflecting on her article 15 years prior that it is troubling to find it necessary to engage in the same examination and assessment of the same issues my hope is that this resourcing will allow us in a more effective way to address the most pressing challenges of preservice teacher education for teaching migrant learners in the twentyfirst century examines focus group discussions with 17 preservice english language teachers about their perceptions of newly arrived immigrant children from mainland china findings reveal that participants widely perceived these children as deficit and consider them a serious professional challenge and media life and teaching practicum experiences with immigrant children were crucial in forming these perceptions calls for teacher education programmes to involve preservice teachers in critical engagement with the mass media and their own experiences so that they can address the deficit model applied by teachers to immigrant children declarations and conflicts of interest research ethics statement not applicable to this article consent for publication statement not applicable to this article conflicts of interest statement the author declares no conflicts of interest with this work all efforts to sufficiently anonymise the author during peer review of this article have been made the author declares no further conflicts with this article

this article has been peerreviewed through the journals standard doubleanonymous peer review where both the reviewers and authors are anonymised during review

introduction over 30 years ago a deadly disease that would initially affect men homosexuals young and healthy people emerged at that time one could not imagine how much aids would provoke discussion of complex issues such as human rights and social issues 1 although the overall increase in the distribution of antiretroviral therapy contributed to the 48 decline in aidsrelated deaths 2 in brazil more than 880000 cases of the disease were detected in the country from 1980 to june 2017 with an annual average of 40000 new cases and a gradual fall in the detection rates of the disease in recent years however this is not the case in the northeast of the country where there was a linear trend of growth in aids detection rates with an increase of 357 between 2006 and 2016 3 in this context it is plausible to affirm that socioeconomic inequalities can lead to inequalities in health in some countries the mortality of the general population varies according to the socioeconomic situation of the localities with regard to aids late diagnosis can occur in economically disadvantaged regions 4 leading to an increase in opportunistic diseases and early deaths there are many variables related to the healthdisease process including social and economic status education employment housing and physical and environmental exposure these factors affect health and may influence the increase in morbidity rates studying the social determinants of health is important especially in countries characterized by large economic and health disparities such as brazil and it is possible to introduce public policies that integrate health social and economic actions 5 stigma discrimination and homophobia are examples of conditions that increase the chances of developing diseases 6 resumo introdução os determinantes sociais de saúde podem influenciar na distribuição das taxas da síndrome da imunodeficiência adquirida de uma região este trabalho teve o objetivo de analisar os dss que se relacionam com a aids método estudo ecológico com técnicas de análise espacial analisaramse 7896 notificações dos casos da doença em um período de 11 anos cujos indivíduos possuíam idade igual ou superior a 13 anos e eram residentes no estado do ceará região nordeste do brasil a unidade de análise foi o município calculandose a taxa média de aids e a taxa média transformada de freemantukey para a suavização das medidas foi feita correlação espacial das taxas de detecção de aids com os determinantes sociais de saúde utilizandose o modelo de regressão linear simples empregaramse os sistemas de informações geográficas para manuseio dos dados georreferenciados resultados altas taxas de aids foram encontradas em municípios que apresentaram melhores condições de vida observouse relação significativa entre cobertura da atenção primária em saúde e baixas taxas da doença no ceará conclusão os indicadores socioeconômicos com correlação estatisticamente significativa com a distribuição da aids devem servir de base para políticas de combate à doença palavraschave análise espacial síndrome da imunodeficiência adquirida determinantes sociais de saúde rev bras epidemiol 2019 22 e190032 there is therefore a need to address sdh in order to achieve equitable health outcomes 7 responsibility for social indicators that affect aids rates calls for a diversified workforce whose actions are focused on broad access to quality health care with resources for all populations 8 also understanding the relationship between the health behaviors adopted by individuals and the characteristics of the places where they live is essential for the understanding of sdh 9 the relevance of the study is related to the need to know the main sdh for aids in ceará with a 42 increase in disease detection rates in the state from 2006 to 2015 10 despite the great efforts of the government current prevention measures require considering the socioeconomic reality that interferes with the healthdisease process of aids in order to make effective its actions to control the epidemic in the region in view of the above the study aimed to analyze sdhs that are related to aids method an ecological study was carried out and the unit of analysis was the municipality spatial analysis techniques were used and geographic information systems were used as data manipulation tools located in the northeastern region of brazil the state of ceará is divided into 184 municipalities and has an approximate area of 1488863 km 2 the estimated population in 2015 was 89 million inhabitants with a human development index of 0682 11 the study included all individuals aged 13 years old or older living in ceará and reported with aids in the period from 2001 to 2011 totaling 7896 notifications the aids notification forms of the disease notification system were used whose information was provided by the health department of the state of ceará the socioeconomic variables of ceará were obtained from the last demographic census available in the country conducted in 2010 by the brazilian institute of geography and statistics data were transformed into rates and proportions and their values aggregated by municipality unemployment rate gini index coverage of the family health strategy service and coverage by the community health agents program were information provided by the department of informatics of the unified health system sus and by the department of primary care the collinearity between the socioeconomic variables was evaluated by the calculation of the variance inflation factor the mean aids detection rate for the period and the municipality was calculated from the sum of the rates calculated per year divided by the number of years studied using the population data available on the ibge website as the denominator the freemantukey transformed rate was calculated in order to reduce the variations of detection rates with very small values and to allow the identification of spatial patterns 12 this rate was considered as a dependent variable and used for correlation with sdh rev bras epidemiol 2019 22 e190032 the pearson test was used to verify the statistical correlation between the dependent variable and covariates the shapirowilk test was used to measure the normality of the dependent variable for all of the studys tests alpha below 005 was considered necessary for rejection of the null hypothesis being this the independence of the values of aids rates in relation to the socioeconomic indicators of the region for the creation of thematic maps a shapefile type vectorial cartographic base was obtained from the ibge website containing polygons that delimit the political divisions of ceará by municipality the neighborhood matrix employed was the contiguity criterion the moran index was used to verify the spatial correlation between neighboring areas and the jarquebera index to test the normality hypothesis of the residues spatial analysis was performed using the global spatial regression method the simple linear regression model the model allows us to identify whether the explanatory variables tested remain associated with the response variable considering the influence of socioeconomic and demographic factors on their spatial distribution the residuals generated by the mrls modeling were analyzed which should be free of spatial autocorrelation not presenting clusters the absence of spatial autocorrelation in the model residuals reveals a random spatial pattern for the specified model indicating good modeling fit we used the spss 200 and arcgis 10 results characterization of the studied population in ceará there was a progressive increase of the disease in the studied population which went from 769 cases per 100000 inhabitants in 2001 to 1414 cases per 100000 inhabitants in 2011 most of the cases were detected in the male population corresponding to almost 67 of total notifications of brown coloration and in the age range of 30 to 39 years the highest detection rates were concentrated in the capital of ceará and its surroundings pearsons correlation the bivariate analysis showed a significant association between aids rates and the majority of social indicators except for gini index unemployment rate and proportions of owned households households without sanitary sewage households with open sewage and semiadequate and inadequate households rev bras epidemiol 2019 22 e190032 the coverage by fhs and pacs presented an inversely proportional relation that is municipalities with high coverage of primary care had lower disease rates also according to the bivariate analysis most of the socioeconomic indicators that indicate the better living conditions of the studied population showed a direct and significant relationship with the values of aids rates especially income averages the proportions of households with water connected to the general network households with sanitary sewage households with more than three restrooms adequate households and the proportion of female respondents we also identified a direct and statistically significant relationship between the response variable and the proportion of rented households spatial correlation the spatial correlation of the socioeconomic indicators obtained by the moran index showed the spatial dependence of the great majority of the variables especially indicators related to income households with three or more restrooms and households with an illiterate person in charge the bivariate analysis of the transformed aids rate and socioeconomic indicators also using the moran index showed a positive value and statistical association of the following indicators proportion of households in the poverty line of individuals considered poor illiterate people in charge illiterate females in charge households without a restroom and male individuals i charge of the household the application of the mrls showed statistical and inverse significance between the transformed rate of aids and the fhs coverage however significant and direct relation to the average of household members the proportion of households with three or more restrooms the proportion of illiterate female people in charge of the household and the average per capita household income were verified the rates of aids were higher when the values of these variables had larger proportions the spatial autocorrelation of the adjusted values of the aids rate was significant the mean income indicator however showed a weak influence in the model with a lower coefficient verified in the regression the fhs coverage however was shown as an indicator of greater influence the multivariate analysis showed an adjusted coefficient of determination that explained 2823 of the variability of the aids rate one can observe the random spatial distribution of the residues which by the moran index was not significant a normality test was carried out to verify whether there were residues with normal distribution the distribution of the residues was approximated to the normal curve in this way the jarquebera index 48 was obtained with p 009 discussion this study carried out the analysis of multiple socioeconomic determinants in the occurrence of aids social inequalities in the state of ceará define inequalities in the pattern of rev bras epidemiol 2019 22 e190032 viral load between the untreated individuals in the northeast region compared to the centersouth region 16 it is considered therefore that the area of the studied municipality is heterogeneous and may present greater variability in the distribution of indicators and consequently in aids rates in addition it is important to consider that the disease is prevalent in large cities of the state where the family income is highest thus aids may be predominantly more associated with the pace and risk behaviors of modern and urban life than with povertyrelated factors the 2010 census found an improvement in the countrys social indices compared to previous years this result however diverges among brazilian regions the northeast which contains ceará has the highest illiteracy rate in the country with 176 as opposed to the south region with only 47 17 ceará itself does not have equitable socioeconomic indexes in its geographic space since more than 75 of the literate individuals live in the urban area 11 with regard to aids however previous studies have not identified a higher level of schooling with knowledge about the disease let alone with behaviors for the prevention and control of illness 18 the increase in disease rates verified not only in large urban centers but also in small municipalities is a factor that assists managers and health professionals in the planning of strategies for the control of the syndrome 19 a direct association between aids and rented property was observed one study also found a relationship between stable homelessness and difficulties in accessing medical care and adherence to antiretroviral treatment for people with hivaids 20 in addition it can be said that the constant change of residential address can increase the network of sexual partners increasing the probability of contact with infected partners the positive association between per capita income and aids rates evidenced between the two variables in this study was explained in a previous study which identified ease and greater access to diagnostic tests and serological testing in territories with better economic conditions 18 still on regional disparities the important elements in hivaids care should be socioeconomic and health deficiencies among lowincome countries while in rich countries aspects to be considered are clinical psychosocial and sexual identity issues 21 there was a significant relationship between primary health care coverage and low rates of aids in ceará it is possible to affirm that the internalization process of aids was accompanied by the expansion of primary health care in different municipalities of the state this fact associated to public policies to combat aids which defines strategies for health promotion prevention and early diagnosis may have contributed to the low rates of disease in regions with greater coverage of fhs and pacs teams fhs reduces geographic barriers by acting near the household of the people under its responsibility spatial disparities define geographical access and the effectiveness of interventions in health institutions 22 the use of spatial correlation and slrm allowed the identification of socioeconomic characteristics related to the difference in aids rates found in the state of ceará the contemporary use of spatial modeling tools has allowed the formulation of intervention strategies integrating public health with other sectors 23 despite the important results found it is important to mention the limitations of the present study which are related to the low quality verified in the registry of some data obtained and the underreporting of the cases in the state potential damage caused by poor record quality and underreporting of cases would conceal the actual disease situation in ceará however sinan used in the present study was considered the most adequate source of data to reach the defined objectives due to the large amount of information contained in the system on the other hand the integration of data provided by other systems that also manipulate information related to hivaids such as the laboratory examination control rev bras epidemiol 2019 22 e190032 system and the logistic control system of medicines could have collaborated to decrease underreporting of disease cases also because it is an ecological study it is not possible to make individual inferences regarding the results such restrictions however did not compromise the main findings and the relevance of the research since the objective was to identify the socioeconomic indicators that interfere in the detection rates of aids in the population of ceará conclusion aids rates were higher where there were better living conditions it was observed that sites with greater coverage of fhs and pacs have lower rates of aids detection it can be concluded that social disparities can lead to different vulnerabilities of the disease in the same geographic territory this research may contribute to the understanding of the relationship between sdh and aids this way the political and assistance actions to control the epidemic can be directed to the most relevant sdh identifying social elements that affect the healthdisease process of aids allows directing the planning of actions both at the macro level in the establishment of public health policies and programs of care and at the level of less complexity in the care context of individuals affected by the infection the techniques of autocorrelation and spatial analysis adopted using gis resources were very useful to verify the epidemiological patterns of the distribution of a certain disease and its relation with other factors characteristic of the geographic space this technology can be replicated in aids studies in other locations as well as being useful for revealing epidemiological patterns of other diseases due to the social inequalities between municipalities it is recommended to carry out researches considering smaller units of analysis and comparative investigations between different territories in order to better understand the dynamics of sdh in different locations it is also recommended to apply this study design to aids rates transformed by gender and age group to evaluate if the impact of sdh in different subgroups occurs unequally rev bras epidemiol 2019 22 e190032 distribution of aids differentiated socioeconomic indicators among municipalities are reflected in localities with no or few reported cases in detriment of other sites with high disease rates the present investigation evidenced high rates of aids in places with better living conditions corroborating an earlier study which also identified higher disease rates among the residents of wealthier households 13 previous research however has suggested the influence of national per capita gross domestic product and the gini index on reducing the incidence rate of hivaids 14 another brazilian study observed the current challenge of spreading the epidemic among poorer people living in certain regions of the country 15 this fact points to the influence of the heterogeneity of brazilian regions and states on the epidemiological behavior of certain diseases that suffer from their sdh a mapping study of the circulating volume of hivaids in the country also revealed the heterogeneity of the infection among brazilians with areas of concentration of the community

the social determinants of health sdh are factors that can influence the distribution of rates for acquired immunodeficiency syndrome aids in a given region the objective of this study was to analyze sdhs related to aids method ecological study using spatial analyses techniques 7896 disease case reports were analyzed over a period of 11 years subjects were 13 years or older and residents of the state of ceará in the northeast of brazil the area of analysis was the municipality calculating both the average rate of aids and the freemantukey transformed average rate for measuring softening we used the simple linear regression model to make the spatial correlation between aids detection rates and sdh a geographic information systems gis was used to manipulate georeferenced data results high rates of aids could be found in cities with better living conditions additionally there was a significant relationship between primary health care coverage and lower rates of the disease in ceará conclusion socioeconomic indicators with statistically significant correlation to the distribution of aids should be targeted by strategies policies in the fight against the disease

introduction participation in regular physical activity 1 as well as reducing sedentary behaviors such as television viewing 2 has a strong cardioprotective role however recent research has indicated that these behaviors may also play an important role in the treatment and prevention of depression 3 depression is the worlds most incapacitating illness 4 with nearly 20 of women from developed countries suffering from depression within their lifetime 5 several population groups have been found to be at a greater risk of depression including women 6 and adults of low socioeconomic position 7 these population groups are also at increased risk of physical inactivity 89 highlighting the importance of research that focuses on those target groups in order to improve mental health through the promotion of healthy lifestyles much research has indicated the beneficial effect of pa on the risk of depression 10 however little is known about the specific characteristics of pa that are most beneficial to mental health for example the domain and social context in which pa occurs although various observational 11 and intervention 12 studies have found leisuretime pa to be inversely associated with depression among women few studies have assessed the association with pa undertaken in other domains until now only three observational studies had specifically compared the association between pa in various domains and risk of depression in women 111314 all three studies concluded that leisuretime pa was inversely associated with risk of depression one of the three also found an association in the opposite direction between domestic pa and risk of depression 13 and another demonstrated a positive association between workrelated pa and risk of depression 14 no associations were evident between transportrelated pa and risk of depression in women 11 however that study did not distinguish between different types of transportrelated pas which may be an important factor 11 similarly the association between pa undertaken in different social contexts and risk of depression has received very little research attention only one observational study has considered the social context of pa and its association with risk of depression in women 11 that study found that being active with a family member was associated with lower odds of depression compared with never being active with a family member conversely two intervention studies have compared the effects of differing social contexts of pa on depressive symptoms in women 1516 both interventions compared individual pa programs with groupbased activity programs and found significant effects of both formats in reducing participants depressive symptoms with no clear benefit of either format over the other however one of those studies included a small sample size as well as a short followup period which limited results 16 recently research attention has focused on the association between sb and depression but this remains poorly understood most observational studies have found positive associations between time spent in sb and risk of depression 3 17 18 19 20 21 in contrast two intervention studies assessing the risk of computer or internet use and risk of depression found inverse associations between computer use and depression 2223 suggesting that time spent on the computer may reduce risk of depression only one study has assessed whether the relationship between sb and depression may be moderated by pa 3 that longitudinal study found lower levels of sb to be associated with reduced risk of depression when pa levels were low yet it was not a critical aspect when pa levels were high 3 the purpose of the current study was to examine the associations between components of pa and risk of depression as well as the association between sbs and risk of depression using data from a large populationbased sample of women living in socioeconomically disadvantaged areas furthermore the study aimed to test for the presence of an interaction between pa sb and risk of depression it was hypothesized that leisuretime pa would be more strongly associated than other domains of pa with lower risk of depression and that activities undertaken in a social context would be more strongly associated with lower risk of depression compared with pas undertaken alone it was also hypothesized that sbs such as tv viewing and sitting at the computer would be associated with higher risk of depression finally it was hypothesized that the positive association between sb and risk of depression would be stronger among women doing nonelow levels of pa than those who were highly active methods analyses were based on crosssectional survey data collected in 200708 from the resilience for eating and activity despite inequality study data used in the present analyses were provided by 3645 women living in socioeconomically disadvantaged areas of victoria australia aged between 18 and 45 years methods have been described in detail elsewhere 24 and are summarized below procedures the study was approved by the deakin university human research ethics committee women were sent a presurvey letter in the mail informing them that they had been selected to take part in a study on womens health and that the survey would be sent to them shortly surveys were posted 1 week later following the dillman protocol 29 nonrespondents received a mailed reminder 2 weeks later and a second reminder with a replacement survey a further 2 weeks later women received small incentives with their initial survey package written consent to participate was obtained from all respondents measures domain of pa selfreported pa was measured using the longform selfadministered version of the international physical activity questionnaire a validated and reliable measure involving a 7day recall of pa behaviors 30 questions included the frequency and duration of time spent undertaking various intensities of pa in leisure time transportrelated activity workrelated activity and domestic pa for each of these four domains participants were required to estimate the number of days hours and minutes they spent undertaking such activities in the past week the total duration of pa was calculated for each variable by multiplying the frequency of activities by the duration within each domain further leisuretime and workrelated pa variables were summed across intensities and transportrelated pa was summed across activities to give a total duration of pa within each domain total weekly duration of pa across all domains was also calculated because of the skewed nature of the distributions and the large proportions of women reporting no pa on several variables each continuous pa variable was transformed into a categorical variable with three levels based on the tertiles within the respective distributions social context of pa the social context of leisuretime pa was assessed through the following question developed for this study thinking about all of your walking moderate and vigorous leisuretime pa in the last 7 days about how much of this was done on your own response categories included all most about half a little and none the reliability of this measure was tested and found to be adequate 31 sedentary behavior three measures of sbs were included in the survey time spent sitting at a computer time spent sitting watching tv and overall time spent sitting time spent sitting watching tv and time spent sitting m teychenne et al using the computer were examined separately participants were asked to estimate the number of hours and minutes they spent undertaking those activities on a usual weekday as well as a weekend day overall sitting in the past week was assessed using the ipaql participants were asked to estimate the number of hours and minutes spent sitting on a usual weekday as well as a weekend day these measures have been found to be reliable and valid in an australian adult population 32 computer time tv viewing time and sitting time were each summed to give a total weekly duration of time spent usually undertaking each of those sbs this was done by multiplying the duration of each sb performed on weekdays by 5 then adding this to the weekend days total duration duration multiplied by 2 the variable weekly screen time was created by summing the weekly duration for the variables tv viewing and computer use each continuous sb variable was then transformed into a categorical variable based on the tertiles of the distribution depressive symptoms depressive symptoms were assessed using the 10item version of the centre for epidemiologic studies depression scale a wellvalidated measure of depression 3334 that has been used in previous studies examining the association between pa and depression 35 it includes questions that relate to various symptoms of depression that may have been experienced in the past week which indicate whether a woman is at risk of depression respondents rated themselves on a fourpoint severity scale cesd scores of 10 or greater indicated that the participant was at risk of depression 343637 covariates selfreported age body mass index bmi not overweight overweight and obese marital status education employment status household income children living at home country of birth and physical health were included in the analyses as potentially confounding factors as these variables were bivariately associated with the risk of depression in chisquare analyses statistical analyses demographic characteristics pa sb and risk of depression were initially examined using descriptive univariate analyses performed using spss version 140 statistical software bivariable associations between domains of pa social context of pa sb and risk of depression were examined using chisquare analyses crude and adjusted odds ratios and 95 confidence intervals were then calculated for each of the pa and sb variables and risk of depression using logistic regression analyses further logistic regression analyses were used to test for an interaction between sb pa and risk of depression logistic regression analyses controlled for clustering by neighborhood of residence using stata version 101 statistical software package results table i presents the sociodemographic characteristics and risk of depression among participants the mean age of participants was 35 years just over half of the women were classed as not overweight the majority of participants was born in australia and was marrieddefacto a total of 1874 reported their highest qualification as completing high school or an apprenticeship or certificatediploma just under half reported a weekly household income of 1500 or less and the majority of women had children living at home a total of 1328 participants were classified as being at risk of depression table ii shows the proportion of women at risk of depression according to pa and sb variables from chisquare analyses leisuretime walking moderate and vigorous pa and total leisuretime pa were pa and depression each inversely associated with risk of depression although women in the middle tertile of moderate workrelated pa were less likely to be at risk of depression than those reporting higher or lower durations no association was found between workrelated walking vigorous or total workrelated pa and risk of depression no other domains of pa were related to risk of depression the proportion of participants at risk of depression was higher among women who reported doing all leisuretime pa on their own when compared with those who reported doing some proportion of their leisuretime pa with someone of the sb variables risk of depression was positively associated with tv viewing time screen time and overall sitting time but not associated with time spent sitting at the computer table iii shows the crude and adjusted ors and 95 cis from logistic regression models predicting the odds of risk of depression according to pa and sb variables physical activity both the unadjusted and adjusted results showed that compared with those in the lowest tertile of total leisuretime pa per week those in the middle and highest tertiles had lower odds of risk of depression when examined according to specific intensities both the unadjusted and adjusted results indicated that compared with those who reported no walking those who reported some walking in leisure time had lower odds of risk of depression results from both unadjusted and adjusted models showed that compared with women who reported no moderateintensity leisuretime pa women in the middle tertile of moderateintensity leisuretime pa per week had lower odds of risk of depression both the unadjusted and adjusted results showed that compared with those who reported no vigorous leisuretime pa per week those in the highest tertile had lower odds of risk of depression pa and depression while moderateintensity workrelated pa was associated with risk of depression in the unadjusted model this was no longer significant in the adjusted model both the unadjusted and adjusted results indicated that compared with those in the lowest tertile of transportrelated pa those in the highest tertile had lower odds of risk of depression when examined according to specific activities the adjusted results show that compared with those who reported less than 30 min per week of walking for transport those who reported greater than 25 hours per week had lower odds of risk of depression no associations were evident between domestic pa and odds of risk of depression in either unadjusted or adjusted models social context of pa before and after adjusting for covariates results showed that compared with those women who reported doing all leisuretime pa on their own those who reported doing about threefourth leisuretime pa alone had lower odds of risk of depression however this was the only category of social context to reach statistical significance sedentary behavior both the unadjusted and adjusted results showed that compared with women in the lowest tertile of computer time per week those in the highest tertile had higher odds of risk of depression tv viewing was not significantly associated with risk of depression in the adjusted model associations between women in the middle tertile of total screen time and risk of depression were not significant in the adjusted model however both the unadjusted and adjusted results showed that compared with women who reported less than 235 hours of total screen time per week those who reported more than 463 hours per week had higher odds of risk of depression unadjusted and adjusted results indicated that compared with women in the lowest tertile of sitting time per week those in the highest tertile had higher odds of risk of depression although there were significant main effects between mid and high amounts of leisuretime pa and risk of depression there were no interactions between leisuretime pa sb and risk of depression in either the unadjusted or the adjusted models discussion the current study provides novel findings regarding the domain and social context of pa as well as pa and depression the sbs associated with risk of depression in women from socioeconomically disadvantaged neighborhoods results showed that women who reported participating in greater amounts of leisuretime pa were less likely to be at risk of depression than those who reported undertaking less than this further results indicated an inverse relationship with risk of depression when examining the duration of leisuretime pa undertaken in each intensity these findings suggest that greater doses of leisuretime pa may reduce the risk of depression or alternatively people experiencing depressive symptoms spend less time in leisuretime pa consistent with findings from previous studies 11 the present study also found that undertaking a high dose of transportrelated pa was associated with lower risk of depressive symptoms compared with those who reported lower doses however when examined according to each transportrelated activity separately only high doses of transportrelated walking was associated with a reduced likelihood of depression suggesting that it may be the type of pa used for transport that is important this finding is in contrast to previous studies that specifically examined and found no association between transportrelated pa and risk of depression 1114 however the sample sizes of both previous studies were much smaller than that of the current study perhaps reducing the power to detect smaller associations consistent with previous studies 11 no association was found between any intensity of workrelated or domestic pa and risk of depression in this study this finding suggests that it may be the typemode of pa rather than the dose that is most important in determining the relationship with risk of depressive symptoms these findings may be due to womens lack of enjoyment or control when participating in workrelated and domestic pa a number of physiological hypotheses have been suggested to explain the inverse association between pa and depression including the endorphin hypothesis which suggests that pa produces endorphin secretion which in turn reduces pain and produces feelings of euphoria 38 however the production of endorphins requires a high exercise intensity 39 since walking for leisure was inversely associated with risk of depression in the current study other hypotheses such as the serotonin hypothesis 40 may be more applicable the serotonin hypothesis suggests that exercise may reduce depression by increasing the synthesis of serotonin 4142 a neurotransmitter found in the brain that regulates mood and stress 43 furthermore spending time outdoors may provide additional mental health benefits when undertaking pa as exposure to light has been found to increase serotonin synthesis 44 nonphysiological hypotheses may also play a role in explaining the inverse association between pa and depression these relate to distraction effects by which improvements in mental wellbeing following exercise may be due to the diversion of negative thoughts during the activity 45 alternatively improvements following pa may be the sense of mastery and success derived from achieving goals 45 the social context of pa was found to be associated with risk of depression in the current study although the association was not linear and only held for those women reporting undertaking onequarter of their leisuretime pa with someone else the finding that reduced risk of depression was associated with doing about onequarter of pa with someone else but not 50 or more is not easily explained this may have been related to the particular categories of pa analyzed however in further investigation of this association we recategorized social context as all leisuretime pa done on own more than half leisuretime pa done on own and less than half leisuretime pa done on own yet results showed no significant associations between either one of those categories and risk of depression further investigation of this nonlinear association is required the current study suggested that additional mental health benefits may come from undertaking some leisuretime pa with someone else yet not all pa with others may be associated with a lower risk of depression this is consistent with findings from the only other crosssectional study that has examined the association between the social context of pa and risk of depression 11 that study found that being active with a family member was associated with a lower risk of depression yet being active with a friend was not conversely our findings may also suggest that perhaps women at risk of depression prefer to participate in pa by themselves as social withdrawal is a symptom of minor depression 46 since social support is widely known to be linked to lower levels of depression 47 the social context of pa may be an important component in the relationship between pa and depression the current study found that undertaking greater doses of computer use screen and overall sitting time were associated with an increased risk of depressive symptoms this is consistent with several studies that assessed sb in terms of computerinternet use 48 and overall sitting time 21 suggesting that greater doses of sb increase the risk of depression or alternatively people experiencing depressive symptoms spend greater amounts of time in sbs the findings of this study indicated no interaction between sb pa and risk of depression in other words contrary to expectancies and to the findings of one existing study 3 positive associations between sb and risk of depression were not altered by participants leisuretime pa levels in the previous study 3 depression was not reported exclusively as the outcome measure eg the outcome measure also included stress and anxiety and a longitudinal design was used which may account for the differences in results however similar to our findings studies investigating physical health and disease pa and depression parameters have found the relationship between sb and physical health conditions such as obesity metabolic syndrome and type 2 diabetes to be independent of pa 49 50 51 therefore assessing the joint sbpadepression relationship may be an important point of consideration and area for further research one major limitation of the current study is its crosssectional design which does not allow for causality or the direction of relationships to be determined a second limitation is that selfreport measures were used to assess pa sb and risk of depression however all measures were well validated 3033 future studies could utilize objective measures such as accelerometers for assessing pa and sb finally women with missing data on any covariates were excluded from regression analyses in the present study chisquare analyses showed that a significantly greater proportion of women excluded for this reason were at risk of depression when compared with those who were included therefore a disproportionately higher number of women at risk of depression may have been missed in analyses a major strength of this study is the large populationbased sample of women living in socioeconomically disadvantaged neighborhoods which provided good power to detect associations even after controlling for a range of important covariates few studies have examined the association between domain and social context of pa and risk of depression or between sb and risk of depression particularly in women 10 furthermore only one previous study has assessed the interaction between sb pa and risk of depression 3 this study extends this evidence to socioeconomically disadvantaged women who are a population group at a great risk of physical inactivity 89 and depression 7 conclusion given that depression is the worlds most incapacitating illness 52 strategies to prevent and manage depression are increasingly important recognizing the crosssectional nature of the current study these findings suggest that promoting pa particularly for leisure and transport could be an important aspect in preventing depression furthermore mental health guidelines may be developed to include some aspect of socialaccompanied leisuretime pa for additional mental health benefits guidelines should also recommend reducing time spent in sbs in order to further reduce risk of depression however confirmation of these findings using prospective and intervention study designs is required conflict of interest statement none declared

this study investigated associations between components of physical activity pa eg domain and social context and sedentary behaviors sbs and risk of depression in women from disadvantaged neighborhoods a total of 3645 women aged 1845 years from disadvantaged neighborhoods selfreported their pa sb and depressive symptoms crude and adjusted odds ratios and 95 confidence intervals were calculated for each component of pa sb and risk of depression using logistic regression analyses adjusting for clustering by womens neighborhood of residence being in a higher tertile of leisuretime pa and transportrelated pa was associated with lower risk of depression no associations were apparent for domestic or workrelated pa women who undertook a small proportion of their leisuretime pa with someone were less likely to be at risk of depression than those who undertook all leisuretime pa on their own women reporting greater time sitting at the computer screen time and overall sitting time had higher odds of risk of depression compared with those reporting low levels the domain and social context of pa may be important components in reducing the risk of depression reducing time spent in sb may be a key strategy in the promotion of better mental health in women from disadvantaged neighborhoods

public health issue for african americans and increasing their rates is essential to eliminating these health disparities and thus promoting health equity health communication strategies are used in clinical settings to address health disparities however because of the history of discrimination and medical mistrust african americans tend to rely on their extended kinship networks for healthrelated information often health communication occurs in african american families through oral histories storytelling and narratives rooted in african american culture these informal methods of passing information from generation to generation have many purposes including an emancipatory function to counter dominant ideologies and to teach younger generations about the resilience and perseverance unique to the african american experience this experience dates back to the historical narratives from chattel slavery that include antiblack racism involuntary breeding sexual assault wetnursing child abduction forced sterilization and maternal vilification and the effects of this legacy are still ongoing stories and rituals are symbolic links to the past performed in the present thus they may be regarded as a means for understanding family communication as an oral tradition family infant feeding communication and the quality and availability of social support influences breastfeeding outcomes for african americans in african american families elders are entrusted keepers of communal knowledge and hailed as the wisest most respected members of the family they play an important role in preserving their cultural beliefs and family values other aspects of their role are passing down communication values and ideals which are foundational for intergenerational support in their flexible family system therefore african american mothers tend to consult their own mother and maternal grandmother for parenting guidance and advice rather than healthcare providers grandmothers play a critical role in infant feeding decisions and may act as a postpartum breastfeeding advocate furthermore researchers have postulated that since many grandmothers in the united states may lack breastfeeding knowledge and experience this may influence the support and advice they provide to new birthing parents in fact a grandmothers lack of understanding of current breastfeeding recommendations may influence a parents breastfeeding selfefficacy supply and overall success however strengthbased literature has suggested that although family feeding history may influence the expression of social support positive social support exists within african american families given that african americans experience breastfeeding disparities and health disparities understanding the key sociocultural contexts in which infant feeding is communicated is important an understanding of the meaning african americans give to shared infant feeding information within their family is necessary african americans are often bombarded with messages images and stereotypes of good motherhood from multiple channels however these messages may conflict with the complex relationships african americans have with their bodies families and communities as a result of their historically negative reproductive experiences in america the authors posit that the sociallyconstructed meanings of infant feeding information passed down from generation to generation by a mothers own mother andor maternal grandmother helps to shape feeding practices among the younger generation to better understand the meaning of sharing infant feeding information it is important to consider how each generation defines and navigates their familial roles these are missing components in the comprehensive study of family health and infant feeding communication therefore the aim of this study was to explore the interplay of generational familial roles and meaning ascribed to communicating infant feeding information across three generations of african american women theoretical frameworks black feminist thought and symbolic interactionism informed and guided this research bft provides a lens to view the intersectional experiences of black women and the ways in which they interact with society as a theoretical framework bft strives to change the narrative of black women highlight their compounding forms of oppression and express the value of culture in their lives collins supported the idea that selfdefinition permits key messages • we explored the interplay of generational familial roles and meaning that african american female family members ascribe to sharing infant feeding information across three generations • concerning the meaning of shared infant feed ing information older generations described their moral responsibility the middle generation expressed comfort and bonding and the younger generation reported their trust in older generations • lactation professionals should recognize the value of multigenerational oral traditions and consider including protection language in addition to support language when including elders into infant feeding conversations black women to rid themselves of the negative images and assumptions created by white society as an act of empowerment that counteracts marginalization symbolic interactionism was chosen alongside bft because symbolic interactionism is a communication theory of human behavior symbolic interactionism provided a framework for making meaning of lived experiences from the actors viewpoint meaning is one of the core essentials for understanding human behavior interactions and social processes symbolic interactionists have suggested that to fully understand a persons social processes one needs to understand the meanings that an individual places on experiences within a specific context both theories emphasize a persons lived experience which includes their internal human behavior the concept of meaning perceived by them and understanding context from their perspective method design based on the gaps identified this study adopted a prospective crosssectional qualitative research design using an assetdriven approach centering african american womens voices and lived experiences compared to other research methods qualitative research is unique because it allows the researcher to capture narratives feelings and thoughts this study was approved by the university of south florida institutional review board setting women living in the southeastern region of the united states tend to breastfeed less often than women living in other regions regardless of sociodemographic characteristics additionally women living in this region tend to experience disproportionately high rates of cesarean sections in addition to several shortterm and longterm health risks for mothers and their infants cesarean sections are associated with lowered breastfeeding rates sample a sample of african american women were recruited using purposive and snowball sampling family triads included the youngest adult generation her mothermother figure and her maternal grandmothergrandmother figure family dyads consisted of g3 and g2 grandmother and mother figures consisted of aunts sisters cousins and stepmothers who were responsible for raising g3 all participants were adult women who selfidentified as african american black colored or negro were a part of a family where at least two generations were willing to participate in the study and at least one generation in each family resided in the southeastern united states additionally the youngest adult generation needed to have had at least one child that they breastfed for 3 months or more and the child was 5 years or younger at the time of the study families were excluded if at least one woman in the dyadtriad reported not being in active communication with the other womanwomen in the family participants were recruited until a sample size adequate for qualitative research and thematic saturation was reached data collection from februarymarch 2019 inperson and telephone interviews were conducted with african american women living in the southeastern united states the first author is an african american female doctoral trained researcher who was the project leader and sole data collector for this project her identity mediated access to the study sample and the depth of information that each participant shared with her throughout the data participants used words and phrases like we us and you know reflecting the race concordance between the first author and participants this is a methodological strength of the study aw b obtained informed consent immediately before conducting the interview for both inperson and telephone interviews participants had the opportunity to ask questions about the informed consent prior to beginning the interview in each instance interviews were audio recorded all recorded and written data were kept confidential measures were taken to protect the storage of researchrelated records on a secure research server to which only a w b had access aw b developed and pilot tested two interview guides one for older generations and one for the youngest generation she used loosely structured interviews to engage with participants using a small list of core questions and probes while also allowing them to tell their stories in their own way considering the sensitivity of discussed topics a w b interviewed participants in a comfortable and convenient environment allowing them to talk freely and in detail interviews lasted 2090 minutes each participant was offered a 20 gift card for a local retailer data analysis participant characteristics were reported using descriptive statistics audio recordings were transcribed verbatim and data were deidentified using pseudonyms after being reviewed for accuracy transcribed interviews and field notes were imported into maxqda software for data management and analysis to add reliability and reduce risk of researcher bias a w b included a black phd candidate trained in qualitative research to serve as second reader and coder a w b used thematic analysis to deductively analyze transcripts that combined inductive coding and created thematic maps trustworthiness was achieved using the following techniques pilot testing the interview guides keeping detailed field notes peer debriefing maintaining a research reflexivity journal member checking utilizing multiple data coders and clarification of bias to ensure accuracy results participant characteristics fifteen african american family dyadstriads were interviewed nine families were dyads and six were triads all participants ranged from 2480 years the majority were married and all had a high school diploma or higher g1s mean age was 716 and parity was 32 live births g2s mean age and parity was 536 and 36 live births respectively g3s mean age and parity was 306 19 live births respectively see table 1 for additional participant characteristics contextualizing african american families selfdefined role in family exploring the perceived role each generation played in their family provided contextual information to understand the meaning they ascribed to sharing infant feeding information within their family each participant discussed their familial role and figure 1 displays a word cloud of each generations responses the larger the word or phrase the more often participants stated it g1s described their role as head mother grandmother great grandmother and advisor g2s described their role as keeps family together mother counselor and communicator finally g3s were careful to clarify to what context they were referring they would often say in their immediate family they were head organizer and provider but in their extended family they were the student learner and baby of the family each word cloud became more intricate and complex with each subsequent generation meaning attributed to communicating infant feeding information each generation was prompted to reflect on their family communication regarding infant feeding the meaning they attributed to communicating infant feeding information was expressed across the following themes my responsibility bonding experience comforting she cared and gained wisdom themes are defined and described below and in table 2 theme my responsibility my responsibility denoted the conviction and duty g1sg2s reported regarding sharing infant feeding information with g3s overall they believed elders were responsible for passing knowledge and values down to g3s louise discussed the importance of elders teaching younger women about infant feeding motherhood and womanhood it was very important to share information with my granddaughter because the scriptures say that the older women are to teach the younger women how to love their husbands how to be chaste housewives and how to raise their children and in todays society this is what we are missing we have information for you to bring you to another level and if we are not teaching then our generation line is missing a lot of stuff in general g1sg2s discussed the joy they experienced from sharing their knowledge vivian explained its good to share your knowledge with somebody you care about whether they take it or not it still makes you feel good to share it and when you find out that they have taken your advice you really feel good…cause you feel like you are here for a purpose to teach or to share… i think its good to pass the information that you done gathered in your life on to the younger people because the information is the same it might be done a different way but you put the idea in their head of how to do this that and the other and they dont necessarily have to do it the same way you do it but you done gave them the idea and the knowledge that this can be done this way cause i believe in not making stuff harder for yourself theme bonding experience bonding experience referred to the closeness g2s described having with g3s regarding their infant feeding discussions betty said it just kind of deepened our relationship because it was something that i had experienced as a mom and was able to pass on to her so its something that we could talk about… we could laugh about i mean because we have something else in our little history that we can talk about additionally roxanne expressed it meant the world to me because i love my daughter and my grandkids teaching her about being a mom and feeding her babies brought us closer to each other g2s enjoyed the idea of being able to bond with g3s over a topic that was as intimate as feeding children additionally yolanda said it was really comforting to know that i had some kind of experience and i could share some things that would make her life a little bit easier… some things that had passed down from my mom theme she cared she cared referred to the trust confidence and belief g3s described regarding the infant feeding discussions they shared with g1sg2s this theme encompassed g3s sentiments that g1sg2s cared for them because they took time to share infant feeding information with them g3s described three main reasons why they perceived older generations cared g1sg2s would not intentionally tell them anything wrong g1sg2s gave a personal touch while sharing infant feeding information and g1s g2s only wanted the best for them and their children asia recalled valuing her mothers advice being young and never experiencing breastfeeding i just kinda said well my momma knows best and i just went with what she said would be the best for my daughter it meant a lot because i was kind of going into the situation blind and young and inexperienced so you know i kinda felt like my momma had my back and she wouldnt steer me wrong additionally dominique recalled the hospital being very clinical but her mother gave something more it really meant a lot to have somebody that cares…not that nurses dont care…some of them do but some of them will my responsibility the conviction and duty g1s and g2s reported about sharing infant feeding information with g3s we supposed to talk to them…its important to talk to the young people to women and everything but its like when you say it dont go in there like a knowitall but kind of make them feel comfortable see it from both sides of the fence g1sg2s bonding experience the closeness and attachment that g2s described having with g3s during their infant feeding discussions it felt good you know because we were like bonding you know over something different you know so it felt good g2s comforting the tranquility and calmness that g2s experienced because of infant feeding discussions with g3s it was really comforting to know that i had some kind of experience and i could share some things that would make her life a little bit easier some things that had passed down from my mom g2s she cared the trust confidence and belief that g2s and g1s cared when having infant feeding discussions with g3s for g3s that were firstgeneration breastfeeders they shared that even though older generations may have initially been critical of their breastfeeding decision they understood their response came from a caring place brianna said i think when my mom and grandma dont understand something they…shun it away or they say that thats something that you shouldnt do but i know they are only doing and saying that because they only want to see the best for me…i know they still care they just dont know how to show that support thats needed theme gained wisdom gained wisdom revealed the value g3s placed on the wisdom expressed through infant feeding discussions with g1g2s g3s gave two main reasons why they valued the wisdom they gained g1sg2s had experienced motherhood before and the wisdom from their elders is priceless kimberly listened to her mothers instructions because of her prior motherhood experience i felt she knew what was going to be best shes been down this road before i feel like why not listen to her…and she was like okay youre going to breastfeed though i had not made up my mind so im thinking in my head she told me im gonna breastfeed maybe this is what i need to do… ill look more into it amber discussed the importance of recognizing and honoring the wisdom that elders contribute some of which was nonverbal well it was more so like with your mother or your grandmother or your aunt its not always…a real conversation its more like they do this to your baby…you just go with it you dont tell them no and i think its funny cause i think as black women the more educated we get the more we get away from letting our elders do what they know to do cause obviously what they know has worked so it was more like they tell you this is what you need to do you need to try this you need to try that oh okay yeah im on it ill do that lakisha lauded her grandmother for the wisdom she shared it really meant a lot because you cant in this day and age pay for that wisdomi feel i was very blessed to have my grandmother g3s generally described trust and acceptance toward the infant feeding information shared within their family discussion our findings may be used to strengthen understanding of the interplay of intergenerational familial roles and meaning ascribed to communicating infant feeding information across three generations of african american women we have added to the literature that using familycentered approaches to breastfeeding promotion and support may be beneficial for african american families as this racial group tends to be collectivistic rather than individualistic these findings have extensive implications for clinicians educators and scholars who work with african american families and have the potential to contribute to achieving health equity in this community novel findings were older generations described a moral responsibility to communicate information with younger generations which includes topics of infant feeding and beyond g2s described comfort and a strong bond from communicating infant feeding information with the younger generation and younger generations described trust and acceptance of the infant feeding information and wisdom they received from older generations g1sg2s discussed the symbolic meaning of moral responsibility related to passing on knowledge and wisdom to the next generation which is a consistent theme throughout african american history african american women and mothers have long used teachings as a form of protection for their children as an act of maternal love and as a central principle of their motherwork our findings also align with generativity concepts which include concern and need to nurture and guide younger generations older generations tended to define their familial role as head advisor communicator and counselor which may help to explain their conviction to share infant feeding information with g3s therefore those who work with african american families should consider integrating concepts of generativity to strengthen and enrich their breastfeeding support efforts leveraging the social influence from older generations and including them in infant feeding conversations at prenatal or wellbaby visits and in educational programs would honor the role of older generations in african american families and provide crossgenerational influence in addition to responsibility g2s reported bonding over something new in their motherdaughter relationship as well as feeling comfort knowing they shared information that g3s could use they described serenity in knowing that g3s gained knowledge and wisdom about motherhood womanhood and other aspects of life this finding contributes to further understanding the dynamics of familial roles among african americans bonding has been associated with trust and positively affects overall selfesteem in african americans as mentioned earlier mothering while black requires constant concern for protection that includes various socialization strategies future breastchestfeeding promotion efforts may benefit from reframing our current approach to including protection language and not solely support language proper messaging is the crux of breastfeeding promotion support and protection for example we could educate older generations about the importance of encouraging breastfeeding which may increase the chances that information funnels down to the younger generation thereby acting as another method of protection to effectively bring older generations into infant feeding conversations lactation professionals must first recognize honor and respect the grandmother role and understand the value each generation places on shared infant feeding information within african american families g3s indicated a high level of reverence for g1sg2s which is a cultural tradition placing value on respecting and obeying elders g3s demonstrated this reverence in the nuanced way they defined their familial rolesbeing the head of their household while also recognizing that they were students and learners in their extended families g3s generally described trust and acceptance of the infant feeding information shared by g1sg2s considering that african americans experience some level of medical mistrust understandably g3s found g1sg2s to be a trusting source of information g3s described the wisdom they gained from g1sg2s and that g1sg2s cared because of their willingness to share their infant feeding knowledge and stories feeling cared for contributes to a mothers sense of overall wellbeing african american communities disproportionately report experiencing substandard maternity care and do not feel cared for by the medical community frankly in the united states african american women are three to four times more likely to die from pregnancy or childbirthrelated reasons because of interlocking systems of oppression including the lack of value placed on their lives within the us healthcare system additionally various researchers have demonstrated that healthcare providers offer breastfeeding advice education and support less often to african americans than other racialethnic groups providers should recognize that this generation associates receiving infant feeding information with feelings of care and concern and provide them with equitable breastfeeding education interventions aimed to increase informal breastfeeding support are likely to increase breastfeeding rates since african americans tend to identify with collectivism there are direct implications for public health programs and interventions the following should be considered during the design phase reverence for the role and authority of elders and cultural traditions are foundational values elders are vital in conveying information to younger generations multigenerational and extended families influence beliefs of individuals within the family intergenerational interactions and communication are key and the communitybased participatory research model is an important element for successful interventions in addressing minority health disparities limitations in qualitative research participants and researchers engage directly which not only encourages prolific discussion and thick descriptions but also can increase the possibility of researcher bias additionally social desirability bias may have influenced participants responses while every effort was made to develop rapport with the participants and to elicit accurate responses a w b asked intimate questions about their familial relationship status and the meaning ascribed to sharing infant feeding information and participants may have felt uncomfortable answering accurately conclusion this novel study provides unique perspectives to existing infant feeding literature as few researchers have examined the interplay of selfdefined familial roles and how three generations ascribe meaning to shared infant feeding information within african american families our findings suggested potentially unexpected pathways to increasing health equity through recognizing and supporting the strengths and resourcerichness of intergenerational infant feeding communication within african american families using strengthbased empowermentoriented and ethnically sensitive approaches the meaning examined may provide a framework for further exploration of grandmothers roles in breastchestfeeding support and the specific contexts under which this may occur providing equitable care to african american families means respecting each generation gauging their feeding attitudes meeting them where they are and listening to them barr during her doctoral program and continue to mentor her dr woods barr serves as a mentor to jacquana smith authors report no conflict of interest disclosures and conflicts of interest the author declared the following potential conflicts of interest with respect to the research authorship andor publication of this article drs austin and schafer served as mentors to dr woods

background breastchestfeeding remains a public health issue for african americans and increased rates would mitigate many health disparities thus promoting health equity research aims to explore the interplay of generational familial roles and meaning or value ascribed to communicating infant feeding information across three generations method this prospective crosssectional qualitative study used an assetdriven approach and was guided by black feminist thought and symbolic interactionism african american women n 35 15 family triadsdyads residing in the southeastern united states were interviewed data were analyzed using thematic analysis results the older two generations described their role using assertive yet nurturing terms while the younger generation carefully discussed the flexibility between their familial roles emergent themes described the meaning each generation attributed to communicating infant feeding information my responsibility comforting bonding experience she cared and gained wisdom conclusions our findings have potential to contribute to achieving health equity in african american families future breast chestfeeding promotion efforts may benefit from reframing the current approach to including protection language and not solely support language lactation professionals should further recognize and support strengths and resourcerichness of intergenerational infant feeding communication within african american families using strengthbased empowermentoriented and ethnically sensitive approaches

introduction during pandemics the populations psychological responses to infection play an important role in both the spreading and containment of the disease influencing the extent to which psychological distress and social disorder occur 1 this may be partly explained by those emotional states that frequently mark pandemics such as uncertainty confusion and sense of urgency 2 in the early stages of a pandemic feelings of uncertainty prevail due to the fear of becoming infected and not having the right information about the best methods of prevention and management 3 4 5 furthermore pandemics are associated with various psychosocial stressors including health threats to oneself and loved ones significant changes in daily routine such as restriction in the physical activity behavior 6 7 8 separation from family and friends shortages of food and medicine wage loss social isolation due to quarantine or other social distancing measures and school closures 9 serious economic difficulties can also occur if a familys primary wage earner is unable to work due to illness 1 for these reasons the effects of the current covid19 pandemic would be more pronounced more widespread and longerlasting than the purely somatic effects of infection with serious impairment on peoples actual and perceived quality of life the covid19 pandemic that has hit the world in the last 12 months has indeed put a strain on our ability to cope with events and revolutionized our daily habits in italy a state of emergency was declared by the italian government on 31 january 2020 10 when two chinese tourists in rome tested positive for the sarscov2 the first case in italy was recorded in february 2020 and the epidemic rapidly spread reaching 220 infections on 24 february 11 the government responded by implementing prevention measures and infection control on 11 march when the number of infections reached 12462 and the total deaths were 827 despite the fact that the infection spread differently between the northern and southern regions of italy the increasingly restrictive containment measures led to a total lockdown throughout the country lockdown measures included the mandatory closure of schools and nonessential commercial activities and industries in addition to travel restrictions both inside and outside the country after 3 may the number of infections dropped below 1221 new cases and many restrictions were gradually eased 12 on 3 june freedom of movement across regions and european countries was restored and other nonessential activities reopened most of the early studies on the psychological impact of covid19 published at the beginning of the pandemic have compared the current situation with the sars epidemic in 2003 13 14 15 16 these studies highlighted the risk for people with suspected or certain infections to experience uncontrolled fear over a long period not only in relation to the disease but also to the condition of quarantine during the previous sars epidemic a peak of incidence of many psychiatric disorders such as depression anxiety panic attacks psychomotorial agitation and suicide had been reported kwek and colleagues 17 brought out the longterm consequences of the pandemic on health and claimed that sars impaired significantly both qol and mental functioning at three months from the acute episode a small number of additional studies conducted during a previous pandemic also showed the consequences of the pandemic on psychological wellbeing of infected people highlighting various factors associated with greater psychological distress including sociodemographic variables such as being a woman and middle aged adult or having a lower level of education 35 moreover the majority of the studies recently reviewed by brooks and coworkers 18 reported on the negative psychological effects of quarantine including symptoms of posttraumatic stress confusion and anger examples of relevant stressors were a long quarantine period fear of infection frustration boredom inadequate supplies of personal security systems inadequate information financial losses and social stigma this evidence has been further supported by an increasing number of publications on mental health demonstrating higher levels of psychological distress among the population during covid19 pandemic 19 20 21 22 for instance a large italian study by rossi and colleagues 19 showed an increase in anxiety and depressive symptoms for people who had lived four weeks of lockdown and found 37 of the sample with posttraumatic stress symptoms whereby female gender and younger age were risk factors for worse mental health however while the attention on the consequences of covid19 over mental health has been increasing there is a limited number of international studies on its effects over qol among already published studies pieh and coworkers 23 found an average psychological score of the world health organization quality of life bref questionnaire significantly lower compared to a study published in 2015 24 the study also reported lower scores for younger adults women individuals without work and those with low income horesh kapel levari and hassonohayon 25 also reported higher stress levels and lower qol for women younger participants and for people with preexisting chronic illness however to our knowledge there have been no studies investigating qol in italian populations during the covid19 pandemic 23 25 26 27 28 in addition to sociodemographic variables it has been suggested that other factors might influence qol during pandemics such as the difficulty in accessing healthcare services 2627 and social isolation 29 van ballegooijen and colleagues 27 described considerable levels of stress a lower qol and concerns about access to healthcare during the first eight weeks of the covid19 lockdown in the netherlands and belgium with respect to the difficulty in accessing healthcare a chinese study showed that the relevant index of qol decreased with increasing age due to the presence of chronic diseases in this segment of the population 26 regarding social isolation a british study reported lower levels of wellbeing and qol for people who felt more isolated than usual during lockdown whereas the level of perceived social support showed significant positive correlations with qol 29 another study from a chinese sample showed relatively lower levels of physical and psychological domains of qol but interestingly not in the social and environmental domains 28 these studies highlight that the pandemic situation including the measures put in place to contain it involves various aspects of life and health monitoring the state of health requires the measurement of indicators capable of grasping the many subjective and functional dimensions of wellbeing and qol particularly the assessment of qol is increasingly often considered as an integral part of any intervention that aims to promote health and wellness qol is actually viewed as an overall and multidimensional indicator of general wellbeing indeed the who defines qol as an individuals perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals expectations standards and concern 30 in measuring qol the whoqol group takes the subjective dimension strongly into account 31 the ability to feel a certain wellbeing regardless of living conditions is a subjective variable directly related to other dimensions genetic variables personality and life events it is a set of factors dynamically interacting with each other in a different way through the life span and across different cultures qol is not a simple and linear entity it is indeed a complex multidimensional construct that according to the who includes six domains physical psychological social level of independence environment and spiritualityreligionspersonal beliefs the present study aimed to explore the impact that both the covid19 emergency and the resulting restrictive measures had on the perception of qol among italian general adult population additionally this study aimed to investigate possible differences in qol depending on sociodemographic variables such as sex age marital status occupational status level of education and area of residence in italy as well as specific factors related to the covid19 outbreak particular reference will be given to the physical psychological social and environmental domains of qol as measured by the whoqolbref materials and methods procedure an online crosssectional survey was performed with qualtrics ® survey platform such a data collection strategy was chosen as it allowed us to reach as many voluntary participants as possible in a phase of forced social distancing the survey started after 7 weeks of quarantine in italy and was performed for about 6 weeks until the end of lockdown measures this measurement point was selected because significant changes in individuals qol need some time to be perceived by the person moreover this timeframe potentially allowed the population to adjust to the new situation the sample was recruited via a snowball sampling strategy a link to qualtrics questionnaires were sent via email social networks and official working platforms the link was shared with personal contacts of the research group members who in turn passed the survey to their friends and acquaintances a brief presentation informed the participants about the aims of the study and electronic informed consent assuring maximum confidentiality in the handling and analysis of the responses was requested from each participant before starting the investigation the survey took approximately 30 min to complete participation was voluntary and free of charge to guarantee anonymity no personal data which could allow the identification of participants were collected participants could withdraw from the study at any time without providing any justification and the data were not saved only the questionnaire data with a complete set of answers by respondents were considered the study was conducted in accordance with the declaration of helsinki and was approved by the bioethics committee of the university of palermo statistical analyses descriptive statistics and frequency analysis were used to investigate demographic characteristics and covidrelated information comparisons on these variables by sex and age range were performed using pearsons χ 2 test and students t test for independent samples for nominal and continuous demographic variables respectively analysis of variance was used to analyze the difference in respondents levels of qol at the global score of the whoqolbref while multivariate analysis of variance was employed to analyze the differences in levels of qol at domain scores of the whoqolbref statistical analyses were performed using spss for windows 34 in all statistical tests a p value of less than 005 was considered significant results demographic characteristics as table 1 shows the final sample comprised 2251 participants collected mainly from the north and south regions of italy respondents were mostly young and middle aged adults while the group of older adults was smaller most of them had a university degree or a high school diploma were employed and either single or married with respect to university students they were enrolled in either social sciences and humanities biotechnical sciences and medical study programs while a few students did not report their major with regards to comparisons between men and women in demographic variables we found statistically significant sex differences in employment status level of education and age range particularly women were less often employed than men so much so that 80 of the unemployed respondents were women although with higher levels of education in fact women reported more often than men to have a university degree or a postgraduate title moreover with regards to age distribution female respondents were mainly from the group of middle adults while fewer of them fell into the older adults group compared to men table 1 reports that 136 respondents had a psychiatric diagnosis at the time of data collection with the highest prevalence in women compared to men within this group 471 individuals have been diagnosed with anxiety disorders 412 with mood disorders while the remaining 117 with other conditions yet 394 participants reported to be in treatment for a medical condition mainly for circulatory system diseases such as hypertension and heart failure and endocrine system diseases such as diabetes and hypothyroidism no significant differences in the distribution between men and women were detected covidrelated information table 2 shows the results obtained from epidemicrelated information most participants had their jobstudy activity moved at home didnt have any family members or friends diagnosed with covid19 were always adherent to control and precautions measures against covid19 and had a household size of mainly three to four persons concerning sex differences among these variables we found a significantly different distribution of answers between men and women in the adherence to control and precautions measures against covid19 particularly most women reported to be more inclined to always adhere to control and precautions measures against covid19 rather than often or not that much compared to men we did not find any significant sex difference with regards to the distribution of changes in jobstudy activity presence of family members or friends infected by covid19 and household size during the outbreak of the disease with respect to age range differences we found a significantly different distribution of answers in the variables changes in jobstudy activity and household size during the outbreak of the disease particularly young and middle adults reported to have mainly their job activity moved at home as well as a household size of three to four persons during lockdown compared to older adults who reported no changes in job or job moved at home to the same extent and a house composition of mainly two persons no significant age differences in the adherence to control and precautions measures against covid19 nor in the presence of family members or friends infected by covid19 were detected quality of life during the outbreak of covid19 table 3 presents means and standard deviations for whoqolbref global and domain scores the overall average score at the whoqolbref for our sample was 5448 analyses performed on the single items showed that the item with the lowest scores was 14 given that 932 participants reported to have little or no time for leisure at the time of data collection said item refers to the domain environment of the whoqolbref regarding the other three domains of the whoqol items with lowest scores were item 15 for the physical domain as 1019 participants reported little or no possibility to do physical activity item 5 for the psychological domain with 712 respondents reporting that they were not enjoying their lives at the time of data collection and item 21 for social relationships as 843 respondents reported that they were little or not at all satisfied with their sexual life results of anova analyses showed that whoqol global scores differed between male and female participants 934 p 0002 with women reaching lower scores compared to men no significant differences were found for age range 191 p 0148 about the factor scores of the whoqol two separate manovas were run by taking into account sex and age range as the only betweensubject factor the model where sex was considered showed a significant main effect for this variable 1351 p 0001 betweensubject tests showed significant differences between men and women in the areas of physical 1758 p 0001 psychological 2585 p 0001 and environmental 700 p 0008 domains as can be seen in table 3 women reported overall worse psychological physical and environmental qol during the pandemic compared to men age range also resulted in a significant betweensubject factor for the detection of differences across whoqolbref domains 1193 p 0001 about this results showed significant differences among groups in the psychological 1169 p 0001 and environmental 1196 p 0001 domains particularly young adults reported the lowest levels of psychological qol which were significantly lower compared to both middle and older adults as attested by bonferronis post hoc comparisons as shown by table 3 middle adults had the lowest scores at the environment domain compared to both young and older adults no significant differences emerged in both physical 039 p 0675 and social relationship 182 p 0161 domains differences in demographic and covidrelated variables the effects of 10 further relevant variables were tested over whoqol global and domain scores in light of the results on sex and age range sex was controlled in all additional anovas while both sex and age in all manova models table 4 presents means standard deviations and statistics of anova and manova analyses overall no interaction term was significant therefore statistics were not reported within the table as reported by table 4 results show that seven out of ten variables significantly differed in whoqol global score while five other whoqol factor scores did not overall three variables namely marital status family member or friend infected with sarscov2 and household size during covid outbreak had no significant effect over both global and factor scores of the whoqol regarding whoqol global score results from table 4 show that individuals with the poorest qol during the outbreak of the disease had the following characteristics lived in the south of italy had lower education levels were unemployed or university students had been diagnosed with psychiatric and medical syndromes had their job activity suspended and did not comply with the restriction measures to contrast covid19 pandemic with respect to the factor scores of the whoqol significant effects were found for the following variables area of residence in italy level of education having a diagnosis of a medical condition changes in employment status and location and for adherence to precaution measures none of such effects pertained the dimension of the whoqol assessing social relationships when area of residence in italy was considered betweensubject tests revealed that only the differences pertaining the dimension of environmental health were significant 1116 p 0001 with respondents living in the south reporting overall worse conditions of their environment which were significantly different compared to respondents from the north of italy betweensubject tests for level of education showed that environmental 543 p 0001 and psychological health 345 p 0016 were significantly different across groups particularly bonferroni post hoc tests showed that individuals with a high school diploma had significantly lower levels of psychological health compared to respondents who had either a university degree or a postgraduate title yet individuals with a postgraduate title reported the highest scores for environmental health which were significantly different to that of individuals with a secondary or high school diploma as well as with a university degree with respect to medical conditions betweensubject tests showed that physical 891 p 0003 psychological 403 p 0045 and environment 490 p 0027 domains of qol were significantly lower for those respondents reporting a diagnosis of a medical condition betweensubject tests relevant to changes in employment status and location showed significant differences across groups in both physical 597 p 0001 and psychological domains 421 p 0006 specifically respondents who were unemployed prior to the covid19 outbreak reported worse levels of both physical and psychological health which were significantly lower compared to individuals who had their jobstudy activity with no changes or moved to home with respect to the variable adherence to control measures betweensubject tests showed that the domain environment 615 p 0002 was significantly different across groups with individuals who reported lower levels of adherence to control measures having the poorest qol pertaining to environment compared to respondents who reported either always or often discussion the study aimed to assess the impact of the covid19 pandemic and lockdown measures on qol in a large italian sample the main objective was to investigate possible differences in qol levels related to both demographic and pandemicspecific factors with particular attention to physical psychological social and environmental dimensions of qol our results show a number of significant differences in qol levels related to several relevant variables although the whoqol does not have cutoff scores allowing a precise definition of qol as poor or good and despite the absence of recent data available on italian qol assessed with the whoqol already existing literature can be taken into account to make some general considerations our results showed that during the lockdown period the mean of both the global and dimensions scores of the whoqol were lower compared to those obtained by both the italian validation study of the questionnaire 33 and an international study comparing the main psychometric properties of whoqolbref among 23 countries 31 along this line it is interesting to note that our results showed a poorer qol for our sample compared to the data reported by another italian study in which the goal was to estimate qol changes over an 18month period in an adult population sample after the laquila 2009 earthquake 35 these results emphasize that the current situation due to the pandemic emergency and the lockdown measures had a severe impact on the qol of the italian general population as confirmed by istat report 36 it was and still is an actual collective trauma in fact although only 74 of the respondents reported to have a friend or relatives hit by covid19 we did not find significant differences in qol compared to participants who had no friends or relatives infected by the virus peoples lives during lockdown were affected by an abrupt and sudden change in their habits a sense of precariousness the indefiniteness of the future and a strong worry for their health all these factors may have affected general qol levels looking into this even further we found that the items that overall had the lowest scores were to what extent do you have the opportunity for leisure activities how well are you able to get around how much do you enjoy life and how satisfied are you with your sex life through these items it is possible to grasp the considerable impact that the lockdown measures have had on the dimensions of life satisfaction and pleasure favoring an impairment of the ability to enjoy life particular attention should be given to the psychological domain which seems to indicate a relapse to depressive nuances related to the loss of pleasure for ones life furthermore it might be that the shelterinplace order could have led to restrictions in physical activity behavior 6 with a possible significant negative impact on psychological wellbeing and qol in fact recent literature suggests that daily physical activity helped to offset the psychological burden and negative emotions caused by covid19 pandemic 6 7 8 a possible explanation is that regular exercise is linked to change in hypothalamicpituitaryadrenal axis with reduced adrenal autonomic and psychological responses to a psychosocial stressor 37 with respect to the influence of demographics on qol results showed significant differences between men and women in line with the literature on qol women reported overall worse psychological physical and environmental qol during the pandemic compared to men 3133 for instance girgus and yang 38 showed that womens increased psychological vulnerability might be due to a higher tendency to ruminate and to use internal attribution for negative events pineles hall and rasmusson reported more cognitive symptoms of ptsd such as selfblame in women compared to men 39 it is important to notice that in our sample 80 of unemployed respondents were women although with higher levels of education than men yet within the 61 of respondents that had a psychiatric diagnosis the highest prevalence was represented by women with this regard epidemiological data have shown that in italy despite a higher longevity women get more illnesses and tend to have a lower quality of physical and psychological health than men 4041 according to bekker 42 gender differences in healthrelated phenomena can be explained through a holistic approach in which the relationships between biological sex gender and health are various diverse operative at many levels and complex in fact this relationship can be moderated by daily life or social circumstances personrelated characteristics and healthcare factors 42 with respect to daily life and social circumstances we can assume that as a consequence of school closures during the covid19 lockdown italian women experienced a greater overload in care and work favoring an organizational family shock 3543 with regards to age range differences young adults reported the lowest levels of psychological health which were significantly lower compared to both middle and older adults middle adults had the lowest levels of environment dimension compared to both young and older adults no significant differences emerged for both physical and social domains compared to other age groups and in the context of the pandemic younger adults represent the most psychologically fragile subjects additionally their age is characterized by important transformations which during the pandemic situation might have exposed them to higher risks for their psychological wellbeing students unemployed young people or young people in the process of building a family or achieving working objectives have suddenly seen a threat to their projects and prospects for the future young adults have certainly experienced more negative emotions and loss of selfconfidence with a possible impact on reasoning ability learning memory and concentration for example for university performances in fact emotional skills are crucial to cognitive processes as they affect cognitive styles use of learning strategies 44 and consequently performance 45 other studies conducted during lockdown 192325 showed a lower qol and high levels of stress anxiety and depression in younger adults pieh and colleagues 23 reported a clear agerelated effect in all tested mental health scales in which the younger adult groups showed the worst scores in contrast to a previous study before covid19 the authors hypothesized various explanations for these findings such as more uncertain conditions and financial difficulties that occurred in covid19 lockdown according to horesh and coworkers 25 instead older age seemed to act as a protective factor for psychological health and this could be attributed to their richer life experience 46 and a possible reduced fear of illness and death despite the fact that the elderly are constantly being identified as a highrisk population 26 47 48 49 middle adults showed less impact on mental health but greatest dissatisfaction with the availability of financial resources accessibility and quality of health and social care 2627 the domestic environment conditions access to information and sense of safety for their own health regarding to the physical environment and to the possibility to access to means of transport in safety compared to younger and older ones during lockdown about 50 of young people and 53 of middle adults underwent changes in work conditions this can also explain the dissatisfaction about housing conditions in which simultaneously parents and children shared the same spaces to carry out their activities with a probable lack of personal space but about 18 of middle adults and about 14 of older had to stop their work activities and this could have led to dissatisfaction with their own financial resources with these not being considered adequate to meet their needs in addition in the first weeks after the declaration of emergency state mass media were overwhelmed by information which was not always accurate given the little knowledge on the contagion and the care of covid19 people probably felt a sense of uncertainty confusion and serious threat for their own physical safety high intolerance of uncertainty has been found to exacerbate the relation between daily stressors and increased anxiety 50 and not unexpectedly increased intolerance of uncertainty as well as the desire to reduce uncertainty was found to predict increased information seeking and monitoring of a situation 51 therefore obtaining information that only provides uncertain estimates related to viral threats may serve to increase perceptions of uncertainty and thus increase anxiety 5 our results also showed that individuals who were living in the south of italy at the moment of the lockdown had lower education levels were unemployed or university students were diagnosed with psychiatric and medical syndromes had their job activity suspended and did not comply with the control measures to contrast covid19 pandemic had the poorest qol during the outbreak of the disease it is interesting to point out that southern italy during the first period of lockdown was less affected by the epidemic yet the population showed lower levels of satisfaction with their general state of life on the one hand this can be related with structural differences that have always recorded lower qol levels in the south than in the regions of northern italy 52 especially with regard to the environment dimension starting from these structural differences between the north and south of italy it is possible to assume that the population of southern italy has perceived greater concern and distrust in the ability to cope with the pandemic to support this rossi and colleagues 19 showed higher odds of several psychological outcomes such as anxiety depression perceived stress and insomnia in people who lived in southern italy in regards to the relationship between low education level and low scores in the quality of life measure it appears that the most compromised dimensions were psychological health and the interaction with the environment skevington 53 reported worse qol levels in people without education especially in some areas of qol vice versa most highly educated respondents reported a more positive environmental qol in terms of financial resources and physical environment eg pollution and access to information and skills 5354 it is conceivable that during lockdown a lower educational level probably impaired more wellbeing because it hindered access to nonalienated paid work and economic resources and may have reduced the sense of control over ones life as well as the access to stable social relationships especially marriage then a lower educational level could increase emotional distress physical distress and levels of dissatisfaction as to work conditions individuals who were unemployed prior to the covid19 outbreak reported overall worse levels of both physical and psychological qol which were significantly lower compared to individuals who had maintained their jobstudy activity with no changes nor moved to home these findings are supported by previous studies highlighting a relationship between unemployment and poorer healthrelated qol explained by the economic and social consequences of unemployment 5556 work has a central part in most individuals lives it meets the requirements of both material needs and social needs 57 and these requirements are further compromised by limitations about job search activities during lockdown 36 with reference to persons suffering from medical diseases they reported lower scores in the physical and psychological domains but also in the interaction with the environment probably due to the difficulties of access to healthcare services during the pandemic italian hospitals were converted into covid hospitals and entire wards and surgeries were closed making it difficult to access for all those with chronic or acute noncovid19 medical conditions furthermore as assumed by van ballegoijen and coworkers 27 patients could have been anxious to visit their physician due to fear of infection or to avoid further burdening the healthcare system this could lead to secondary healthcare problems such as delay in diagnosis of critical medical conditions and exacerbation of existing health conditions horesh and colleagues 25 hypothesized that having a preexisting medical condition is associated to distress because covid19 is more dangerous for those with existing illness and for that reason these patients may have felt more vulnerable most of our participants said they adhered to the governmentenacted measures much or very much and there was a significant difference between women and men in favor of the former these data are in line with the study of carlucci dambrosio and balsamo 58 where it was assumed that the increased adherence of women to containment measures can explain sex differences in mortality and vulnerability 5960 to the covid19 disease in this case womens adherence has been a protective factor as suggested by findings from previous studies regarding age and gender patterns of risktaking behaviors 6162 men would be more likely to engage in risk taking behaviors finally the present results have also highlighted that people who felt a greater dissatisfaction in all areas of qol especially the environment dimension had a lower adherence to containment measures after all qol is given by the interaction between environmental and personal factors and it is possible that people who have perceived higher dissatisfaction with the availability of financial resources physical safety and accessibility and quality of health and social assistance may have had a more passive attitude linked to the sense of helplessness concerning the real possibility that their personal contribution could contain the spread of contagion moreover feelings of helplessness and passivity in dealing with the threat may result from high perception of risk that can promote the adoption of strategies to minimize infection 63 conclusions there are limited international studies that have investigated how severe the impact of covid19 pandemic is on qol and to our knowledge there have been no studies on the italian population 23 25 26 27 28 we believe that the assessment of qol represents an important indicator of global health which allows us to grasp the state of health of a population in a multidimensional way especially in this particular moment in which all the dimensions of life have been disrupted our study highlights significant differences in qol and its dimensions depending on a number of variables including sex age status of employment area of residence in italy and being diagnosed with a medicalpsychiatric condition during the covid19 pandemic and lockdown strengths of the present study include the focus on a large italian representative sample which could be reached in a relatively short time period since the pandemic situation developed rapidly and the use of an internationally validated questionnaire of course the present study has some shortcomings such as gender imbalance crosssectional data collection the lack of information on the population of the central regions of italy and no exclusion criteria except minors under the age of 18 and those not living in italy during covid19 lockdown we are aware that we have analyzed only some of multiple aspects that influence qol and many others should be tested and considered in further research such as the role of physical activity on psychological wellbeing however based on our findings attention should be given to people showing a combination of risk factors including younger age female gender unemployed status having a preexisting illness and living in the south of italy thereby assisting them in coping with the pandemic especially now that the continued exposure to the epidemic and to the necessary measures to contain it above all in italy could lead to further impairment of the peoples quality of life we believe that subjective wellbeing measures are needed to assess a societys population and it is important to add them to the health and economic indicators that are now favored by policymakers such measures include qol which may be conceptualized as a multidimensional construct that is influenced by personal and objective factors as well as by their interactions the subjective evaluation that people make about their living conditions their expectations and their beliefs could also play a very important role for the adherence to both contagion containment measures and vaccination actually health authorities have devoted relatively little attention to the identification and management of psychological and social factors likely to significantly influence a persons qol our results can offer guidelines regarding which social groups may be at a high risk of decreasing qol revealing areas of vulnerability during a pandemic this line of research is particularly important for the management of public health interventions especially in regards to the need for an optimal allocation of resources findings suggest the following recommendations for future interventions more attention needs to be paid to vulnerable groups such as the young women unemployed and people living in the south of italy implementing psychological interventions for vulnerable individuals who cope with the longterm consequences of this pandemic accessibility to medical resources and the public health service systems should be further strengthened and improved comprehensive crisis prevention and psychological intervention are needed to reduce distress and prevent further impairment of qol data availability statement data available on request due to restrictions acknowledgments with grateful thanks to marianna franco simona piraino and sofia scordato to help us to data collection informed consent statement informed consent was obtained from all subjects involved in the study

the covid19 pandemic that has hit the world in the year 2020 has put a strain on our ability to cope with events and revolutionized our daily habits on 9 march italy was forced to lockdown to prevent the spread of the infection with measures including the mandatory closure of schools and nonessential activities travel restrictions and the obligation to spend entire weeks in the same physical space the aim of this study was to assess the impact of the covid19 pandemic and lockdown measures on quality of life qol in a large italian sample in order to investigate possible differences in qol levels related to both demographic and pandemicspecific variables a total of 2251 italian adults 1665 women mainly young and middle adults were recruited via a snowball sampling strategy participants were requested to answer to an online survey which included demographic and covidrelated information items and the world health organization quality of life bref questionnaire whoqolbref the results showed statistically significant differences in qol depending on a number of variables including sex area of residence in italy and being diagnosed with a medicalpsychiatric condition to our knowledge this is the first study to assess qol during covid19 pandemic in italy therefore the present findings can offer guidelines regarding which social groups are more vulnerable of a decline in qol and would benefit of psychological interventions

pdi july 2015 vol 35 no 4 ses and pd peritonitis by occupational status rental status living arrangements marital status or surface area of residence finally the brazilian peritoneal dialysis multicenter study study observed that lower educational level but not family income was independently associated with increased risk of peritonitis these studies have all investigated indicators of individuallevel ses to our knowledge there has been no study investigating associations between arealevel ses and peritonitis rates or any published nationwide study of associations between ses and peritonitis the aim of the present study therefore was to investigate the associations between area ses on the rate of peritonitis time to first peritonitis and the outcome of peritonitis using national registry data in australia material and methods study population in the present study all nonindigenous australian patients from the anzdata registry who received treatment with pd between 1 october 2003 and 31 december 2010 were analyzed the data collected included demographic data postal codes at the time of commencing renal replacement therapy cause of primary renal disease comorbidities at the start of dialysis smoking status body mass index and late referral the data were collected throughout the calendar year by medical and nursing staff in each renal unit and submitted annually to the anzdata registry indigenous patients were excluded because residential postal code at the commencement of pd does not always reflect their usual place of residence socioeconomic status socioeconomic status was obtained based on australian socioeconomic indexes for areas from the australian bureau of statistics similarly to previous investigations socioeconomic indexes for areas are summary measures of a number of variables that represent different aspects of relative socioeconomic disadvantage and or advantage in a geographic area they provide more general measures of ses than are given by measuring income or unemployment alone in this study postal codes were used as the area unit postcodes were ranked into deciles based on each of the four seifa variables decile 1 is the most deprived or disadvantaged group of postcodes a summary measure for a particular community was created by combining information about the households and individuals who live in that area based on australian census data each of the four available seifa variables were separately evaluated a index peritonitis rate was defined as the total number of episodes of peritonitis per number of years of pd therapy in keeping with ispd recommendations relapsed peritonitis was counted as a single episode and patients with a pd catheter in situ who were not receiving pd were not included in peritonitis rate calculations the clinical outcomes examined were peritonitis cure peritonitisassociated hospitalization catheter removal temporary hemodialysis transfer permanent hd transfer and peritonitisrelated death a peritonitis episode was considered cured by antibiotics alone if the patient was symptom free the pd effluent was clear and the episode was not complicated by relapse catheter removal or death peritonitisrelated death was defined as any death within 30 days after an episode of peritonitis statistical analysis categorical results were analyzed using chisquare tests and presented as frequencies and percentages normally distributed results were analyzed using anova and presented as mean ± standard deviation nonnormal continuous variables were analyzed using kruskalwallis tests and presented as median predictors of rates of pd peritonitis were determined by mixedeffects poisson regression with initial pd hospital treated as a random effect the independent predictors of the clinical outcomes of peritonitis were determined by mixedeffects multivariable binomial logistic regression model with both initial pd hospital and patient treated as random effects mixed models are one of the standard tools for the analysis of clustered data where a sample of cases is repeatedly assessed the covariates included in all the models were seifa deciles age gender racial origin bmi late referral within three months of dialysis commencement endstage renal failure cause smoking status and comorbidities and estimated glomerular filtration rate initial empiric antibiotic regimens were added in the model of peritonitis outcomes as covariates all the models were run separately for each seifa index data were analyzed using the software packages pasw statistics for windows release 180 and statase version 120 p values 005 were considered statistically significant results from 1 october 2003 to 31 december 2010 a total of 7419 nonindigenous australian patients received pd treatment with 3585 patients experiencing 7299 peritonitis episodes seifa were unavailable for recorded postcodes in two patients consequently 7417 patients were included in the analysis and were followed for 16242 patientyears their characteristics are depicted in table 1 peritonitis rate the overall peritonitis rate was 045 episodes per patientyear of treatment calculated peritonitis rates for deciles of each seifa variable are shown in figure 1 no clear pattern was able to be identified between any of the seifabased deciles and peritonitis rate mixedeffects poisson regression demonstrated that incident rate ratios for peritonitis were generally lower in the higher seifabased deciles compared with the reference although the reductions were only statistically significant in some deciles in a subgroup analysis of grampositive bacterial peritonitis no clear or consistent relationship was observed with ses peritonitis outcomes a total of 7417 patients with 7295 episodes of peritonitis in 3583 pd patients were included in the final peritonitis outcome analyses clinical outcomes of peritonitis within deciles of each seifa variable were generally similar with the exception of significantly lower percentages of hospitalization in decile 10 of each seifa variable and significantly shorter hospitalization durations in decile 10 of each seifa variable except irsad using mixedeffects multivariable logistic regression with decile 1 of each seifa variable as reference after adjusting for other confounding factors ses did not predict cure of peritonitis catheter removal or permanent hd however the lower probabilities of hospitalization were predicted by better ses advantage status less ses disadvantage status greater access to economic resources and higher educational and occupational status respectively moreover lower probabilities of peritonitisassociated death were predicted by less ses disadvantaged status present study a recent large multicenter study of 2032 incident and prevalent brazilian pd patients showed that ses based on family income was not clearly associated with peritonitis risk however contrary to the findings of the present study lower educational level was associated with heightened time to first peritonitis risk in contrast a hong kong study involving 102 consecutive incident pd patients demonstrated that peritonitis risk was predicted by receipt of social security payments at pd commencement although not by occupational status rental status living arrangements marital status or surface area of residence a subsequent study of 1595 incident pd patients in the usa observed that indices of lower ses such as unemployment student status and renting a house were independently associated with increased risks of discussion this retrospective multicenter registry analysis found that compared with the lowest decile of area ses higher ses was generally associated with lower peritonitis rates although these risk reductions were only statistically significant in some deciles and they varied both within and between each of the four seifa variables used the highest deciles of ses for each of the four seifa variables were associated with lower probabilities of hospitalization and the least disadvantaged decile and the decile with greatest access to economic resources experienced significantly lower probabilities of peritonitisassociated death studies investigating the relationship between ses and peritonitis are sparse similar to the findings of the the disparity in findings between the different studies may be explained by the appreciable differences in healthcare education and welfare systems that exist between the different countries australia provides universal access to governmentfunded free healthcare heavily governmentsubsidized medications universal mandatory free education to high school and welfare payments for disadvantaged groups these factors which are not uniformly present in the countries of the other studies may have significantly mitigated the impact of lower ses on pd peritonitis risk and outcomes in contrast ses may be expected to have more impact in countries which require individuals to make significant copayments towards their healthcare thereby potentially disadvantaging patients from lower ses backgrounds who cannot even afford small outofpocket expenses for example disadvantaged us citizens are less likely to have insurance and may face significant outofpocket costs for many services consequently the observed associations between ses and peritonitis risk may be healthcare systemspecific such that the results of the present study may not be generalizable to other countries with appreciably different healthcare systems another potential factor accounting for the observed differences in impact of ses on peritonitis risk and outcome in australia compared with other countries may relate to differences in methods used to evaluate ses the present study utilized socioeconomic indexes for areas rather than individuallevel ses used in previous studies which by utilizing up to 21 different census variables for each ses index provided a more comprehensive assessment of ses than the limited number of single variables used in other studies to our knowledge the present study is the first to have investigated the effect of ses on peritonitis outcomes although no association was observed between ses and rates of peritonitis cure catheter removal or permanent hd transfer we found that groups with the least ses and pd peritonitis socioeconomic disadvantage and the greatest access to economic resources experienced significantly lower risks of both hospitalization and peritonitisassociated death in spite of the availability of universal access to free healthcare previous investigations have shown that australians from advantaged backgrounds were more likely to have additional health insurance and more likely to receive longer consultations with general practitioners these factors may have contributed to superior peritonitis outcomes in the highest ses decile in the current study for example it is possible that higher ses patients may have had better access to healthcare leading to earlier presentation with peritonitis symptoms earlier diagnosis and treatment and ultimately better outcomes alternatively other factors such as lesser household crowding in higher ses patients may have been operative these hypotheses were unable to be tested in the present study due to the limited data collected by the anzdata registry in addition there is likely to be differential selection of patients who commence pd in australia pd is uncommon in privatelyfunded hospitals and is more common among patients from remote areas of australia who have generally lower ses than city dwellers the strengths of this study include its very large sample size and inclusion of virtually every australian patient receiving pd during the study period ses was evaluated using four indices which in turn include a range of factors rather than being primarily related to income moreover a range of peritonitis outcomes was in conclusion in australia where there is universal nearlyfree healthcare higher ses was associated with lower risks of both peritonitisassociated hospitalization and death but similar risks of peritonitis cure catheter removal and permanent hd transfer the effect of ses on peritonitis rates was uncertain as the general reductions in peritonitis rates observed in higher ses categories were modest and only statistically significant in some categories in a manner which varied within and between each of the four ses variables examined further research evaluating strategies for overcoming poorer peritonitis outcomes in socioeconomically disadvantaged patients is warranted

background the aim of the present study was to investigate the relationship between socioeconomic status ses and peritoneal dialysis pd related peritonitis ♦ methods associations between area ses and peritonitis risk and outcomes were examined in all nonindigenous patients who received pd in australia between 1 october 2003 and 31 december 2010 peritonitis outcomes ses was assessed by deciles of postcodebased australian socioeconomic indexes for areas seifa including index of relative socioeconomic disadvantage irsd index of relative socioeconomic advantage and disadvantage irsad index of economic resources ier and index of education and occupation ieo ♦ results 7417 patients were included in the present study mixedeffects poisson regression demonstrated that incident rate ratios for peritonitis were generally lower in the higher seifabased deciles compared with the reference decile 1 although the reductions were only statistically significant in some deciles irsad deciles 2 and 4 9 irsd deciles 4 6 ier deciles 4 and 6 ieo deciles 3 and 6 mixedeffects logistic regression showed that lower probabilities of hospitalization were predicted by relatively higher ses and lower probabilities of peritonitisassociated death were predicted by less ses disadvantage status and greater access to economic resources no association was observed between ses and the risks of peritonitis cure catheter removal and permanent hemodialysis hd transfer ♦ conclusions in australia where there is universal free healthcare higher ses was associated with lower risks of peritonitisassociated hospitalization and death and a lower risk of peritonitis in some categories

introduction sport as a necessary component of life sports have developed into a significant subject of study and practice that has a significant impact on the person society and the social structure sports activities have sparked the development of significant and universal values like camaraderie solidarity and tolerance that support peoples longterm social and personal growth sports activities have a significant role in combating against illnesses brought on by modern lifestyles sports is an important phenomenon that supports people physiologically psychologically and sociologically in their lives as well as many common norms and unites individuals in a common characteristic sports events which are an inseparable part of daily life appear as a human event that consists of the trio of spectators champions and medalists whose visual aspect is prominent which drags the masses after them and which can be fanaticism or fanatical behavior has been researched for many years independent fanaticism represents the sport between matches and teams having the knowledge of revealing the identity of people who follow football and getting help in addition to this they can become losers with the indispensable passion of football groups that receive fanaticism enhancements may engage in choices antisocial or violent behavior fanaticism on the other hand exhibits extreme actions including violence in a socially undesirable framework in contrast to the way that love and attachment to a team are shown in the context of societal acceptance the size of the sports industry its cultural support the large number of spectators and its strong economic impact appear as one of the most important factors that increase this interest and feeling of admiration fanatic viewers may resist losing competitively or failing the relevant sports service resulting in apathy or pessimism towards the team in this case since fanatic behavior can turn into violence the necessity of managing the interest in question arises because the concept of sport is a social phenomenon and continues to exist in order to support healthy individuals with the reduction of violence in society this purpose also conforms to the living principles of the modern world sport literacy the concept of literacy can be expressed as the ability to read and write texts written in alphabet in its most general form the concept of literacy with its most basic feature means having the ability to read written texts in any language to make sense of what they read and to understand all these if we look at the definition of literacy which is understood today it is the state of having the competence to use a set of communicative symbols that are understood correctly by the society in which one lives the concept of literacy is a skill based on the correct use of operational symbols interpreted by the general public the quality of being a communicative symbol interpreted by society is a system that renews literacy and is put forward in line with the expectations of every age from this perspective although literacy is seen as a skill that meets the conditions and needs of the period it has an identity that renews itself and its meaning in periodical changes since the concept of literacy is found in all areas of life some types have emerged for example information literacy in the sense of having and using the information necessary for life cultural literacy that explores the factors that make up the society and the causes and causes of these elements and universal literacy that aims to look at events situations and phenomena are some of them different and multiple applications can occur in education systems multiple intelligences multiple learning environments multiple perspectives and interdisciplinary perspectives can be given as examples literacy which has taken its place in the lives of individuals and societies can provide important gains for them however many different understandings of literacy may emerge literacy used today can be classified in more than one way in the emergence of these types the social status perspectives expectations and interests of individuals are effective individuals can show their talents in different types of literacy this shows that their areas of interest are different the concept which was defined as media education media pedagogy media education when it first appeared is now expressed as media literacy when media literacy is examined as a concept the first condition is to have the ability to reach media messages to perceive these messages correctly and to produce new messages paker perceives the concept of media literacy as reading and critically evaluating the incoming messages in detail understanding the hidden meanings if any and producing new messages mora on the other hand defined media literacy education as a practice that enables children youth and adults to be evaluated with an inquiring and rational perspective in order to protect them from the current negative effects of the media özel stated that media literacy is different from the classical media and discussed media literacy as the purpose of the message and the stages of formation of this message it is a wellknown fact that sports have aims such as raising individuals who are physically and mentally healthy open to change sports literacy which is expressed as the level of proficiency which enables to make informationbased decisions in the selection of sports equipment used in our lives is considered necessary for the creation of sports awareness due to economic and technological developments the quality and level of education is increasing day by day this situation results in an increase in the duties and responsibilities of the students studying this phenomenon of fanaticism among todays sports fans shapes peoples tendencies and orientations in many ways it is seen in the current literature research that this attitude has effects on their lives from shopping in daily life to adjusting their daily activity planning according to the matches sports literacy is also an important factor when following the teams they support from the media social media print media television and stadiums sports literacy of students also affects their fanaticism in line with the interests needs and expectations of the students their followup status is shaped accordingly it is thought that the interaction between sports literacy and fanaticism is affected by many variables such as the age of the students their gender the purchasing preferences of the teams licensed products the team they follow and the way they follow their teams in this study it is aimed to examine the fanaticism levels of university students in terms of sports literacy and some variables in the light of current literature information when the existing literature is examined it is thought that the studies on this subject are insufficient as a result of the study it is aimed to contribute to the literature by obtaining information about the sports literacy of university students in terms of gender variable age variable and preference to follow their teams the variable of the team they support and the variables of purchasing the licensed products of the team they support this study has an important place in determining the fanaticism levels of university students and in terms of giving us information in line with the variables mentioned above in addition to these it is expected that our study results will contribute to all the studies that have been done and will be done in the field research questions the questions to be answered during the research are as follows 1 is there a difference in the level of fanaticism of the participants in terms of gender variable 2 is there a difference in the level of fanaticism of the participants in terms of the age variable 3 is there a difference in the level of fanaticism in terms of the participants preference to follow their teams 4 is there a difference in the level of fanaticism in terms of the team variable that the participants support 5 is there a difference in the level of fanaticism in terms of the participants preference for purchasing licensed products 6 is there a relationship between the variable of following the teams of the participants and sports literacy method in this section information on the study model study group data collection tools collection of data and analysis of data subsections are presented study model this study was carried out with the general scanning model it is widely used in quantitative research methods büyüköztürk et al the data obtained from the method can be easily observed measured and analyzed it is a research method with an experimental approach in addition the general survey model successfully reflects the survey by reaching the entire population or reaching a representative sample of the population data collection tool a personal information form developed by the researchers was used to collect information about the independent variables in addition the football fan fanaticism scale was used as a data collection tool the answers given to the football fans fanaticism scale prepared in a likert type and consisting of 13 positive items developed by taşmektepligil et al were a i strongly agree b i agree it consists of answers with four options as c i do not agree and d i do not agree at all when the total scores of the scale are examined those with a total score of 113 are not supporters at all those with a score of 1426 are team supporters those with a total score of 2739 are fanatic and those with a total score of 4052 are extremely fanatic there is no subdimension of the scale the cronbach alpha reliability value for the overall scale was found to be 084 football fan fanaticism scale taşmektepligil et al was taken from its source and included in this study data analysis while evaluating the data in our study spss statistics 25 program was used for statistical analysis while analyzing the study data descriptive statistical methods were used while evaluating the hypothesis tests first of all skewness and kurtosis values were examined to determine the normality of the data since the data obtained were between 15 and 15 it was accepted that the data formed a normal distribution therefore independent samples ttest and one way anova test were used when comparing multiple groups levenes test was applied and scheffes test which is one of the posthoc tests was used the results were accepted as 95 confidence interval and the level of significance was accepted as p 005 findings when table 1 is examined it is seen that the majority of the participants are male looking at the age groups it is seen that the 1820 age group has the highest rate when the groups within the variable of using licensed products are examined it is seen that the group answering no is higher when the variable of preference to follow their team is examined it is seen that the group giving the internet answer is higher when we examine the table in terms of the team variable that is supported it is seen that the group giving the answer to galatasaray has a higher rate when examining whether there is any significance between the gender variable of the participants and the ttest results a statistically significant difference was observed in favor of the male participants considering the age variable of the participants the anova results shown in table 3 it is observed that there is a p 005 and a significant relationship between them when the relations between the groups are examined it is seen that there is a significant relationship between the ab ad bd cd groups regarding the licensed product use variable of the participants there was no statistically significant difference between the football supporter and fanaticism scale when the variables of the preferences of following the teams and the oneway anova test results are examined in terms of the football fanaticism it is observed that the age variable is p 0001 and there is a significant relationship between them when the relationships between the groups are examined it is seen that there is a significant relationship between groups ac ad bc bd in terms of the team variable of the participants there was no statistically significant difference between the participants in terms of the football fans fanaticism scale discussion and conclusion the level of football fanaticism of university students in terms of gender age using licensed products the type of following the competitions and the team variables they support and sports literacy were examined when we analyzed the fanaticism levels in terms of gender variable a statistically significant relationship was p 005 found considering this significance it is observed that the average scores are in favor of male participants when the studies in the literature are examined bahçe and turan concluded that the level of fanaticism in favor of male participants was high in their research on the other hand yıldız and açak found a significant gender variable in their study on high school students but unlike our study they observed that the average scores of female participants were higher in addition to these dimmcok and grove found that there was no significant difference in terms of gender in their study according to the research while women find it difficult to include the phenomenon of football in their own lives men can easily reveal it with a sense of belonging in another study it was determined that people develop a kind of identity perception on consumption and brands this situation emerges as another factor that strengthens the theory that men can develop a perception of fanaticism according to club advertising and brand value according to another study on the psychology of football fanaticism fans are influenced by different phenomena such as advertisements to support their clubs and this leads them to show higher interest in another study which states that the phenomenon of fanaticism shows positive or negative feelings towards the club that is wanted to be supported it is emphasized that this situation develops with the emergence of violence and the feeling of competition according to the research the behavior of showing interest in violence and approaching criminal elements fuels fanaticism when the levels of fanaticism were examined in terms of the age variable a significant relationship was found in our study group it was seen that the average scores of the participants in the 1820 age range were higher it was observed that the average scores decreased as the age of the participants increased research emphasizes that the subjects of interest become less important as the age progresses a different study which examines the changes caused by sportive admiration on the life cycle and is powered by social identity theory shows that adult peoples emotional wellbeing and life satisfaction increase as they get older and accordingly they tend to be less members of clubs or fan groups in another study which examined the relationship between the feeling of fanaticism and the membership cards and the age factor with 1547 participants it was concluded that membership cardstyle club loyalty can strengthen the feelings of fanaticism at an early age when the literature was examined güler obtained similar results in parallel with our study again açak et al reached similar results in their research it was observed that there was a significant difference in terms of the age variable that emerged during the period of kurak when the relationship between fanaticism levels and the variable of using licensed product was examined no significant relationship was found when the data in our study group were examined it was seen that the average scores of those who answered no were higher when the studies in the literature are examined contrary to our study yıldız and açak reached significant results in their study on high school students when we examine the level of fanatics according to the variable of following the competitions it is seen that there is a significant difference when we examine the data in our study group the highest percentage of the participants follow the competitions of their teams on the internet when we examine the average scores between the groups those who watch from the stadium and then those who follow from other channels have higher average scores considering this it is seen that the parties who go to the stadium to support their teams and those who follow their teams with all their means without being limited to this are more fanatical when the literature is examined yıldız and açak and kural have reached significant results in their studies in terms of this variable when the levels of fanaticism were examined in terms of the team variable no significant difference was found when the average scores were examined it was seen that similar scores were achieved when we look at the studies in the literature contrary to our study in the study conducted by kurak it was concluded that the fans who supported the galatasaray team had higher fanaticism scores considering the percentages and frequencies in terms of the variable of students sports literacy and following their teams the number of 208 followed on the internet 156 watched from the stadium 108 watched on television and the number of those who followed all of them 8 was found according to this situation it was concluded that students use social media more to follow the developments in sports teams katırcı concluded in his study that male individuals watch television more to follow sports competitions although this study is seen as different from the result we found when the technological conditions of todays technology and the technological conditions of the time are compared watching sports competitions can be seen as more usual today with the development of technology following many situations over the internet supports the accuracy of the result we found although the results we found regarding fanaticism differ from individual to individual some of the students had high levels of fanaticism according to the variables we shared in the findings in our study group while this situation differed from others researchers we looked at in the literature encountered similar results as a result in our study in which we examined the fanaticism levels of university students in terms of some variables it was concluded that male individuals were more fanatical than females the fact that male individuals were more interested in football than females played an important role in the emergence of this result it was concluded that the younger students were more fanatical than the older students this has played a role in the emergence of this result as individuals have a higher rate of defining their teams and belonging to them at younger ages and because they approach more emotional issues while shaping their attitudes it has been concluded that those who follow the matches of the team they support from stadiums and all channels have higher levels of fanaticism it is important for this result that individuals with high levels of fanaticism want to watch the matches from the stadium which is the closest and most supportive place to their team since they have a high sense of belonging to the team it has been concluded that the students follow their teams more on social media within the scope of sports literacy today with the internet age many hobbies and communication are done through social media accounts so it has played a role in the emergence of such a result in our study of the football fanaticism levels of university students living in turkey male students are fanatics in terms of gender in terms of age factor among university students students between the ages of 1820 are more fanatical than other age groups according to the statistical results of the student group in our study those who watch the matches from the stadium show a more fanatical tendency than the other groups university students use social media the most while following information about sports our suggestions to the researchers who read our study and our expectations from our study it is expected that our study will be a source for other studies in the field and contribute to the literature together with previous studies in this field in future studies different and similar high school and university student groups can be compared and different results can be obtained different results can be investigated by adding different grade levels and age groups to these comparisons studies on students living in different countries and studying in different cultures can compare their levels of fanaticism in the context of country and culture while creating new research by taking into account the results and findings of our study good and new studies can be made based on the existing data in addition to fanaticism researching different emotional states on students and examining the underlying causes of fanaticism with thematic analysis and creating new research plays an important role in the psychological and sociological analysis of fanaticism

commercialized by changing the meaning of politics and ideologies özcan 2001 football which is often regarded as the most thrilling sport and a significant aspect of many peoples lives has implications for many people that go beyond those of a game and a pastime aydın et al 2008 this fan phenomenon has been the biggest benefactor for the football industry supporting is essentially a civic ritual carried out by participants who have a strong attachment to the team eker 2010 on the other hand fanaticism is a behavior that appears in a variety of contexts such as politics and sports the word fanaticism comes from the latin word fanum which means temple or holy place the word fanaticus is used to characterize those who are literally and utterly insanely committed to the temple the word fanatic in english refers to a person who has wild illogical or religious impulses oxford dictionary of english 2018

aim the aim of this study was to explore the influence of characteristics of nurses and older people on emotional communication in home care settings the following research question was addressed which characteristics of nurses and older people influence emotional communication in terms of older peoples expressions of emotional distress elicitations of expressions of emotional distress and nurses responses in providing or reducing space for the further exploration of older peoples emotional distress methods design this study was an explorative crosssectional study of swedish home care settings the number of participants and audiorecordings used was decided under the comhome project to enable analyses and comparisons between sweden norway and the netherlands setting a convenience sample of 12 home care institutions located in a county of central sweden were approached for participation to collect data from audiorecorded home care visits between nurses and older people eight of these home care institutions agreed to participate in this study home care refers to care provided in the home of an older person and involves different activities such as assistance with daily living tasks personal care and medical administration and procedures ethical considerations ethical approval was obtained from the regional ethical review board of uppsala sweden participating nurses and older people received oral and written information on the study their participation and their rights as participants and on how the data would be handled stored and presentedpublished all of the participants had to be able to provide written informed consent to participate the participants were guaranteed confidentiality data collection data from audiorecorded home care visits were collected from august 2014 to november 2015 the study was presented to nurses at different workplace meetings who were then asked to participate those willing to participate were then asked to inform and recruit older people who met the inclusion criteria of the study no information about the nurses and older people who declined was collected nurses deciding not to participate cited reasons such as heavy workloads and feeling stressed and older people choosing not to participate predominantly stated that they did not like the idea of participating naturally occurring communication during the home care visits was recorded by the nurses who were instructed to wear recording equipment on their upper arm to start recording when they entered an older persons home and to stop recording when they left no directives and information about how the communication was to be analyzed were presented as this might have affected the höglander j sundler aj spreeuwenberg p holmström ik eide h dulmen s van eklund jh emotional communication with older people a crosssectional study of home care nursing health sciences 2019 21 p 382389 this is a nivel certified post print more info at nivelnl 4 communication and risked biasing the data the older people could be recorded once or several times depending on the organization of home care visits each nurse made 110 audiorecordings most nurses provided seven audiorecordings the goal was to collect approximately 200 audiorecordings incomplete recordings were excluded from this datacollection approach we collected 188 audiorecordings of home care visits each with a duration between 1 and 86 min data analysis the analysis of this study was based on communication previously coded during home care visits with the verona coding definitions of emotional sequences and participants characteristics the vrcodes is an instrument for coding patients expressions of emotional distress and health providers responses to these emotional expressions the vrcodes is descriptive and nonnormative it does not label responses as good or bad for the coding process elicitations were coded based on whether the emotional distress expressed was elicited by a nurse or older person thereafter the expressed emotional distress was coded as either a concern defined as a clear and unambiguous expression of an unpleasant current or recent emotion where the emotion is explicitly verbalized or as a cue defined as a verbal or nonverbal hint which suggests an underlying unpleasant emotion but lacks clarity examples of verbal hints include words vagueunspecified in describing emotions words emphasizing physiological or cognitive correlates of an unpleasant emotional state exclamations ambiguous words or a patients repetition of hisher previous neutral expression examples of nonverbal hints include crying sighing a trembling voice or silence after a providers question in conjunction with emotional expressions immediate responses from nurses were coded and divided into explicit or nonexplicit responses and whether responses provided or reduced space for the further disclosure of given cues or concerns these were then divided into more categories for the further definition of responses noldus observer xt version 120 was used to code the audiorecordings no allows data to be analyzed without the need for transcription the codes were loaded directly into no audio files as the expressions occurred in the communication interrater reliability for the vrcodes was established by the first and second authors who separately coded 15 audiorecordings this score was calculated with cohens kappa and resulted in an acceptable level of agreement of κ 64 the remaining audiorecordings were coded by the first author expressions of emotional distress consisting of cues and concerns their elicitations and types of responses were analyzed along with characteristics of the nurses and older people via a generalized linear mixedmodel analysis the glmm analysis was conducted using ibm spss statistics for windows 24 to examine how characteristics of the participants influenced emotional communication the glmm analysis was useful when accounting for nested and clusterrelated correlations in the data the nurses and older people participating in the study were recorded more than once and different nurses could visit the same older people all analyses of each research question started with an empty model containing the intercept and residuals for the nurses older people and home care visits the nurses and older peoples sexes were added as variables after which the second languages professions and age groups of the nurses and older people were added as variables höglander j sundler aj spreeuwenberg p holmström ik eide h dulmen s van results sample description in total 316 expressions of older peoples emotional distress with nurses subsequent responses were identified from the home care visits emotional expressions together with elicitations and responses to emotional distress were found in approximately half of the home care visits and are reported in our previous work expressions of emotional distress occurred in both long and short visits the shortest visits including expressions of emotional distress were 2 min long of which one included five cues and one concern the nurses were rn or na both female and male nurses and older people participated and there were visits between the same and different sexes there were no reliable interactions between characteristics used in the models and we thus omitted interactions in the presentation of our results table 1 table 2 table 3 table 4 influence of nurses and older peoples characteristics on expressions of emotional distress expressions of emotional distress during the home care visits were influenced by the sex of the nurses and older people an older female has a slightly stronger effect on expressions of emotional distress than a female nurse older females expressed more emotional distress during home care visits than older males expressions of emotional distress were also associated with being a female nurse female nurses received more expressions of emotional distress than male nurses model 2 had the best fit when explaining some of the variance in the older people but this was mostly due to being female in model 1 8227 remained unexplained model 1 explained more of the variance observed in the nurses r 2 2434 than model 2 which revealed that more nurse variations remained unexplained by the characteristics under study influence of nurses and older peoples characteristics on elicitations of expressions of emotional distress older peoples expressions of emotional distress were elicited either by themselves or by the nurses in model 2 the introduction of language profession and age variables improved the fit of the model the form of elicitation demonstrated a significant association with language and profession whereas age did not profession had twice as strong an effect on elicitation as language nurses whose native language was swedish elicited expressions of emotional distress significantly more often in their communication in relation to the older people nurses with a second language elicited expressions of emotional distress almost as often as the older people did regarding the effects of different professions rn elicited expressions of emotional distress more often in their communication with older people than na did tabel 5 table 6 model 2 was the most beneficial in explaining the nurses level of variance and fully explained the older peoples level of variance however home care visit variance was not further explained in model 2 showing that there were variations in home care visits höglander j sundler aj spreeuwenberg p holmström ik eide h dulmen s van that were not explained by the characteristics used therefore the models were not beneficial in explaining the variance in home care visits influence of nurses and older peoples characteristics on responses to emotional distress in their responses the nurses could either provide or reduce space for the further disclosure of older peoples emotional distress both the sex and age of the older people were found to influence the nurses responses a response could either provide or reduce space for the further disclosure of older peoples emotional distress being an older female had a stronger effect on the type of response given than older peoples age being an older female was significantly associated with the type of response given by the nurse older females mostly received responses that provided rather than limited space for their emotional distress compared to older males who received almost as many responses providing space as those reducing space older people aged between 65 and 84 years significantly more often received responses that provided rather than reduced space for their concerns in comparison to those who were ≥85 years of age regarding random effects the degree of nurse variance was small model 2 was the most beneficial in explaining the older peoples level of variance the characteristics shown in model 2 explain more of the variance in home care visits than model 1 but 8272 remained unexplained discussion nurses and older peoples characteristics affected emotional communication differently depending on how emotional distress was expressed and based on who elicited the expressed emotion and the type of response provided by the nurse nurses play an important role in providing emotional support because they can acknowledge and facilitate disclosure and find coping mechanisms for dealing with emotions in the first glmm analysis being female was associated with the expression of emotional distress these results do not correspond with previous studies using the vrcodes for hospital consultations where sex was not found to be significantly associated with the occurrence of emotional expression this could be partly attributed to the different care contexts of hospitals and home care settings that might influence emotional communication the findings of this study are more consistent with other work on home care showing that older females express their concerns and complaints more often than older males the findings also show that females expressed their emotions more often than males this could be related to gender stereotypes with males being reluctant to seek help or to the possibility that older females experience more emotional distress than males females can also be perceived as being more caring and interested in emotional issues this consideration might help to explain the significantly larger number of expressions of emotional distress from older people received by female nurses than by their male colleagues in a previous study female physicians were found to be more engaged in emotional discussion and to facilitate more patientcentered dialogue than male physicians it is important to be aware of existing differences regarding expressions of emotional concerns and to acknowledge the possible impacts of stereotypes failing to acknowledge the impact of stereotypes can increase the risks of older males emotional distress going unnoticed the differences observed between females and males might also be due to females experiencing more disabilities and concerns than males highlighting the need to explore expressions of emotional distress further from the second glmm analysis profession and language appeared to influence who elicited the expression of emotional distress being a nonnative speaker does not necessarily lead to challenges with communication however native language competence was associated with the elicitation of emotional expression to establish whether the association with elicitations observed was due to differences in native language competence or perhaps due to cultural differences is difficult more knowledge is needed on the impact of language and culture on emotional communication differences observed in terms of professions might be related to the greater focus of rn on medical and healthcare aspects of their home care visits and in their interactions with older people discussions and questions regarding older peoples perceived health statuses illness troubles or medications might elicit expressions of emotional distress in home care visits these informationseeking questions are important in learning more about how older people perceive their health but they might also elicit emotional distress in the third and final glmm analysis the sex and age of the older people presented a significant association with the types of responses provided by the nurses the age differences observed might be related to agerelated differences in how older people express and control their emotions nurses might be challenged in their attentiveness to emotional distress when encountering agerelated changes when nurses do not perceive older peoples hints of emotional distress they might offer fewer responses that provide space for such distress this can be essential in providing space for older peoples needs for emotional talk and comfort emotional communication is emphasized because older peoples abilities to handle their emotions are related to their experience of health the effects of older peoples age and sex on responses providing space for emotional distress might also be related to social norms or stereotypes which might influence how nurses perceive and respond to emotional expressions for example females can be perceived as being more emotional than males such beliefs and expectations might create more space for older females emotional expressions in communication beliefs and stereotypes can influence our expectations of others and of ourselves for example males are perceived to exert greater emotional control than females but less emotionally understanding these expectations could affect both emotional expressions and the responses that they receive as interpretations of emotional expressions can be affected by gender stereotypes beliefs and genderemotional stereotypes therefore cannot be neglected when exploring emotional communication in home care settings these differences need to be acknowledged in emotional communication to develop an awareness of and provide sufficient emotional support for older females and males therefore it is important to help older people talk about their emotions and provide emotional support otherwise unattended emotions and inconsistent comforting might affect older peoples experiences of health and wellbeing limitations as a possible limitation of this study the presented characteristics do not fully explain the glmm models additional characteristics that might affect emotional communication not covered in the study such as how long the participants have known one another working life experiences and older peoples social status and care needs have yet to be explored further research is needed to help ascertain whether the differences observed are due to differences in lived distress levels stereotypes or perhaps something entirely different it should also be noted that the vrcodes only focuses on negative emotions therefore positive emotions were not investigated in this study the audiorecordings used were drawn from a specific swedish care context and region restrictions of the studys generalizability to other contexts or countries could serve as a limitation however the data used cover a large and varied sample of audiorecorded communication revealing the presence and expressions of older peoples emotional needs and nurses responses to these needs the emotional needs of older people who are receiving care are not limited to a specific swedish context which could indicate the studys generalizability to other contexts and countries conclusion the results of this study indicate that emotional communication in home care can be influenced by several factors that might be influenced further by the norms cultural beliefs and stereotypes held by the society in which they occur when emotional communication is affected by stereotypes there are risks of objectification and of a lack of person centeredness in communication there are also risks of overlooking the emotional needs of older people and of inequality in the emotional support provided practical implications the results of this study could raise awareness of the influence of nurses and older peoples characteristics on emotional communication in home care settings this entails both an awareness of ones own characteristics and of those of others and of how they impact communication the results can further be used in education settings to enhance both students and nurses knowledge of and attentiveness to the characteristics and stereotypes that influence emotional communication with older people recognizing older peoples unique needs and differences and making communication and care more person centered these results can further help illuminate and identify the challenges and complexities of emotional communication and its impacts on home care and health outcomes tabels table 1 sample description of emotional communication during the home care visits table 2 sample description of participants of the home care visits höglander j sundler aj spreeuwenberg p holmström ik eide h dulmen s van conflict of interest the authors declare no potential conflict of interests

the aim of this study was to explore the influence of characteristics of nurses and older people on emotional communication in home care settings a generalized linear mixed model was used to analyze 188 audiorecorded home care visits coded with verona coding definitions of emotional sequences the results showed that most emotional distress was expressed by older females or with female nurses the elicitation of an expression of emotional distress was influenced by the nurses native language and profession older women aged 6584 years were given the most space for emotional expression we found that emotional communication was primarily influenced by sex for nurses and older people with an impact on the frequency of expressions of and responses to emotional distress expressions of emotional distress by older males were less common and could risk being missed in communication the results have implications for students and health professionals education in increasing their knowledge of and attentiveness to the impacts of their and others characteristics and stereotypes on emotional communication with older peopleduring home care visits older people reveal essential information about their wellbeing and health such as worries and needs kristensen et al

introduction at the upper secondary level unevenly distributed participation in education is related to more than language barriers it is codetermined by the sociostructural characteristics of origin these characteristics can create educational obstacles for learners as has been particularly welldocumented in crossover research even if young adults succeed in entering higher qualifying training the problems have often not been overcome in most cases the problems continue to exist in the challenge not to immediately drop out of the training after successfully starting it the stress of the training situation for these learners is often only relieved if they have a degree certificate that opens access to a working life and thus creates a good starting point for their further professional biographical development problem setting and questions in order for national education systems to be informed about the extent to which younger generations can integrate into society by acquiring occupational certifications many countries report figures on participation and graduation rates at this level at regular intervals for example according to the oecd the average participation rate in europe in 2019 was 84 the rate is 80 in germany and around 88 in switzerland the number of graduations in the same age group is slightly lower the oecd average is about 80 in germany it is about 73 and in switzerland about 84 these figures may vary depending on the age group studied for example in switzerland some apprentices have not yet completed their education at 19 when considering all learners who have completed upper secondary education by the age of 25 the rate in switzerland is about 90 thus at least in switzerland a large number of young adults seem to be able to achieve a degree in upper secondary education by the age of 25 including gender and family characteristics in the analyses a heterogeneous picture emerges especially with regard to higherlevel qualifications for men the overall graduation rate for higherlevel qualifications is 34 for women the rate is around 44 it is also apparent that learners born in switzerland to swiss parents achieve a 20 higher graduation rate from higher education courses than learners whose parents are not swiss regardless of whether the latter were born in switzerland such inequality distributions are not new and they have long been discussed in relation to questions of justice theory the basic premise of modern education systems with a western influence has been critically questioned it has been explicitly stated that no one in switzerland should be hindered or excluded from participation in education on the basis of their characteristics of origin violations of this assured right to participate centrally affect the educational biographical developments of adolescents however misadministration also affects the economic system which relies on young people who are as welleducated as possible both the individual and the socioeconomic areas concern fundamental issues of common and fair participation in civil society these hold together as social pillars the collective togetherness if damage can be identified in these areas that is if inequalities are found that can be identified as injustices compensatory measures are necessary for those who have been disadvantaged moreover these measures must be maintained until the causes of these injustices are eliminated this paper is a first step in this regard the focus is on the conceptualization and implementation of corrective regulatory support for learners whose training risks are increased this support must be effective during transitions and throughout the entire training period at the relevant levels of education this study concerns support throughout the training period the focus is on young people with a parental migration background who have completed higherqualifying education at the upper secondary level however if their grades at this level of education are not sufficient or if their selfconception of their abilities is unstable and their perceived selfefficacy at school and motivation to work are weak the probability that they will be able to complete their education decreases to counter this situation an intervention was carried out in a higherqualifying training course in switzerland the aim was to support committed and motivated learners so that they could complete the training the initial question of this study begins at this point the question is to what extent does supportoriented intervention succeed in positively influencing the development of learners grades selfconception of subjectspecific skills general perceived selfefficacy at school and motivation to work the intervention the intervention proposed to achieve the objectives was open to learners with a parental migration background the learners had to be committed and willing to attend an additional weekly learning session the intervention was located at a business school in switzerland this is a higherqualifying fulltime upper secondary level vocational school that prepares learners for a qualified vocational qualification at the same time this training gives them the option of attaining the federal vocational baccalaureate the intervention is presented below in conformity with its structural framework the embedded contents are discussed finally the characteristics to which the intervention was directed are reported an attempt is made on the basis of these steps to represent the intervention effect structural phase i the first phase of the intervention lasted from january 2020 to december 2020 a period understandably referred to as the covid19 setting the covid19 setting was characterized by distance teaching and distance learning formally meetings during this phase can be described as adhoc online meetings we refrained from imposing an obligation to participate nevertheless attempts were made to meet with the young people regularly electronically largely through individual exchanges structural phase ii during the second phase which lasted from the beginning of 2021 until the end of june 2021 the structural teaching conditions normalized this phase can thus be referred to as a normal setting in terms of the intervention it was possible to work with the learners as planned weekly and facetoface participants were expected to participate regularly in person content phase i during the first phase an attempt was made to actively approach the learners in the intervention group and to respond to their difficulties and questions arising from the situation looking back the focus was not only on school learning problems but in some cases also on questions about the challenges of shaping life in general these questions could be explained more and more in terms of the learners connection to their home attempts were also made to advance the adolescents in their learning differentiated by questions about their learning organization particular care was taken to clearly see the progress they had made and to attribute the causes to their own abilities wherever possible in general the content of the first phase was not very systematic however this phase is discussed here because it allows at least the development of a sense of how the features discussed here changed under the condition of highly dynamic school realities content phase ii at the beginning of 2021 the teaching situation changed again to a more structured level at that time it became possible to implement the systematically organized intervention units as planned it was possible to work with the intervention participants as planned for three hours a week teachers in german mathematics english economics and law were available to them thus those subjects that are particularly lucrative in the training plan were prioritized work was focused on problems that students brought with them basically the intervention was designed as a learning setting in which the learners largely selfdirectedly advanced their tasks on the basis of unresolved questions and upcoming contentrelated problems or deficiencies this usually included the areas of task aids and upcoming tests stabilizing the selfassessment of various abilities was also an important part of the intervention this was attempted by identifying strengths during individual support that were then made visible by the supporting teachers as learning successes work organization issues were also addressed and learners were supported in this regard the learners were thus given individually supervised learning time as well as the opportunity to design the time available to them together this also made aspects of socialemotional learning visible dimensions of impact based on the structural and contentrelated frameworks and on the background of the intervention objectives three impact dimensions were examined first the grades in the subjects of german and mathematics second the learners subjectspecific selfconcept of their own ability in these subjects and third two motivational aspects of learning general perceived selfefficacy at school and the motivation to work with respect to the grades the intervention focused on the area that centrally decided on whether to stay in training they were therefore the focus of the intervention as a performative criterion cognitive and motivational processes are linked to grades and are promoted in an interventional manner here as target dimensions and recorded as dimensions of impact hypotheses design instruments and sample the initial question is differentiated in relation to the two intervention phases into the following hypotheses • hypothesis intervention phase i the grades in the subjects of german and mathematics as well as the associated subjectdifferentiated selfconception of abilities the perceived selfefficacy at school and the motivation to work change to the same extent in the intervention group as in the reference groups 1 • hypothesis intervention phase ii the grades in german and mathematics in the intervention group increase more strongly than in the reference groups the selfconception of ability in mathematics and german increases more in the intervention group than in either reference group perceived selfefficacy at school and motivation to work also increase in the intervention group as compared to the two reference groups 1 note no substantive work was possible during this phase of intervention the corresponding variables could not be systematically worked on so no effects are expected specifically h0 cannot be rejected design as the reported basic model shows the first phase of intervention work started at the end of february 2020 it preceded the t0 measurement in january 2020 the time span between the t0 measurement and the start of the intervention was used to identify those young people for whom the intervention was designed young people could be admitted to the program only if their parents had a migration status by default the intervention was designed for a weekly work unit of 3 hours in addition to processaccompanying qualitative evaluation formats which were carried out monthly with the learners and once per term with the teachers sixmonth quantitative impact tests took place in a quasiexperimental intervention control group design with four repetitions of the measurements the first three measuring dates have been fully evaluated and are included in the present study sample the intervention was carried out with students from the 20192022 cohort at an upper secondarylevel business school this schoolbased organized vocational training leads either to a certificate of professional competence or to a vocational qualification it thus enables a higherqualifying grade at the upper secondary level learners were offered the intervention based on possible parental migration status regular participation and personal commitment were required this condition was met by 14 young people who formed the intervention group two reference groups were also formed the first comprised 26 young people they could have joined the intervention group because of their parental migration status but they decided not to participate the second reference group consisted of 13 learners their parents had no migration status they were therefore not eligible for intervention the average age was comparable in all groups 1764 years 1712 years and 1731 years in the intervention group 7 participants were male and 7 were female in reference group i 16 learners were male and 10 were female in reference group ii 9 learners were male and 4 were female after selecting the learners it was recorded whether the learners spoke german at home in the intervention group 4 adolescents spoke german and 10 adolescents did not in reference group i 12 young people spoke german at home and 14 did not in reference group ii whose parents had no migration status and who were therefore not eligible for the intervention 10 learners spoke german at home and 3 learners stated that they did not speak german at home the proportion of learners who speak german at home therefore sees an increasing trend from the intervention group to reference group i up to reference group ii instruments the grades of the students in the subjects of german and mathematics were recorded the subjectspecific selfconceptions of ability in mathematics and german as well as motivation to work and general perceived selfefficacy at school were also gathered evaluation methodolog y to test the hypotheses a kruskalwallis test for independent samples and corresponding posthoc comparisons with the change values were calculated a nonparametric approach was chosen because the change values of some variables could not be assumed from normally distributed data there were inhomogeneous group variants and no interval scaling of the values could be assumed in addition due to the risk of distortions due to outliers in the change values and the rather small group sizes the less presupposed procedure was chosen results intervention phase 1 during the first intervention phase the socalled covid19 phase no significant differences between the groups were found in the values of the analyzed characteristics however the german and mathematics grades tended to show a slight decline in all three groups the change in the characteristics of perceived selfefficacy or motivation to work was similar here too a descriptive decrease can be observed in all three groups with regard to the subjectspecific selfconceptions of ability in mathematics and german it can be stated again descriptively that in the area of german there was a slight increase in all three groups in the area of mathematics it was reduced in the intervention group while the values in the two reference groups increased however these mean value differences cannot be statistically assured as group differences looking at the intervention group specifically in comparison with the two reference groups the following trends are shown again descriptively for grades the values in the intervention group were reduced to a greater extent than in the two reference groups in the selfconception of ability in german the increase for the intervention group was greater than in the reference groups in the selfconception of ability in mathematics there was a slight decrease in the intervention group and a slight increase in the reference groups in terms of motivation to work the decrease in the value for the intervention group was somewhat less than in the two reference groups intervention phase 2 during the second intervention phase there was a statistically significant change in the german grades and in the subjectspecific selfconception of ability in mathematics downstream individual group comparisons show that both effects were due to the differences between the intervention group and reference group ii this means first that a positive change in the german grades of young people from families with a migration background was offset by a decrease in the german grades in the group without intervention and without parental migration second with regard to the subjectspecific selfconception of ability in mathematics the decreasing value for reference group ii was faced with an increasing value among young people with a parental migration background all other characteristics showed statistically insecure trends in change the mathematics grades tended to decrease in the reference groups and increase in the intervention group the selfconception of ability in german increased somewhat in the intervention group and in reference group ii while it decreased slightly in reference group i perceived selfefficacy tended to increase in all three groups in terms of motivation to work a decreasing trend can be seen in the intervention group and in reference group i in reference group ii it rose somewhat during this phase discussion the positive development of the german grade during the second intervention phase was a central result of this study learners whose parents had a migration background and whose language at home was less frequently german made greater progress than learners without a migration background who more often spoke german at home this finding indicates an optimistic direction with the effect in german the positive change affected an area that is highly significant for general school development if german grades improve for learners who due to migration are at increased risk of not completing their training the basis for other subjects taught in the local language of instruction will also be stabilized the second central finding is the positive change in the subjectspecific selfconception of ability in mathematics this change concerned the same two groups it was again the learners of the intervention group who changed positively compared to the change in reference group ii the attempts to positively influence the development of grades and in parallel to this to stabilize young people in their selfassessment with regard to their ability in subjects seem to have had a desirable effect here at least to some extent however the analyses of the qualitative data of this study will show exactly how internal interrelationships are to be understood this will stabilize the basis somewhat in order to be able to further develop the structure and implementation of the intervention in a differentiating manner these two effects cannot hide the fact that the analyses leave central questions unanswered for example further thought should be given to how the effectiveness of the intervention could be broadened and thus extended to other characteristics in addition further analysis is needed to address the question of why the developments between the intervention group and reference group i are not more different in concrete terms this means trying to discuss the extent to which the proportion of young people who speak german at home may play a role here this proportion was higher in reference group i than in the intervention group in general this could mean that the intervention had an effect primarily on the young people with a parental migration background who did not speak german at home the fact that the intervention also produced stronger effects during the second phase could indicate that supportive funding at the upper secondary level should be coupled with an obligation to participate regularly in facetoface formats if participatory and selfregulated forms of learning are to be sought which must also be the responsibility of the learners themselves a formal obligation to participate regularly seems to be a prerequisite for learning and training success without structuring framework requirements learners have to create formal learning structures themselves this is undoubtedly important however it takes away the time and attention they need for learning specific subject matter we saw this clearly during the first phase of intervention which was not very systematically structured it was necessary to clarify questions about the structuring of the day in general with the young people before addressing the subject matter moreover in light of the developments during the first phase of the project this topic may need to be considered in general at the upper secondary level in educational terms the findings indicate that young people are empowered in their responsibility to regulate and shape their own learning in more open learning formats which can include distance formats in this context the development of the selfconception of ability seems to be of particular importance however all the findings reported here must not give the impression that this offer creates educational justice as the study was implemented its main concern was to ensure that the negative effects of educational inequality not become even more pronounced however the basic lever for mitigating this inequality cannot be exclusively compensatory individual support it must start at the level of educational structure at the same time the course must be set here so that structural risk factors for educational inequality can also be eliminated at the upper secondary level and beyond that is not easy and if it means taking specific countermeasures especially with programs such as this one then that is what must be done it is necessary to structurally anchor new approaches to knowledge as may emerge from the study presented here in compulsory compensation channels perhaps this is not particularly fair as some have to give more time and commitment to their education at the upper secondary level because of their characteristics of origin than others without these risk factors however protecting individuals from a situation in which they are released into the labor market without a degree seems to be a primary objective and one that does not prevent them from undertaking their professional development with as much freedom as possible this is a professional biographical lifedesign justice that should be further developed situationally and prospectively as well as structurally

this study addresses the question of how learners whose parents have a migration background can be supported in upper secondary education to prevent their dropping out of education to that end we conducted interventions in an upper secondary education setting in order to improve school grades subjectspecific selfconceptions of ability in mathematics and german motivation to study and perceived selfefficacy and we evaluated the effects on learner achievements we applied a twophase process a more virtual approach during restrictions imposed during covid19 and a more facetoface approach in which learners were tutored by teachers the intervention showed an improvement in grades in german and in the selfconception of ability in mathematics however this was only established during the facetoface intervention phase during the covid19 phase and thus when there was no possibility of standardized intervention no specific effects were observed

unsafe sex is the second most important risk factor for morbidity and mortality in lowincome areas 1 the world health organization estimates that there are 150 million new curable sexually transmitted infections in south and southeast asia each year 2 but traditional medical and public health approaches to sustainably change sexual behavior have been wrought with failure moreover the process of framing these public health issues has often been charged with assumptions about sex work distancing sex workers from important resources and complicating effective research programs although there is international consensus about the importance of sex worker human immunodeficiency virus and sexually transmitted infection medical programs there are no best practices for social responses on behalf of vulnerable sex workers and not all sex workers are vulnerable to hiv infection the social response of each asian nation to its sex industry intimately depends on culture normative structures and legal boundaries implicit in these notions of sex work are value judgments and moral assessments that extend well beyond the traditional framework of biomedicine charged with organizing stihiv control measures a broad spectrum of social responses to sex work has emerged in asiadsome nations arrest or detain prostitutes in topdown mobilized state responses connecting commercial sex to human trafficking and other transnational criminal activity other asian nations foster grassroots ngo efforts to empower sex workers in client negotiations and reproductive health choices using empowerment approaches the consequences of sex worker regulation for the spread of hivstis are unclear but empirical data from our multidisciplinary working group helps to inform these critical policy positions a better understanding of the social context shaping commercial sex policy in asian states can facilitate implementation and rollout of hivsti social policy and public health programs in asia and beyond this interdisciplinary workshop brought together specialists across various fields to examine the commercial sex enterprise in asia emphasis was placed on a biosocial framework to integrate historical social political legal economic biological and public health perspectives this is not a matter of simple translation across disciplines but rather a serious consideration of the contribution of many different factors not as separate influences but as mutually constitutive and inherently intertwined parts of a complex whole event in order to illuminate new aspects of sex work and the relationship to stis this conference addressed the following major conundrums how can traditional dichotomous theoretical frameworks of sex work that rely on simplification of sex workers to either fully autonomous empowered individuals or nonautonomous victims be reframed how have nongovernmental organizations and the spread of civil society in many parts of asia changed the potential for sex workers to organize hivsti prevention how does sex worker agency measured individually or collectively influence sexual risk taking what are the implications of transnational sex trafficking and sex work for interasian state relationships and collaborative medical and public health responses the collection begins with a piece by dr joseph d tucker at the harvard school of medicine and dean astrid tuminez at the national university of singapore 3 their article highlights the importance of choosing an appropriate conceptual framework when analyzing sexual health much of the research on sex work in asia has focused on using an empowerment approach although there have been increasing efforts to use an abolitionist framework to understand commercial sex a new behavioralstructural conceptual framework is described with implications for clinicians policymakers and public health practitioners they point out that using such a behavioralstructural framework can incorporate some elements of both prevailing conceptual frameworks advancing our knowledge of how sex work becomes unsafe and what structural factors can be changed to attenuate sexual risk among sex workers in asia and beyond one example of how the social environment of sex workers increases sexual risk comes from india where violence and mesolevel environmental factors are critically linked annie george shagun sabarwal and p martin from the international center for research on women investigate the organization of sex work on exposure to physical and sexual violence 4 they report an alarmingly high prevalence of violence among all female sex workers with a 3fold increased risk of physical violence and a 2fold increased risk of sexual violence among women engaged in contract work this groups research reveals the connection between sex worker terms of working and risk of violence with important policy implications in their article jennifer t erausquin elizabeth reed and kim blankenship of duke and american universities investigate the relationship between selfreported sexual risk and interactions with police among 850 indian female sex workers 5 although there has been much speculation regarding the effect of punitive police measures on sexual risk this article provides an empirical analysis of this relationship in the context of avahan a bill and melinda gates foundationsupported aids initiative they find that a number of dimensions of police maltreatment of sex workers are associated with increased sexual risk their findings highlight the importance of including police and others who implement local policy in the process of designing and sustaining effective sexual health programs continuing with the theme of violence among female sex workers jay silverman and colleagues examine coercion among hivinfected female sex workers in mumbai india 6 of their sample of 211 women 417 were trafficked into sex work coercion into sex work is associated with increased exposure to violence poor condom use higher number of clients per day and greater alcohol use coercion and agency play a key role in mediating sexual risk with forced sex work playing a role in expanding stihiv transmission better understanding of the terms and context of sex work can help to promote sexual health interventions in their article suiming pan and yingying huang of the institute of sexuality and gender at the peoples university and william parish of the university of chicago examine the clients of female sex workers in china 7 drawing on a 2006 populationbased representative sample of adult men they find that 56 of urban men reported visiting a female sex worker in the past year this percentage was similar to that found in 2000 suggesting that chinas punitive antiprostitution campaigns have not substantially transformed the sti epidemics the bulk of selfreported stis were associated with unprotected commercial sex consistent with earlier populationrepresentative studies interestingly they did not find that young migrant men have an increased risk of unsafe sexual behaviors instead higherincome businessmen report having more unprotected commercial sex this analysis serves as a useful reminder of the importance of male determinants in promoting sti spread in the chinese context in her article joan kaufman of harvard and brandeis universities examines the influence of civil society on improving the effectiveness of sti prevention among sex workers 8 criminalization of sex work in several asian contexts pushes marginalized female sex workers farther away from the government outreach workers officially charged with stihiv prevention in many asian states a weak civil society and poorly coordinated ngos stall comprehensive sexual health programs she argues that a labor rightsbased approach to communitybased stihiv prevention is the most likely to succeed highlighting the recent success of sonagachi in india and other peerorganized ngos that represent sex workers interests and needs greater cooperation between government and ngos and more ngoled responses are key parts of effective stihiv responses the goal of this supplement is to provide an evidence base to further our understanding of how sex worker and client health can be promoted in asia there are many challenges in designing sexual health programs focused on sustainably decreasing unsafe commercial sex high rates of migration within and across borders limited sex worker ngos and lack of agency among sex workers create structural barriers for stihiv prevention programs while many innovative programs for sexual health have been implemented in asia few have been comprehensively evaluated further interdisciplinary research is needed to understand the context and outcomes of such programs a broader evidence base could help inform programmatic and policy efforts focused on stihiv control in this critical region notes

hosted a symposium in october 2010 focused on sex work and sexually transmitted infections in asia engaging a biosocial approach to promote sexual health in this region asia has an estimated 151 million cases of curable sexually transmitted infections stis eg syphilis gonorrhea chlamydia each year with commercial sex interactions playing a large role in ongoing transmission substantial human movement and migration gender inequalities and incipient medical and legal systems in many states stymie effective sti control in asia the articles in this supplement provide theoretical and empirical pathways to improving the sexual health of those who sell and purchase commercial sex in asia the unintended health consequences of various forms of regulating commercial sex are also reviewed emphasizing the need to carefully consider the medical and public health consequences of new and existing policies and laws

introduction since the beginning of the acquired immune deficiency syndrome epidemic female sex workers have been nationally and internationally recognized as a population at high risk for acquiring human immunodeficiency virus infection 1 2 3 4 5 6 worldwide studies point to the high levels of hiv prevalence among fsws compared to the general population in african countries there is emerging data showing that fsw carry a disproportionate burden of hiv even in generalized epidemics 78 studies in asia 9 10 11 as well as in developed countries also report higher rates among fsw 1213 a systematic review of hiv prevalence studies among key populations in latin america and the caribbean estimated a median hiv prevalence among fsw of 26 14 while the estimated prevalence in the adult population was 05 15 in brazil a study carried out in 2000 to 2001 in some capital cities estimated a prevalence of 61 among 2712 fsw 2 a rate of about 15 times higher when compared with that of the brazilian female population aged 15 to 49 years 16 fsws are considered a highrisk group for acquiring hiv infection 317 due to their social vulnerability and factors associated with their work such as multiple sex partners inconsistent condom use or coinfection with other sexually transmitted infections 18 studies show that hiv infection is associated with sociodemographic and commercial sex work characteristics 19 20 21 22 23 such as age and schooling time span of sex work place of work price of commercial sex and use of drugs 24 25 26 which in turn is associated with unprotected sex 27 findings from a snowball survey carried out in santos são paulo showed that the use of illicit drugs especially crack was one of the main factors associated with hiv infection 4 furthermore structural issues such as stigma and discrimination act as important barriers and hinder access to and use of health services 2829 the burden of hiv syphilis and other sti urged researchers to conduct studies in brazil among fsw 30 31 32 furthermore in brazil concentrated hiv epidemic 33 small interventions in this vulnerable group can significantly decrease hiv incidence in the general population 34 thus monitoring factors associated with hiv infection is important not only to support interventions focused on this population group but also to reduce the spread of hiv infection among clients of fsw which constitute a bridge population for stihiv transmission into the brazilian population 35 in general brazilian studies conducted among fsw until the mid2000s used convenience samples making it difficult to estimate parameters for monitoring the hivaids epidemic in this population group at the national level 36 in 2009 an hiv biological and behavioral surveillance survey carried out in 10 brazilian cities was the first study to use a probabilistic sampling methodrespondent driven sampling for the recruitment of fsw 37 for the analysis of data collected by rds a statistical method has been proposed for the estimation of hiv prevalence and its variance taking into account the dependence of observations resultant from the recruitment pattern 38 this approach was extended to other statistical analyzes such as measures of association and multivariate models 39 in 2016 a 2nd hiv bbss among fsw was carried out in 12 brazilian cities aiming at monitoring sti and risky practices among fsw based on improvements in data analysis techniques 39 the aim of this study was to identify factors associated with hiv infection using logistic regression models methods this study is part of the 2nd bbss a crosssectional rds survey among 4328 fsw collected in 12 brazilian cities from july to november 2016 the bbss was designed to estimate the prevalence of hiv syphilis and hepatitis b and c and to evaluate knowledge attitudes and practices related to hiv infection and other stis among fsw the research project was approved by the ethics committee of the oswaldo cruz foundation twelve brazilian cities were a priori chosen by the department of stiaids and viral hepatitis ministry of health according to both geographical criteria and their epidemiologic relevance in the hivaids epidemic in the country the sample size was set at 350 fsw in each city figure 1 shows the 12 cities considered in the study and their correspondent sample sizes women were eligible to participate in the study if they met the following inclusion criteria age 18 years old or over to report working as a sex worker in one of the cities of the study to have had at least one sexual intercourse in exchange for money in the past four months and to present a valid coupon to participate fieldwork was conducted in health services located in the 12 cities for each city 6 to 8 initial participants herein referred to as seeds were chosen purposively following previous formative research seeds were wellconnected fsw in their community who reported large social networks to provide diversity of recruited fsw seeds were chosen with different characteristics each seed received 3 coupons to distribute to other sex workers from her social network recruits of the seeds in the survey were considered the first wave of the study after participating in the interview each participant received 3 additional coupons to distribute to their peers and this process was repeated until the sample size was achieved in each city the rds method also draws on the strategy of giving incentives to the participants a 1st incentive that is primary incentive is given to participants when they complete their participation in the study thereafter a 2nd incentive that is secondary incentive is given to participants for each peer successfully recruited into the study in this study the primary incentive was a gift payment for lunch and transportation in addition to a reimbursement for their time lost from work the secondary incentive was a payment of us 1000 for each recruited person who participated in the study the choice of sites in general a health service for data collection and the level of incentives were established according to the formative research carried out in each city before the rds survey the questionnaire included modules on sociodemographic characteristics and information related to commercial sex activity knowledge about hiv and other sti transmission sexual behavior history of hiv and syphilis testing sti history use of alcohol and illicit drugs access to prevention activities access to and utilization of health services discrimination and violence the questionnaire was designed for tablets and could be selfadministered according to the participants desire and readiness tests for hiv syphilis and hepatitis b and c were conducted by standard rapid tests using peripheral venous blood collection according to protocols recommended by the brazilian ministry of health all tests occurred before the interview and all participants received preand posttest counseling participants who tested positive for any of the rapid tests had their blood samples taken for confirmatory laboratory testing and received additional posttest counseling both for psychological impact and to encourage partner notification and were referred to public health systems for followup screening for hiv hepatitis b virus hepatitis c virus and syphilis antibodies used the following assays hiv hbv hcv and syphilis treponemal assay a reactive result on the initial hiv rapid test was followed by a 2nd hiv rapid test from a different manufacturer and samples reactive on rapid tests were further submitted to confirmatory assays data analysis the proposed weighting for data collected by rds is proportional to the inverse of network size of each participant 40 in this study the question used to measure the network size of each participant was how many sex workers who work here in this city do you know personally each one of the 12 cities composed a stratum and in each one the weighting was inversely proportional to the size of the network totaling the size of the stratum the tendency of a participant to recruit peers with similar characteristics is usually referred to as homophily 41 to take into account this bias in the recruitment pattern and a potential overrepresentation of individuals with certain characteristics in the study population we used logistic regression models to estimate factors associated with hiv infection according to a method proposed by szwarcwald et al 38 for each participant the result of the recruiters hiv test was taken into account to control for the homophily effect additionally the logistic regression models were performed by taking into account the complex sample design by considering each city as a stratum and the participants recruited by the same fsw as a cluster 38 the following variables were included in the analysis sociodemographic variables characteristics related to sex work prevention activities sexual behavior consistent condom use with clients in vaginal sex history of physical and sexual violence alcohol and drug use utilization of health services and sti results hiv prevalence was estimated as 53 with a 95 confidence interval the odds ratio of an hivpositive recruiter choosing an hivpositive participant was nearly 4 times higher than that of an hivnegative recruiter taking into account the homophily effect and the dependence between recruiters and their recruited participants the design effect was estimated at 176 38 in the logistic regression analyses presented in table 1 many of the studied variables were significantly associated with hiv infection even after controlling for hiv recruiters result regarding sociodemographic characteristics the older the fsw the higher the hiv prevalence and the lower the educational level the higher the odds of hiv infection however no statistically significant difference was estimated for skin color race regarding commercial sex characteristics hiv infection was associated with time in commercial sex work hiv prevalence ranged from 19 for less than 5 years to 119 for greater or equal to 20 years of sex work sex work venue was also significantly associated with hiv infection with an or of 34 when point of street is compared to other workplaces additionally an inverse association was found for the price of each sexual encounter the higher the price the smaller the odds of hiv infection in relation to participation in prevention activities women who were affiliated to or participated in an fswngo in the past 6 months had 17 times greater chance of being hiv infected sti counseling in the last 6 months prior to the survey was not statistically significant results related to history of violence use of alcohol and illicit drugs and sexual behavior are presented in table 2 the odds of being hiv infected among fsw who had been exposed to sexual violence at least once in a lifetime was significantly higher as to alcohol use only the indicator unprotected sex under the effect of alcohol or drug use at least once a week showed a statistically significant association with hiv infection on the other hand the use of illicit drugs at least once a week was highly significant hiv prevalence varied from 45 to 106 or 25 with a marked effect for frequent crack use although hiv prevalence was smaller for consistent condom use with clients the or was not statistically significant however the situation of not using condom for not having one available at the time of the sexual encounter was significantly associated with hiv infection other circumstances for not using condom such as many sexual encounters during the day allergy to condom unconsciousness due to use of alcohol or drugs or any other motive showed borderline associations as well among the indicators of health service utilization neither uptake of the pap smear exam nor hiv testing in the previous 24 months before the survey showed a significant effect on hiv infection although prevalence estimates were smaller among fsw who used health services regarding the occurrence of sti signs over the 12 months prior to the survey presence of blisters on the vagina or anus indicated a chance 26 times higher of hiv infection when compared to those who did not report sti signs the or was highly significant among those fsw who had been exposed to syphilis in table 4 we present the results of the multivariate analysis educational level remained statistically significant highlighting the stronger effect of illiteracy or very low level of education as well as price per sexual encounter time of exposure to sex work and the workplace after controlling for all other variables that also showed significant effects on hiv infection among the indicators of alcohol and illicit drug use only the use of crack showed an adjusted significant or syphilis was the most important predictor of hiv infection with corresponding adjusted or of 27 discussion in the first bsss among fsw recruited by rds in 2009 in 10 brazilian cities 38 hiv prevalence was estimated as 48 approximately 12 times higher than the estimated prevalence in the brazilian female population seven years later the findings of the present study showed no significant change in hiv prevalence which remain at the same 5 level with overlapping 95 ci a large and significant homophily effect was found as well the recruitment of a large number of fsws in 12 brazilian cities in a short time period at a relatively low cost compared to studies conducted in highincome countries and the use of appropriate statistical procedures in data analysis indicate that rds is a feasible methodology for the study of fsw in brazil the experience of the previous rds study enabled us to improve the techniques for data analysis and all the logistic regression models used in the present study took into account the hiv infection homophily effect and the intraclass correlation between recruited fsw by the same participant 39 to identify the main predictors of hiv infection we constructed indicators based on different aspects that characterize the current hivaids epidemic in brazil among fsw in relation to sociodemographic and commercial sex characteristics low educational level street as the main work venue low price per sexual encounter and longer exposure time as a sex worker were found to be the main predictors of hiv infection our results corroborate the results of other international studies among fsw 42 43 44 and the results of the previous 2009 bbss 39 older women in addition to having a longer period of sex work exposure who charge less for their services have lower education levels and for the most part work in the streets are factors that have been shown to be associated with hiv infection as to the use of alcohol and illicit drug use our findings reiterate the effects of a greater hiv vulnerability associated to unprotected sex 45 the possibility of not using condoms in some specific situations such as not having condom available at the time of the sexual encounter showed a significant effect on hiv infection as well data from previous surveys in brazil evidenced a tendency for fsw to report consistent condom use with clients especially when interviewed by health staff however when questions are asked indirectly they reveal not using condoms in several circumstances 49 regarding participation in prevention activities the results showed a higher chance of hiv infection among women who reported being affiliated to or participating in fsworiented ngos this finding suggests that hivinfected women may have sought the support given by ngo activists because of their hiv infection unfortunately in the current situation of weakening of ngos in brazil the role of these institutions has been less and less focused on prevention and health promotion as had historically occurred in brazil 46 the findings on health services utilization indicated a smaller hiv prevalence among fsw tested for hiv over the past 2 years frequency of hiv testing represents the individual concern with preventive health care but also selfperception of risk despite the nonsignificant or the lower chance of being hiv infected among fsw who had tested for hiv over the past 2 years suggests improvements in hiv testing mainly due to prevention attitudes 4748 the occurrence of other sti indicated by the presence of blisters on the vagina or anus and syphilis were the most significant determinants of hiv infection these findings reveal not only exposure in the past to unsafe practices related to sti 9 but also may reflect the enhancement of sti on hiv transmission 49 history of sexual violence was shown to be a relevant factor associated with hiv infection although prostitution in brazil is not considered a crime under the national constitution fsw constantly experience human rights violations such as physical and sexual violence usually perpetrated by partners family members and clients 50 according to the world health organization 51 violence has a direct impact on the adoption of safe sex practices among fsw engagement in violent and unprotected sexual practices even against their will reflects the stigma and discrimination suffered by these women factors that have been shown to be strongly associated with adverse health outcomes 5253 the results of the multivariate analysis showed that the association of some variables with hiv infection persisted such as effect of lower education and cheaper fee for services working at street spots longer exposure time of sex work syphilis and crack use at least once a week it is important to note that the use of multivariate models on the data collected by rds often renders variables that lose statistical significance due to the complex sampling design with overcontrol of the homophily effect or to adjustments for confounding other limitations are related to the crosssectional design for which the analysis of causality is restricted since temporality is not addressed in this type of study 54 in conclusion the main factors associated with hiv infection identified in this multivariate analysis characterize a specific type of streetbased commercial sex work in brazil older women with none or very low degree of instruction who charge less for the sexual encounter and frequently engage in higher risk sexual behavior the small fee per sexual encounter is a determinant of the type of client in general of low socioeconomic status and who are more likely to request unprotected sex 27 besides providing prevention knowledge and health promotion interventions focusing on lowpaying sex workers must emphasize the risk associated to unsafe sexual behavior with both clients and steady partners 17 ultimately although the statistical analyses provide valuable information for developing targeted interventions there is a further need to address other contextual factors fsws are exposed to multiple harms including illicit drug use violence and criminality exploitation as well as stigma and discrimination 55 thus comprehensive social interventions must focus on the multiple needs of this vulnerable population including individual and contextual factors that can influence sexual behavior the datasets used andor analyzed during the current study are available from the corresponding author on reasonable request

background female sex workers fsws are one of the mostatrisk population groups for human immunodeficiency virus hiv infection this paper aims at identifying the main predictors of hiv infection among fsw recruited in the 2nd biological and behavioral surveillance survey in 12 brazilian cities in 2016 method data were collected on 4245 fsw recruited by respondent driven sampling rds weights were inversely proportional to participants network sizes to establish the correlates of hiv infection we used logistic regression models taking into account the dependence of observations resultant from the recruitment chains the analysis included sociodemographic sex work characteristics sexual behavior history of violence alcohol and drug use utilization of health services and occurrence of other sexually transmitted infections stis results hiv prevalence was estimated as 53 44 62 the odds ratio or of an hivpositive recruiter choosing an hivpositive participant was 39 times higher than that of an hivnegative recruiter p 001 regarding sociodemographic and sex work characteristics low educational level street as the main work venue low price per sexual encounter and longer exposure time as a sex worker were found to be associated with hiv infection even after controlling for the homophily effect the or of being hiv infected among fsw who had been exposed to sexual violence at least once in a lifetime or 15 p 028 and the use of illicit drugs at least once a week were highly significant as well particularly for frequent crack use or 36 p 001 among the sexual behavior indicators not using condoms in some circumstances were significantly associated with hiv infection or 18 p 016 regarding the occurrence of other sti the odds of being hiv infected was significantly higher among fsw with a reactive treponemal test for syphilis or 46 p 001 the main factors associated with hiv infection identified in our study characterize a specific type of streetbased sex work in brazil and provided valuable information for developing interventions however there is a further need of addressing social and contextual factors including illicit drug use violence exploitation as well as stigma and discrimination which can influence sexual behavior

introduction patient satisfaction is consumers evaluation about the effectiveness safety and benefit of health care service which is a combination of patients experience and perception 1 2 3 patient satisfaction is an important and commonly used indicator for measuring the quality of health care and higher patient satisfaction would lead to better clinical outcomes and less care resource utilization therefore patient satisfaction survey is essential for patients health care provider and health care payer 4 5 6 correspondence ying bian institute of chinese medical sciences university of macau avenida da universidade room 2055 n22 building taipa macau sar china tel 86 853 6520 5586 email patient preference and adherence downloaded from for personal use only this article was published in the following dove press journal patient preference and adherence most patient satisfaction studies were conducted in the usa and european countries suggesting that patients in the flourishing regions tend to evaluate the quality of health care service based on waiting time medical staffs proficiency hospital environment and participation in the medical decision making 34 7 8 9 10 there are several recent patient assessment studies which were conducted in developing countries including india thailand tanzania and ethiopia patients in these countries care more about the location of health facility hospital comfort and access to appropriate services 11 12 13 14 15 patients perception varies according to education level age income and residence 15 as proposed in previous literature 16 with the increasing population and patient expectation patient satisfaction analysis is essential to evaluate the accessibility and quality of medical service especially in developing countries such as china some researchers had explored the outpatient satisfaction and factors affecting chinese patients satisfaction mostly from developed provinces or tertiary hospitals performing descriptive analysis and satisfaction ratings survey 1718 questionnaire is a commonly used satisfaction survey instrument as reported in studies conducting univariate or regression analysis factors including hospital environment medical facility service attitude patients involvement in decision making doctors and nurses proficient skills effective communication between patients and doctors disease severity medical cost waiting time and service time were associated with chinese outpatients satisfaction in advanced areas or tertiary hospitals 19 20 21 22 23 similar results were also previously demonstrated in hong kong and taiwan studies 24 25 26 according to grossman 27 patients demand for medical services is associated with demographic characteristics and socioeconomic conditions therefore patients demand and satisfaction in backward areas should be measured in a different way from developed areas 28 so far no questionnaire studies have been designed to assess primary health care outpatients satisfaction with a largesample evidence covering different backward provinces in china considering the relatively lower education level less individual income and heavier economic burden it is necessary to process a regionspecific questionnaire survey for the outpatients satisfaction in rural western china consequently the objective of this study was to conduct a satisfaction survey in primary outpatient service in rural western china and explore the factors affecting outpatients satisfaction materials and methods this research was approved by the research ethics committee of institute of chinese medical sciences university of macau questionnaire development the initial questionnaire draft was designed based on the literature review and the literature search was conducted using cnki and pubmed database in june 2014 by keywords including outpatient satisfaction china and questionnaire more than 50 previous outpatients satisfaction survey and relevant studies were screened and the adaptive information was extracted to compose the item pool and local medical price reimbursement percentage residents income and education level were considered during the pilot study according to the pilot study results and local physicians advice the final draft version contains 9 items including time spent in commuting to hospital waiting time doctors disease description patients participation in decision making staff service attitude hospital facility hospital environment medical cost and doctors and nurses professional skills interviewees were also asked to fill their background information including age gender occupation education level monthly income medical insurance type and condition of chronic diseases the questionnaire was designed as a 5point likert scale 29 and interviewees were asked to rate each item very dissatisfied dissatisfied neither satisfied nor dissatisfied satisfied and very satisfied sampling eleven provinciallevel divisions in western china were selected to explore the outpatient satisfaction including ningxia hui autonomous region guangxi zhuang autonomous region xinjiang weiwuer autonomous region gansu province shaanxi province qinghai province sichuan province guizhou province yunnan province inner mongolia and tibet autonomous region in each province all counties were divided into 3 levels by gdp per capita and 1 sample county was randomly selected from each level of 11 provinces the county general hospital maternal and child health center and hospital of traditional chinese medicine in each sample county were recruited as sample hospitals fifty outpatients drawn randomly from each sample hospital were enrolled into the study receiving the questionnaire when leaving the hospital written informed consent was obtained from all interviewees before filling the questionnaire all questions were explained by trained investigators the questionnaire for interviewees aged 14 years was answered by their adult supervisor statistical analysis the missing item and total response rates were used to assess the questionnaire acceptability and feasibility descriptive data were tabulated to present participants demographic and other background characteristics exploratory factor analysis using principal component analysis and varimax rotation was conducted to assess the dimensionality of overall satisfaction evaluate the structure validity and reduce the number of variables 30 31 32 multiple linear regression analysis in a stepwise method was implied to explore the association between outpatients characteristics and satisfaction factor scores outpatients background characteristics that showed significant difference in univariate analysis were included as independent variables with dimensional and overall factor scores as dependent variables all data analysis was performed using spss version 190 results the questionnaire survey was conducted from october to december 2014 a total of 3193 patients participated in the survey and 2754 questionnaires were fully completed the missing value rate for each item was 02 05 and the total response rate was 887 indicating that the questionnaire was acceptable and feasible descriptive findings the descriptive results of participants demographic and other background characteristics are presented in table 1 the mean age of respondents was 3686 40 were female and 60 were male only 40 of interviewees had completed at least high school education farming was the most common occupation and 704 of responders income was 2001 yuan per month most participants were enrolled in public medical insurance 146 of respondents were insured by urban employee basic medical insurance 95 by urban resident basic medical insurance and 602 by new rural cooperative medical scheme a total of 20 of the participants had chronic diseases outpatients satisfaction item scores the results of the outpatients satisfaction survey are shown in detail in table 2 according to the mean scores respondents were most satisfied with medical staff service attitude and second doctors disease description medical cost was the least satisfactory item the sum of mean scores of 9 items was 3058 with the maximum score of 45 which was relatively lower than the average satisfaction scores in previous studies factor analysis efa was conducted to explore the dimensionality of the overall outpatients satisfaction in rural western china and analyze the validity of the dimensional structure the overall cronbachs α value was 075 suggesting good reliability the kaisermeyerolkin measure for the dataset was 0804 the bartletts test was 6002289 and all itemtotal correlations exceeded 050 implying that the data were adequate for efa 31 32 33 principal component analysis and varimax rotation were adopted as shown in table 3 only 2 factors had eigenvalues 1 34 however combined with the cumulative variance percentage and scree plot 3536 a 3factor solution was applied in the factor analysis according to the factor loading values 9 items were explained by 3 dimensions factor 1 service attitude consisted of the 3 items of the questionnaire including patients participation in decision making doctors disease description and medical staff service attitude factor 2 facility and professional skills consisted of hospital environment hospital facility and doctors and nurses professional skills factor 3 patients cost consisted of 3 items including waiting time time spent commuting to hospital and medical cost the internal consistency of the matrix was examined for factors 1 and 2 the cronbachs α values were 0733 and 0740 respectively which were considered very good the interitem correlation can also be adopted as a measure of internal consistency when the number of items in the scale was 10 which was acceptable between 02 and 04 thus the internal consistency of factor 3 was considered acceptable although the cronbachs α value was only 0542 3237 more details of efa results are available in table 4 factors associated with outpatients satisfaction the regression method was used to estimate the factor score coefficients and the scores of factor 1 factor 2 and factor 3 were produced by spss software to comprehensively explore the characteristics associated with outpatients satisfaction the factor score of overall satisfaction was calculated based on the score and variance contribution rate of the 3 main factors 3138 f 022872 f 1 021113 f 2 018192 f 3 stepwise multiple linear regression was conducted to investigate the factors influencing the 3 main dimensions and the overall satisfaction patients age sample hospital type education occupation monthly income medical insurance type and chronic disease condition showed significant differences in the univariate analysis thus included in regression model as independent variables with f 1 f 2 f 3 and f as dependent variables table 5 presents the results of the stepwise multiple linear regression which demonstrated that the age sample hospital type education occupation monthly income and according to the coefficients and pvalues significant differences were observed among different respondent populations in dimensional satisfaction older outpatients had higher satisfaction score in all 3 dimensions interviewees from general county hospitals were more satisfied with facility and professional skills but less satisfied with other 2 dimensions than other county hospitals compared with lower educated patients respondents who had completed at least junior middle school were more satisfied with service attitude and facility and professional skills less satisfied with patients cost outpatients with chronic diseases graded higher in service attitude and facility and professional skills higher income participants were more satisfied with patients cost and less satisfied with service attitude and teachers governments staff service industry workers business workers enterprise employee and retirees in comparison with farmers workers students and the unemployed were more satisfied with service attitude different respondent populations also had significant differences in overall satisfaction the overall satisfaction increased significantly with age interviewees from other county hospitals were more satisfied than those from general county hospitals outpatients with chronic diseases graded higher overall satisfaction and higher educated respondents were more satisfied teachers governments staff service industry workers business workers enterprise employees and retirees compared with farmers workers students and the unemployed were more satisfied with overall outpatient health care discussion patients satisfaction is an important and commonly used indicator to analyze the patients demand performance and utilization of medical service therefore patients satisfaction research is essential in the process of chinas health system reform although several patient satisfaction reports had been published before no intensive study was conducted to investigate outpatients satisfaction with largesample evidence covering chinas backward provinces in this research county hospital outpatients satisfaction of 11 provinces in western china were analyzed a total of 2754 outpatients completed the questionnaire and the response rate was 887 among included respondents 455 were farmers and 602 were insured with the nrcms according to chinas national health service survey report 2013 39 western china residents have lower outpatient satisfaction rate than middle and eastern china rural residents have higher satisfaction rate with regard to medical staff than hospital environment and waiting time supporting the results of higher satisfaction in service attitude doctors disease description and medical staff proficient skills in this paper medical cost was the least satisfactory item which had also been previously presented in nhss report and outpatients satisfaction study in beijing 2339 in this study no satisfaction item core exceeded 38 less than the overall satisfaction scores for outpatient in tertiary hospitals 20 the result is consistent with previous references 4041 suggesting that outpatients in primary health care in rural western china were relatively less satisfied with medical service than developed areas or tertiary hospitals efa results showed a 3dimension structure of overall outpatient satisfaction service attitude facility and professional skills and patients cost with 3 items respectively and demonstrated acceptable reliability and validity the stepwise multiple linear regression results indicated that age sample hospital type education occupation monthly income and chronic disease condition were statistically associated with dimensional or overall outpatient satisfaction the overall satisfaction increased with age which was agreeable to the report of outpatient satisfaction in ningxia province and shanghai 2142 respondents with chronic diseases tended to have higher overall satisfaction and a similar trend was observed in satisfaction study from developed areas 23 it is possible that the elderly and chronic patients compared with the young and patients without chronic diseases were more experienced and trusted their doctors due to their health status participants from countylevel general hospital were less satisfied with patients cost than other county hospitals since waiting time was reported as the most important item of patient satisfaction in general hospitals 43 this result was in agreement with the lower overall satisfaction in county general hospital outpatients with higher income were more satisfied with patient cost but less satisfied with service attitude predicting the increasing demand for better service attitude with the growing income of chinese residents contrary to previous evidence 44 although less satisfied with patients cost better educated outpatients were more satisfied with service attitude facility and professional skills and overall outpatient service it is probably the accessibility to highquality medical service rather than the affordability that influence the overall satisfaction of educated outpatients in rural western china teachers governments staff service industry workers business workers enterprise employees and retirees had higher overall satisfaction than farmers workers students and the unemployed which may be related to the stable income and higher reimbursement rate of the former patient satisfaction is a reflection of the residents health care demand understanding the demand of patients under different conditions plays a crucial role in improving the performance and efficiency of medical services there are similarities and differences between the results in this survey and previous literatures which suggest that outpatients health care demand in rural western china have their own uniqueness as reported in chinas nhss 2013 39 high medical cost was the primary cause of rural outpatient dissatisfaction in recent years and then poor professional skills and bad service attitude however considering the association between outpatients characteristics and satisfaction in this study primary demand of some rural outpatients has altered from lower price to higher efficiency better service attitude and professional skills since china has implemented the national essential medicines list in 2009 and required no drug profit margins in public hospitals in 2017 a universal access to affordable essential medicines would be promoted in a few years health care providers should identify and target more initiatives to improve service attitude environment and professional skills in rural western china efficient hospital management methods modern technologies and more staff training are needed to improve the health care service quality implementation of electronic patient record system and consultation desk in each department may reduce the patient queue time and doctor preparation time in general hospitals 45 more interpersonal communication training would help doctors and nurses in disease explanation and promoting service attitude 46 rural primary health care institutions are also suggested to develop more patient education about chronic disease management promote patient participation and improve the care efficiency 47 most of published satisfaction questionnaire survey on chinese patients were singlecenter study in tertiary hospitals or developed regions 2348 conducting regression analysis on mean satisfaction score or satisfaction rate 2144 compared with previous literature a questionnaire was developed in this study to collect primary health care outpatients satisfaction score in rural western china then efa and multiple linear regression were conducted to describe the satisfaction dimension and associated factors exploring rural outpatient satisfaction from another perspective it is the first outpatient satisfaction questionnaire study based on efa with multiprovince evidence in backward china and the questionnaire showed acceptable reliability and good feasibility limitations although there was a large sample size and reliable results it should be noted that this study has some limitations 1 the research sampling was not conducted based on the population distribution of 11 provinces which may cause the deviation of sample resource 2 differences of economic level and medical service quality among 11 provinces were not controlled by which the satisfaction difference caused could not be explained in this study conclusion on the whole the primary health care outpatient satisfaction in rural western china is lower than developed areas and tertiary hospitals service attitude facility and professional skills and patients cost were the main 3 dimensions of overall satisfaction with significant differences among patients with different demographic characteristics and chronic disease conditions local health care institutions should evaluate and manage the outpatient service quality based on the actual need of patients considering patients demographic characteristics and health status efficient hospital management methods modern technologies and staff training are needed to improve the quality of medical service and care efficiency in backward areas disclosure the authors report no conflicts of interest in this work patient preference and adherence publish your work in this journal submit your manuscript here patient preference and adherence is an international peerreviewed open access journal that focuses on the growing importance of patient preference and adherence throughout the therapeutic continuum patient satisfaction acceptability quality of life compliance persistence and their role in developing new therapeutic modalities and compounds to optimize clinical outcomes for existing disease states are major areas of interest for the journal this journal has been accepted for indexing on pubmed central the manuscript management system is completely 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background with a growing health demand patient satisfaction analysis is essential for evaluating the accessibility and performance of medical services previous studies had explored the chinese outpatient satisfaction and influencing factors in developed areas and tertiary hospitals considering the lower education level less income and heavier economic burden it was necessary to conduct a regionspecific questionnaire survey for the outpatients satisfaction in rural western china objective to analyze the satisfaction of primary outpatient service in rural western china and explore the factors affecting outpatients satisfaction methods questionnaire composed of nine 5likert items was applied to survey outpatient satisfaction among randomly selected samples in 11 provinces of western china exploratory factor analysis efa was conducted to study the factor structure of questionnaire stepwise multiple linear regression analysis was performed to study the influencing factors results a total of 2754 outpatients completed the questionnaire the response rate was 887 respondents were most satisfied with medical staff service attitude 371±083 and least satisfied with medical cost 297±083 a 3factor solution was adopted in efa to explain the overall satisfaction factors identified were service attitude facility and professional skills and patients cost and the questionnaire was proved to have good reliability and acceptable internal consistency the stepwise multiple linear regression analysis results presented that factors including sample hospital type p005 age p0001 education level p005 occupation p001 monthly income p005 and chronic disease conditions p001 were significantly associated with the dimensional or overall satisfactionthe primary health care outpatient satisfaction in rural western china is lower than developed areas and tertiary hospitals care providers in backward regions should pay more attention to patients demographic characteristics and health status to meet outpatients actual demand efficient hospital management methods modern technology and staff training are needed to improve the service quality and care efficiency

introduction globally head and neck cancers comprising cancers of the oral cavity oropharynx hypopharynx and larynx account for over 700 000 new cases diagnosed and over 350 000 deaths each year representing 4 of all new cancers in europe and south america 1 2 worldwide trends of these cancers are on the riseparticularly in the oropharyngeal cancer subsite 3 4 5 the major risk factors for head and neck cancer are tobacco use and alcohol consumption which comprise around 70 of the population attributable risk 6 7 human papillomavirus infection is an emerging risk factor for oropharyngeal cancer 8 9 across all head and neck cancers socioeconomic risk associations are comparable in magnitude to those of behavioural risk factors with the greatest burden of head and neck cancer observed in those with the lowest incomes and education levels 10 tobacco smoking and alcohol consumption explain approximately twothirds of the socioeconomic relationship and this association persists when controlling for smoking or alcohol behaviour and among never smokers and never alcohol drinkers 10 a previous systematic review and metaanalysis of published risk estimates found consistent elevated risk for oral cancer associated with low occupational socioeconomic position 11 and an earlier small casecontrol study of larynx cancer suggested the occupational socioeconomic relationship was partly explained by smoking alcohol consumption and substantially attributed to occupational exposures 12 the relationship between occupationalrelated socioeconomic factors and head and neck cancer risk has not been examined in detail socioeconomic classification of occupations is multidimensional original research and includes measures of occupational social position prestige and class 13 14 while occupational social classifications are largely related to the income andor educational attainment required for the job occupational social prestige explicitly relates to ranking of jobs based on normative admiration or respect 15 occupational socioeconomic prestige is derived from multiple factors such as psychosocial aspects work stress job control and social support networks 13 14 low relative to high and downward lifetime trajectories of occupational socioeconomic prestige have previously been linked with cancer risk 16 and particularly lung cancer in men 15 here we investigate the risk associations of occupational social prestige occupational socioeconomic position and manual occupations for head and neck cancer we thoroughly assess explanatory factors including smoking alcohol and occupational exposures and we explore differences in these risk associations by gender global region and head and neck cancer subsite methods the original data studies of the international head and neck cancer epidemiology consortium have been described in detail elsewhere 6 17 briefly we used data from five frequencymatched casecontrol studies which provided databases with occupational histories containing occupational and industrial codes in addition to the inhance pooled database we included studies from western europe 18 latin america 19 germany 20 and two studies from france 21 and 22 which were all multicentre studies except for the german study online supplemental file 1 shows the main characteristics of these studies we omitted participants with missing information on smoking behaviour alcohol consumption and missing or largely incomplete occupational history data cases comprised cancers of the oral cavity oropharynx hypopharynx and larynx control participants were recruited either in hospitals latin america or in the general population germany both types of recruitment were used in the western europe study occupational socioeconomic position and prestige data we assigned indices of socioeconomic position and prestige on the basis of participants occupational histories which contained job periods already coded by the international standard classification of occupations of 1968 23 we considered occupational histories before retirement reviewed all job periods and deleted periods with missing or implausible information for isco68 start year or end year we then excluded data of participants from the analysis if their occupational history spanned less than 10 years but only if they were also 30 years at the time of the study 15 and if less than 50 of their job history had isco68 codes we assigned treimans standard international occupational prestige scale to the job histories 24 siops assigns prestige ratings to occupations ranging from 14 to 78 based on the distribution of siops scores among controls we categorised the siops score range into quartiles we also coded the jobs to the international socioeconomic index of occupational position in the version corresponding to isco68 25 which comprises scores with a range from 10 to 90 as for siops we constructed quartiles based on the isei distribution in the control group both siops and isei were assigned on the basis of threedigit levels of isco68 codes we further applied isco68 codes to manual and nonmanual job groupings as previously described 26 for analyses from the coded occupational histories we selected the longest held job for the primary analyses but also assessed the first job last job the jobs with the highest ever reached siops and isei scores and ever employed in manual job respectively occupational data were further used to represent occupational exposure to carcinogens for head and neck cancer we integrated the investigated isco68 categories in a new list of risk occupations where ors for the comparison of ever versus never having worked in an isco68 occupation were elevated and if ors were increasing for 10 or more years of employment our job history data did not contain sufficient information to accurately assign industries and assess their risk associations although based on results for men we applied the new list of risk occupations to both men and women we distinguished whether participants were ever employed in risk occupations for 10 or more years 27 28 finally based on additional coding from three studies and germany we characterised participants as ever or never having experienced unemployment statistical analysis we investigated head and neck cancer risk associations with occupational socioeconomic prestige position manual versus nonmanual occupation and unemployment experience we estimated ors with 95 cis by unconditional logistic regression based on a model adjusting for sex age and study centre we added further variables in cumulative steps to study the impact on the investigated association we first added cigarette smoking behaviour duration smoking intensity and cigarette packyears never smokers were participants who had smoked less than 100 cigarettes during their lifetime former smokers were participants who quit smoking more than 1 year before study participation in the next step we additionally considered alcohol consumption by adjusting for drinking status drinking intensity that is average amount of alcoholic drinks per day and an interaction term of smoking and alcohol 6 we further adjusted for evernever employed in a risk occupation sensitivity and stratified analyses we further adjusted for the respective other socioeconomic position and prestige variables we applied model 5 to analyse unemployment but did not adjust for unemployment due to the missing data the main analyses were based on the longest held job additional sensitivity analyses involved using the first and the last job as well as the highest ever reached siopsisei or ever employment in manual job respectively we alternatively included siops and isei as continuous variables all further analyses were also based on siops for the longest job and the full model analyses were stratified by sex tumour subsite study region original research type of control recruitment and single as well as combined stratification for ever or never use of cigarettes and alcohol further sensitivity analyses included exploring differences observed by study regions andusing model 1examining those participants who were initially excluded because of largely incomplete occupational histories finally we performed multiple imputation on missing smoking and alcohol information and recalculated model 4 all analyses were performed with sas v94 results we included 13 144 participants in the final analysis table 1 describes the study population lower categories of socioeconomic position and prestige indices were more frequent among cases only about onethird of overall cases had longest held jobs in the first or second quartiles of siops and isei respectively whereas this proportion was about 50 among controls overall 36 of cases compared with 22 of controls had ever worked in a risk occupation for at least 10 years with lower proportions for women unemployment experience was slightly higher for male cases than male controls associations of occupational socioeconomic position and prestige are shown in table 2 for all indices ors increased with lower positionprestige ors were attenuated by all further adjustments with the greatest effect through adjustment for cigarette smoking adjustment for alcohol consumption and employment in risk occupations only marginally reduced risk estimates after adjustment for all behaviours and risk occupations strong associations between low positionprestige and head and neck cancer persisted with ors for the lowest relative to highest categories of siops 188 isei 174 and manual occupations 149 accordingly siops and isei on a continuous scale were significant parameters in the fully adjusted model in the model mutually adjusting for other socioeconomic measures siops risk association remained or 159 additional sensitivity analyses showed risk associations were slightly lower for the first job and elevated for the last job and highest siops and isei the subgroup analysis of participants who had ever experienced unemployment showed slightly elevated risks for head and neck cancer in the fully adjusted model results for the stratified analyses of risk associations are shown in table 3ab for siops and in online supplemental file 5ab for both isei and manualnonmanual occupation the risk associations were consistently lower for women than men in contrast to the european studies we did not find a similar strength of association in latin america when we stratified by tumour subsite we found stronger associations for cancer of the larynx and hypopharynx than oral cavity or oropharynx stratification by type of control recruitment showed increased ors for populationbased recruitment and reduced ors for hospitalbased recruitment risk associations for low relative to high siops reduced among never smokers and never alcohol drinkers with greater attenuation associated with never smokers than never drinkers sensitivity analysis including participants initially excluded due to largely incomplete occupational histories did not change estimates either for europe or for latin america nor did multiple imputation for missing smoking and alcohol information only marginally changed estimates discussion we found consistently elevated risk associations for head and neck cancer with low occupational social prestige low occupational socioeconomic position and manual work these findings were only partly explained by smoking alcohol drinking or working in recognised higher risk occupations however among the small subgroup of never smokers and never drinkers the risks associated with lower social prestige and class were completely attenuated the overall findings were stronger among men than women for cancers of the larynx and hypopharynx and observed in europe but not in latin america inequalities in health outcomes are driven by social determinantsby inequalities in income wealth and power 29 our analysis taps into several of these domains particularly the power relationships that arise from different occupational strata and shown to be important in health outcomes 30 siops is based on the social prestige given to different occupational groupings mccartney et al recently reappraised theories of social class and their application to the study of health inequalities 31 they noted that siops and isei unlike traditional categorical occupational social class schemes employ a continuous or gradational hierarchybased on relative social advantage 32 while isei captures more material aspects of socioeconomic position as it is derived from education and income aspects of occupations the use of the siops measure enables more direct inference of the psychosocial dimension 13 14 15 16 although siops isei and manual versus nonmanual reflect different socioeconomic class dimensions they all are occupationbased indices and are known to be strongly correlated 25 we found the strongest head and neck cancer risk associations for prestige with socioeconomic position and manual occupations slightly lower this points to the importance of psychosocial and material dimensions of occupational socioeconomic relationship with head and neck cancer although the environmental aspect is also relevant while there are recognised head and neck cancer risk associations with certain occupations 27 we found only a limited interrelationship between occupational risk and the socioeconomic dimensions of occupations earlier studies suggested that occupational exposures were responsible for about onethird of total cancer difference between high and low socioeconomic groups 33 in our data for head and neck cancer occupational exposures attenuated the socioeconomic excess risk associations by around 20 however this type of comparison of estimates may be biased in logistic regression models 34 35 smoking is undoubtedly a major risk factor for head and neck cancer 6 and a major explanatory factor for all socioeconomic health inequalities 10 alcohol consumption also compounds head and neck cancer risk 6 7 and clustering of these risk factors is also observed in lower socioeconomic groups 11 we observed following thorough adjustment of many dimensions of smoking and alcohol behaviours that the risk associations with occupational socioeconomic measures reduced elevated head and neck cancer risks associated with lower socioeconomic positions among never original research continued original research smokers andor never alcohol drinkers suggest some potential residual effects of smoking and alcohol consumption however it should be noted that there are very small numbers of never smokers and never drinkers which make this estimate less reliable nonlinearity of smoking and alcohol could risk misspecification and residual confounding 36 we undertook a posthoc analysis with logtransformed smoking and alcohol variables which did not change the socioeconomic factors risk association stronger socioeconomic risk associations for hypopharynx and larynx cancers compared with oral cavity and oropharynx cancers point to a dominant role of smoking in explaining these associations a previous inhance analysis showed that smoking had a significantly greater risk association for laryngeal cancer than oral cavity pharynx cancer 37 however because alcohol and smoking are highly correlated when adjusting for smoking there is likely to be some adjustment for alcohol drinking so alcohols role in contributing to inequalities in head and neck cancer cannot be discounted health inequalities and cancer risks associated with socioeconomic factors have generally been observed to be stronger among men than women 38 our study is no exception the likely explanations include lack of data in women and particular difficulties in older generations in classifying women by occupational social classifications 13 reflected in the male database that was used for construction of siopsisei 24 25 suggestions that health inequalities affect women to a lesser degree are increasingly recognised as unfounded 39 40 our finding of a lower risk association in latin america was unexpected as it contradicted those of the original publication of socioeconomic analysis of the data 40 which found elevated ors associated with nonmanual occupations the socioeconomic distribution of controls was different from the other studies that is the latin american controls were generally original research original research from lower socioeconomic groups and more similar to the case distribution posthoc analysis building siopsisei quartiles based on the latin american control distribution did not change the findings the latin american study employed hospital controls which we found overall had lower risks in a further posthoc analysis removing the latin america data from the stratified analysis the ors for hospital controls did not change which could indicate that type of recruitment accounted for the difference rather than study region moreover this continental difference observed was unlikely to be due to conceptual sociological differences in the measures across the countriesas siops has been shown to be stable across very diverse cultures 24 and isei was validated internationally 25 our study has several strengths including the relatively large size with nearly 6000 cases and over 7000 controls from five robust welldesigned multicentre casecontrol studies with harmonised data 17 41 the large size of the study with good quality socioeconomic and behavioural risk factor data enabled risk estimates to be examined and confounders to be thoroughly adjusted for analyses method strengths included multiple sensitivity analyses to test the robustness of the results there were also limitations of this study including unquantifiable measurement errors data availability limitations and residual confounding we were only able to include 5 of the possible 35 studies in inhance with no studies from north america or indeed south asia 41 included studies had to have prior iscocoded occupational histories the occupational risks derived from these codes are probably too imprecise to indicate specific exposure to occupational carcinogens so residual confounding is a possibility it was also not possible to examine the industrial dimensions of occupations in this study as have previously been shown to be related to socioeconomic inequalities in cancer incidence 42 43 lifetime duration of alcohol has begun to be shown to increase cancer risk 44 however this variable was missing from some of the studies and could not be included in the analysis data on hpv were also not available for the studies in this analysis and could be an important factor particularly in relation to oropharyngeal risks 8 9 recall bias is also a possibility although it is unlikely that cases reported their occupational history differently from controls 27 in addition periods of housework or parttime work were excluded and could have underestimated socioeconomic effects 45 selection bias could potentially impact the findings particularly in the hospitalbased centres where the controls are potentially of similar socioeconomic and risk behaviour profiles to the case participants indeed our findings were stronger in study centres with populationbased design previous inhance socioeconomic analyses of income and education found no differences between hospital and populationbased controls reassuring against the risk of selection bias and the measures undertaken in the studies which used hospitalbased control sampling to reduce selection bias included recruiting patients attending hospital not for cancer nor conditions related to the main behavioural risk factors 10 finally siops and isei have not been updated since their creation in the late 20th century and may not reflect recent occupational socioeconomic structures however the indices used were appropriate for the decades when most of the participants were employed and job ranking by siops has been shown to be consistent over time 24 there has been a general shift from manual to lowlevel service occupations which may not be captured by these socioeconomic measures although this would have had a minimal impact as our data were largely collected in †ors and 95 cis adjusted for sex age study centre cigarette smoking alcohol consumption an interaction term drinksday×duration cigarette smoking and worked ≥10 years in risk occupations ‡test of interaction between stratification factor and siops §categories separately for siops distribution in control groups for men and women ¶evernever drank 156 ml of ethanol evernever smoked ≥100 cigarettes in lifetime and evernever drank alcohol siops standard international occupational prestige scale table 3 continued original research the early 2000s and further analyses of trajectories of occupational socioeconomic prestige could be subsequently undertaken conclusions our results indicate that occupational socioeconomic prestige position and manual work are associated with head and neck cancer and this risk is only partly explained by smoking and alcohol exposure occupational exposures were not a major explanatory factor as expected given the occupational source of our socioeconomic measures this points to the importance of psychosocial impacts of socioeconomic factors as well as the more recognised material dimension in head and neck cancer risk the implications of these results could also extend to the inclusion of psychosocialsocioeconomic occupational factors in the future development of head and neck cancer risk assessment prediction tools and to informing prevention and early detection efforts what is already known on this subject ► the association between socioeconomic disadvantage and head and neck cancer risk is well established ► less is known on the risks of head and neck cancer associated with socioeconomic aspects of occupations and the interrelationship with occupational exposures what this study adds ► low occupational socioeconomic prestige and position and manual work are associated with head and neck cancer and such risks are only partly explained by smoking alcohol and occupational exposures ► perceptual occupational psychosocial status appears to be strongest socioeconomic factors relative to socioeconomic position and manualnonmanual work ► implications could extend to the inclusion of psychosocioeconomic occupational factors in future development of head and neck cancer risk prediction tools and to informing prevention and early detection strategies orcid org 0000000177624063 jan hovanec orcid org 0000000318111465 wolfgang ahrens orcid org 000000033777570x alastair ross orcid org 0000000329523182 ivana holcatova orcid org 0000000213660337 diego serraino orcid org 0000000305658920 cristina canova orcid org 0000000170277935 lorenzo richiardi orcid org 0000000303169402 claire healy orcid org 0000000179404611 kristina kjaerheim orcid org 0000000306913735 gary j macfarlane orcid org 0000000323223314 peter thomson orcid org 0000000220077975 antonio agudo orcid org 0000000199005677 ariana znaor orcid org 0000000205188714 danièle luce orcid org 0000000217084584 gwenn menvielle orcid org 0000000232616366 simone benhamou orcid org 0000000158538047 heribert ramroth orcid org 0000000159581717 paolo boffetta orcid org 0000000238112791 maria paula curado orcid org 0000000181722483 ana menezes orcid org 0000000229969427 rosalina koifman orcid org 0000000227467597 thomas behrens orcid org 0000000245835234 competing interests none declared patient consent for publication obtained ethics approval ethical approval was obtained from appropriate institutional local review boards and all participants provided written informed consent for the original studies provenance and peer review not commissioned externally peer reviewed data availability statement data are available upon reasonable request data are available from the corresponding author dic upon reasonable request with the permission of the inhance consortium supplemental material this content has been supplied by the author it has not been vetted by bmj publishing group limited and may not have been peerreviewed any opinions or recommendations discussed are solely those of the author and are not endorsed by bmj bmj disclaims all liability and responsibility arising from any reliance placed on the content where the content includes any translated material bmj does not warrant the accuracy and reliability of the translations and is not responsible for any error andor omissions arising from translation and adaptation or otherwise

background the association between socioeconomic disadvantage low education andor income and head and neck cancer is well established with smoking and alcohol consumption explaining up to threequarters of the risk we aimed to investigate the nature of and explanations for head and neck cancer risk associated with occupational socioeconomic prestige a perceptual measure of psychosocial status occupational socioeconomic position and manualwork experience and to assess the potential explanatory role of occupational exposures methods pooled analysis included 5818 patients with head and neck cancer and 7326 control participants from five studies in europe and south america lifetime job histories were coded to 1 occupational social prestigetreimans standard international occupational prestige scale siops 2 occupational socioeconomic positioninternational socioeconomic index isei and 3 manualnonmanual jobs results for the longest held job adjusting for smoking alcohol and nature of occupation increased head and neck cancer risk estimates were observed for low siops or188 95 ci 164 to 217 low isei or174 95 ci 151 to 199 and manual occupations or149 95 ci 135 to 164 following mutual adjustment by socioeconomic exposures risk associated with low siops remained or159 95 ci 130 to 194 conclusions these findings indicate that low occupational socioeconomic prestige position and manual work are associated with head and neck cancer and such risks are only partly explained by smoking alcohol and occupational exposures perceptual occupational psychosocial status siops appears to be the strongest socioeconomic factor relative to socioeconomic position and manualnonmanual work

introduction across diverse con texts one of the most com mon bar ri ers to using effec tive fam ily plan ning meth ods is the belief that hor monal con tra cep tives and con tra cep tive devices have adverse effects on future fer til ity in many regions of the world espe cially where pres sure to bear chil dren is sig nifi cant these bar ri ers are per va sive and expressed by both men and women historically these con cerns have been dismissed as mis per cep tions but emerg ing evi dence indi cates that such beliefs may in fact be rooted in per sonal expe ri ence or obser va tions of oth ers slowerthanexpected returns of fecun dity follow ing con tra cep tive dis con tin u a tion although pre vi ous reviews have gen er ally con cluded that oneyear preg nancy rates fol low ing ces sa tion of con tra cep tion are sim i lar across a range of con tra cep tive types recent stud ies from highincome countries have indi cated that some con tra cep tives might impact fecun dity espe cially in the short term a 2020 study by yland et al using pro spec tive cohort data col lected in denmark and north america found tran sient delays in return of fecun dity among women who stopped use of oral con tra cep tives the con tra cep tive ring and some longact ing revers ible con tra cep tives com pared with bar rier meth ods with the larg est decreases in fecundability among inject able and patch users importantlyand in con trast to prior stud iesthe authors employed a timetopreg nancy study design for esti mat ing fecundability or the prob a bil ity of con cep tion per men strual cycle which is recommended to assess bio logic fer til ity in a pop u la tion a key ques tion is the extent to which the results from the yland et al study which was conducted among indi vid u als plan ning a preg nancy in denmark and north america gen er al ize to women in lowand mid dleincome countries given sev eral key dif fer ences in the con tra cep tive and fer til ity land scapes between highincome countries and lmics first con tra cep tive for mu la tions which refer to the types of active ingre di ents and doses found in hor monal meth ods are not uni form across set tings these for mu la tions are linked with dif fer ent mech a nisms of action and rates of metabolization in the body that may influ ence the return of fer til ity fol low ing dis con tin u a tion second there may be dif fer ences in the sociodemographic char ac ter is tics or life course stages asso ci ated with method pref er ences and use across set tings these con textspe cific dif fer ences in user pro files may limit the exter nal validity of stud ies conducted in highincome countries third stud ies from highincome countries have mostly focused on pat terns of fer til ity fol low ing oral con tra cep tive use and the lim ited stud ies incor po rat ing users of the con tra cep tive inject able or implant have been based on few study par tic i pants this lat ter lim i ta tion is espe cially concerning given the rap idly increas ing num bers of women in lmics who use inject ables and implants fourth there are geo graphic dif fer ences in the bur den of infer til ity with higher prev a lence of both pri mary and sec ond ary infer til ity in lmics than in highincome coun tries reasons for these dif fer ences are not clear but may relate to dif fer ences in expo sure to untreated repro duc tive tract infec tions hiv infec tion postabor tion com pli ca tions and injuries or infec tions caused or aggra vated by child birth to date one study by bardenofallon and col leagues eval u ated the return of fecun dity among west and east afri can pop u la tions and found that the 12month prob a bil ity of preg nancy was low est among those who had discontinued a hor monal method in order to become preg nant the study which used sin gledec re ment life tables was able to explore dif fer ences in these pat terns by type of method discon tinued age and par ity but did not adjust for other known risk fac tors that might influ ence fecundability such as socio eco nomic sta tus part ner ship sta tus and health contraceptive method use and return of fecundity con di tions and behav iors this study also did not com pre hen sively describe poten tial shortterm reduc tions in fecun dity which may be enough to dis suade women from using more effec tive meth ods the lim ited prior research on the topic of con tra cep tive use and return of fer til ity as well as dif fer ing fer til ity con texts between the global north and south makes a com pel ling case for conducting a sys tem atic eval u a tion in lmics while there are var i ous ways to study fecundability in pop u la tions the field of epi de mi ol ogy has made great strides in inves ti gat ing and iden ti fy ing fac tors that impact indi vid u als or cou ples abil ity to become preg nant using mul ti var i ableadjusted timetopreg nancy study designs this meth od o log i cal approach how ever is rarely applied to pop u la tions from lmics using pooled pop u la tionbased data from 47 lmics the cur rent study employs a ret ro spec tive timetopreg nancy design to rig or ously eval u ate the return of fer til ity among women who discontinue con tra cep tion in order to become preg nant our mult i var i able approach accounts for dif fer ing dis tri bu tions of risk fac tors for impaired fer til ity across pop u la tions that have not been fully con sid ered by prior stud ies this study there fore pro vi des urgently needed quan ti ta tive evi dence about methodspe cific impacts of use on return of fecun dity in understudied set tings ultimately such infor ma tion is of par a mount impor tance to poten tially val i date and addressrather than dis miss and ignorewomens con cerns about con tra cep tion and to enhance per soncen tered coun sel ing and con tra cep tive auton omy methods data and measures we con sid ered all demographic and health surveys conducted after 2010 that included a repro duc tive cal en dar mod ule in which women were asked to pro vide reasons for discontinuing a method if a coun try had more than one sur vey in this period we used the most recent sur vey fortyeight dhss conducted between 2010 and 2018 met the inclu sion cri te ria one sur vey was excluded because infor mation on an impor tant covariate edu ca tion was not included in pub licly avail able data online appen dix table a1 dis plays a list of all 47 sur veys and cor re spond ing sam ple sizes included in our anal y sis dhs cal en dar data are ret ro spec tive monthbymonth his to ries cov er ing the fiveyear period prior to the inter view the cal en dars record womens repro duc tive sta tus in each month pos si ble states include preg nancy birth ter mi na tion and con tra cep tive use or non use in any month when a woman reported discontinuing a con tra cep tive method she was asked why she discontinued we lim ited our study to women with a his tory of sex ual activ ity who discontinued con tra cep tion because they wanted to become preg nant which assumes that women in our study are exposed to the risk of preg nancy and are not tak ing delib er ate action to avoid preg nancy calendar data allowed us to deter mine the num ber of cycles postcon tra cep tive dis con tin u a tion it took women to become preg nant or if they were unsuc cess ful dur ing the period of obser va tion for all obser va tions timetopreg nancy inter vals began when women discontinued a method to become preg nant women were followed until one of the fol low ing end points which ever occurred first a preg nancy occurred a woman began using con tra ceptives again after a period of non use and no observed preg nancy or until three months prior to the inter view this last end point avoids underestimating early preg nan cies at the time of the inter view that are underreported either because women do not yet rec og nize they are preg nant or because women do not yet want to dis close their preg nancy sta tus women who may have been in the early stages of preg nancy at the time of the inter view are still included in the study but they are included as cen sored obser va tions including all months up to the sur vey inter view does not change the results we also accounted for the pres ence of lon ger timetopreg nancy inter vals by cen sor ing all obser va tions at 12 months among those pre sum ably at risk for preg nancy for more than a year we imposed sev eral inclu sionexclu sion cri te ria for our ana lytic sam ple first we restricted data to obser va tions for which the month fol low ing con tra cep tive dis con tin u a tion was coded as either not using or preg nancy second we excluded obser va tions for which con tra cep tive dis con tin u a tion occurred within the three months prior to the inter view to account for poten tial underrecognition of preg nan cies at the time of the sur vey third to reduce the threat of recall bias we lim ited our anal y sis to women who discontinued a con tra cep tive in the two years prior to the sur vey which led to the exclu sion of an addi tional 61753 obser va tions in addi tion if a woman con trib uted more than one eli gi ble obser va tion we used the most recent one so our unit of anal y sis is women rather than epi sodes we also excluded obser va tions reporting less com monly used meth ods such as the female con dom and those using the lac ta tional amen or rhea method lastly we excluded those miss ing data on key covariates mea sured in all sur veys the final sam ple size for our main anal y sis com prised 33827 women attempting preg nancy representing 25641 pregnan cies and 128263 monthly cycles because the num ber of eli gi ble women for analy sis for some countries and meth ods was small we pooled data across all sur veys to ensure an ade quate sam ple size for com par ing timetopreg nancy by prior con tra cep tive method used our main inde pen dent var i ablecon tra cep tive method discontinuedwas cat e go rized by method type we included meth ods in the anal y sis if at least 500 women in the pooled sam ple reported using that method to ensure an ade quate num ber of methodspe cific obser va tions for anal y sis meth ods meet ing this cri te rion are the oral con tra cep tive pill iud inject able male con dom implant peri odic absti nence and with drawal for anal y sis we grouped peri odic absti nence and with drawal into a cat e gory of tra di tional meth ods the sur veys included in our study did not col lect fur ther infor ma tion on what type of pill iud implant or inject able was used so we were unable to fur ther dis ag gre gate these meth ods by more spe cific char ac ter is tics we con sid ered sev eral confounding fac tors for anal y sis that are prob a ble risk factors for impaired fecundity or have been empir i cally asso ci ated with fecundability in prior stud ies to account for reduced fecundability asso ci ated with age we included a cat e gor i cal var i able with the fol low ing clas si fi ca tion which was based on respondents age at the time of dis con tin u a tion 1519 2029 3034 3539 and 40 or older information on coi tal fre quency and part ner char ac ter is tics was unavail able instead we used a threecat e gory mea sure of union sta tus that incor po rates whether women were in a polyg y nous union some research has suggested that infer til ity and fecundability are pat terned by socio eco nomic attri butes such as edu ca tion and income these pat terns do not reflect inher ent bio log i cal dif fer ences across socio eco nomic posi tion but instead are medi ated by behav ioral and life style char ac ter is tics as well as access to health care over the life course we there fore included var i ables mea sur ing socio eco nomic posi tion or access to health care that may help reduce the threat of resid ual confounding for risk fac tors cor re lated with impaired fecun dity the first edu ca tion was coded as no edu ca tion pri mary sec ond ary or higher the sec ond was a mea sure of house hold wealth that was coded according to the dhs wealth quin tile clas si fi ca tion for each coun try based on assets and house hold char ac ter is tics we also included a mea sure of urban ver sus rural res i dence based on urban and rural clas si fi ca tions for each coun try we included three sex ual and repro duc tive health mea sures that may influ ence fecundability parity at the time of con tra cep tive dis con tin u a tion was assessed as a binary var i able as noted ear lier expo sure to untreated stis may affect fecun dity we there fore included a mea sure of sti his tory that was assessed from ques tions ask ing if par tic i pants had an sti or symp toms of an sti in the 12 months prior to the sur vey any indi ca tion of an sti or sti symp toms was coded as yes our third mea sure assessed whether the respon dent reported cor rect knowl edge of the fer tile period dur ing an ovu la tory cycle as this knowl edge could be used to opti mize the chance of preg nancy in each cycle our ana ly ses also included two known risk fac tors for infer til ity body mass index and expo sure to tobacco prod ucts we cal cu lated bmi from weight and height data that were mea sured directly dur ing the sur vey and cat e go rized the mea sure according to the con ven tional who clas si fi ca tion of adult under weight nor mal over weight and obese our sec ond mea sure was a com pos ite binary indi ca tor for use of tobacco prod ucts deter mined from sev eral ques tions assessing cig a rette cigar and chewing tobacco use mea sured at the time of the sur vey all covariates except for age and par ity were mea sured at the time of the sur vey age and par ity sta tus corresponded to when the woman discontinued con tra cep tion all sur veys in our ana ly ses contained the fol low ing mea sures age par ity edu ca tion urban or rural res i dence wealth union sta tus and knowl edge of the fer tile period measures of bmi recent his tory of an sti and use of tobacco prod ucts were not avail able for all sur veys therefore in a sen si tiv ity anal y sis we tested whether our results were robust to a more exten sive set of con found ers in a sub sam ple of countries that had all avail able covariates statistical analysis first we used the kaplanmeier method to esti mate sur vival curves and oneyear prob a bil i ties of preg nancy sep a rately for each eli gi ble con tra cep tive method we also cal cu lated median time to preg nancy for each method using the num ber of months when at least 50 of women became preg nant second we used cox pro por tional haz ard mod els for dis crete sur vival data to model time to preg nancy and esti mate fecundability ratios frs com pare the odds of becom ing preg nant between the exposed and unex posed groups an fr less than 1 indi cates that the exposed group expe ri enced decreased odds of preg nancy com pared with the unex posed or ref er ence group within the first year after con tra cep tive dis con tin u a tion these mod els account for changes in the aver age fecundability of the pop u la tion at risk over time which result from more fecund women being removed from the risk set in later months all mod els accounted for rightcen sor ing and included coun try fixed effects to con trol for unob serv able charac ter is tics within each coun try tests of proportionality includ ing visual inspec tion of loglog sur vival plots showed that the proportionality assump tion was gen er ally upheld we assumed that women using tra di tional meth ods or con doms served as appro pri ate coun ter fac tu als for women using meth ods pre vi ously hypoth e sized to affect the return of fecun dity fol low ing dis con tin u a tion such as hor monal meth ods and iuds in the main anal y sis women using tra di tional meth ods were selected as the contraceptive method use and return of fecundity ref er ence cat e gory owing to con cerns that con dom users may dif fer from tra di tional method users with regard to their sti or hiv risk which could impact time to pregnancy that said we also inves ti gated whether infer ences were the same when we used con dom users as the ref er ence group as this would pro vide addi tional sup port for the idea that hor monal meth ods and iuds influ ence future fecun dity because of bio log i cal mech a nisms of action we conducted sev eral addi tional sen si tiv ity ana ly ses to eval u ate the robust ness of our find ings first for users of inject ables we assumed an addi tional lag of three months to account for the pos si bil ity that women may have received their last injec tion in the month they reported discontinuing the method and there fore could be fully protected from preg nancy up to three months second as described ear lier we lim ited our sam ple to sur veys that included the full set of covariates includ ing bmi and tobacco use to exam ine whether our results were robust to their inclu sion third we conducted all ana ly ses sep a rately for women aged 40 or older as any poten tial reductions in fecun dity could be ampli fied for this age group and finally we expanded our sam ple to all eli gi ble epi sodes within the entire fiveyear con tra cep tive cal en dar following prior multicountry dhs stud ies we used cus tom weights account ing for com plex sam pling designs to allow each coun try to con trib ute equally to the pooled anal y sis this approach ensures that results are not weighted more heavily toward sur veys with larger sam ple sizes specifically we mul ti plied the dhspro vided sur vey weights by a coun tryspe cific con stant such that the sam ple of women from each of the 47 coun tries in our anal y sis makes up 147th of the pooled sam ple the der i va tion of which is outlined in detail else where as an addi tional robust ness check we also conducted a jack knife anal y sis to ensure that results were not driven by countries with larger sam ple sizes statistics pres ent unweighted ns and weighted per cent ages analyses were conducted in stata 140 using the svy suite of com mands ethics approval was obtained by the insti tu tions that admin is tered the sur veys and all ana ly ses used anonymized data bases results characteristics of the study sam ple are presented in table 1 the major ity of women were in their 20s had at least one prior birth and had at least a pri mary edu ca tion most women were in a union and 8 reported being in a poly g ynous union a lit tle less than one third of women reported cor rect knowl edge of the fer tile period almost half of women in the weighted sam ple were from the subsaharan africa region whereas less than 10 were from either europe or south asia descriptive sta tis tics for users of each con tra cep tive method type are also pre sented in table 1 women who discontinued inject ables and pills made up 31 and 26 of the weighted sam ple respec tively sixteen per cent of the weighted sam ple discontinued either peri odic absti nence or with drawal 13 dis continued con doms 8 discontinued iuds and 6 discontinued implants there were also sociodemographic and regional dif fer ences by type of con tra cep tive dis continued which pro vide strong moti va tion for mul ti var i able anal y sis figure 2 pres ents kaplanmeier sur vival curves of time to preg nancy by type of method discontinued for ease of com par i son both pan els include the same ref er ence curve for tra di tional meth ods represented by the black line the top panel pres ents addi tional curves for the iud and the pill and the bot tom panel pres ents addi tional curves for the implant and the inject able condoms are not included because they over lap closely with tra di tional meth ods both fig ures dem on strate that users of the iud pill implant and inject able experi ence lon ger times to preg nancy than users of tra di tional meth ods these curves are quan ti fied in table 2 which dis plays the median time to preg nancy and 12month prob a bil i ties of preg nancy observed for each method the median ttp for tra di tional method and con dom users fol low ing dis con tin u a tion is two months while median ttp for pill and iud users is three months those using the implant and the inject able expe ri ence a median ttp of four and five months respec tively the median ttp for users of the inject able short ens to two months after account ing for a threemonth lag as evidenced by the figure 2 curves and table 2 data there are also dif fer ences in 12month prob a bil i ties of preg nancy traditional users had the highest prob a bil ity at 91 followed by women using the con dom the pill and the iud women discontinuing inject ables and implants had the low est 12month prob abil i ties of preg nancyeach at 80 thus among women discontinuing inject ables or implants in order to become pregnant approx i ma tely 1 in 5 did not achieve preg nancy in a year on aver age com pared with approx i ma tely 1 in 10 women using tra di tional meth ods women aged 40 or older had lon ger median ttps by con tra cep tive type discontin ued as well as reduc tions in the 12month prob a bil ity of preg nancy for all meth ods among older women who discontinued tra di tional meth ods the 12month prob a bil ity of preg nancy was 81 which is approx i ma tely 10 per cent age points lower than the prob a bil ity among all women of repro duc tive age who also dis continue tra di tional meth ods this dif fer ence likely cap tures wellknown agerelated declines in fecun dity notably 12month prob a bil i ties of preg nancy were much lower for older women who discontinued either hor monal meth ods or the iud com pared with all women of repro duc tive age for exam ple about 64 of women aged 40 or older became preg nant within a year fol low ing dis con tin u a tion of inject ables on aver age com pared with 80 among all women of repro duc tive age table 3 pres ents results from a mul ti var i able model that accounts for poten tial dif fer ences in under ly ing fecun dity between women the base line model adjusts for age par ity edu ca tion urban or rural res i dence union sta tus edu ca tion level and knowl edge of the fer tile period the model also includes coun try fixed effects the first col umn in table 3 employs users of tra di tional meth ods as the ref er ence cat e gory compared with these indi vid u als users of the pill iud inject able and implant had lower fecundability ratios fol low ing con tra cep tive dis con tin u a tion the larg est reduc tions in odds occurred among women who used inject ables or implants 041 and 051 respec tively patterns are largely sim i lar when employing con dom users as the ref er ence group although frs increase slightly there were no sig nifi cant dif fer ences in fecundability between con dom users and tra di tional users findings remain sim i lar after conducting sev eral sen si tiv ity ana ly ses with some excep tions first after account ing for a threemonth lag for inject able users we found that the adjusted fr increases from 042 to 066 second we reran our ana ly ses among a sub set of sur veys that col lected infor ma tion on the full set of covariates and found that results do not change sub stan tially third as shown in col umn 7 and mirroring our agespe cific results in table 2 we find large reduc tions in fecundability ratios for women aged 40 or over by con tracep tive type after adjust ment for covariates fourth when we expand our anal y sis to all eli gi ble epi sodes that occur within five years of the sur vey we find sim i lar results for all meth ods except for con dom users specifically con dom users have a lower fecundability ratio than tra di tional users that was not observed in our main anal y sis finally results do not change after conducting a jack knife anal y sis discussion in this anal y sis using pooled data from 47 lmics we found that some con tra ceptive meth ods when used prior to attempting to get preg nant are asso ci ated with tran sient delays in return of fecun dity with the lon gest delays occur ring among women who discontinued inject ables and implants these rela tion ships persisted after adjust ment for impor tant con found ers suggesting that womens con cerns about poten tial shortterm reduc tions in fecun dity fol low ing use of cer tain con tra cep tives are not unfounded we acknowl edge that our results can be interpreted dif fer ently by fer til ity researchers while our find ings show that at least half of women will become preg nant within 23 months fol low ing dis con tin u a tion of tra di tional meth ods con doms the pill and the iud we see dif fer ent pat terns for inject ables and implantstwo meth ods that are widely pro moted and used across lmics more impor tantly because fecun dity is het ero ge neous the median esti ma tes of time to preg nancy presented in table 2 do not suf fi ciently cap ture how the entire dis tri bu tion of time to preg nancy shifts to the right fol low ing dis con tin u a tion of hor monal meth ods this dis tri bu tional shift leads to lower 12month prob a bil i ties of preg nancy for users of hor monal methods than for those who discontinue tra di tional meth ods these impacts are rarely dis cussed by fam ily plan ning research ers but may lead to notice able dif fer ences within com mu ni ties and social net works as an exam ple in a hypo thet i cal pop u la tion of 10000 women who discontinue inject ables or implants nearly 2000 of these women may still not expe ri ence preg nancy one year later this delay is twice as long as what we would expect from a pop u la tion of 10000 women who discontinue tra di tional meth ods our study cor rob o rates some but not all find ings from yland et al who eval u ated the asso ci a tion between pregravid con tra cep tive use and sub se quent fecundability in denmark and the united states similar to yland et al we find that users of inject ables have the lon gest delays in return of fer til ity both stud ies found aver age or median timestopreg nancy of about five months however our study find ings diverge from those of yland et al regard ing other con tra cep tive types for exam ple whereas yland et al found that users of iuds had increased time to pregnancy com pared with users of bar rier meth ods we do not find this asso ci a tion our study also dif fers in that we find sub stan tial reduc tions in fecundability ratios among implant users whereas this rela tion ship was not appar ent in the yland et al study these dif fer ences could arise from use of dif fer ent for mu la tions of hor monal con tra cep tives across con texts as well as the larger num ber of implant obser va tions in the cur rent study n 1373 in this study ver sus n 186 in yland et al our study also builds on the find ings of bardenofallon et al which found lower returns to preg nancy by 12 months among women in west and east africa who discontinued hor monal meth ods taken together these results indi cate that pre vi ous reviews on the topic which suggested no impact should be urgently updated to incor po rate new evi dence moreover future research should eval u ate the poten tial bio chem i cal or biobehavioral path ways under pin ning these rela tion ships which so far remain spec u la tive critically these find ings have impli ca tions for fam ily plan ning pro grams in lmics several global efforts includ ing fp2030 and the sustainable development goals empha size increas ing the use of mod ern con tra cep tives however these efforts are poten tially at odds with womens con tra cep tive pref er ences and con cerns our find ings bol ster the crit i cal need for increased per soncen tered ness in fam ily plan ning coun sel ing and pro vi sion in line with wider calls to shift the needle on fam ily plan ning successes away from just use to max i miz ing auton omy and use of pre ferred meth ods more con cretely our find ings indi cate that the accept abil ity of delayed return of fer til ity should be eval u ated when recommend ing and choos ing con tra cep tive meth ods our study has sev eral strengths first we use pop u la tionbased data that allowed us to account for poten tial dif fer ences in pop u la tion com po si tion and under ly ing fecun dity across set tings second our sam ple had a large num ber of obser va tions of women who discontinued inject ables and implants by con trast inject able and implant users from the yland et al study represented only 05 and 10 of par tic i pants respec tively third there are few stud ies from lmics that inves ti gate deter mi nants of fecundability and infer til ity our use of cal en dar data adds to the lim ited lit er a ture by employing a timetopreg nancy study design most often used in higher resource set tings there are also sev eral lim i ta tions to note first except for age and par ity all covari ates were mea sured at the time of the sur vey not at the time of con tra cep tive dis con tin u a tion it is unclear if this type of mis clas si fi ca tion might bias our main results since our mea sure of prior con tra cep tive type used does not suf fer from this same error second we relied on ret ro spec tive cal en dar data which are sub ject to recall bias and other types of reporting errors in their report assess ing qual ity of the dhs con tra cep tive cal en dar for exam ple bradley and col leagues results sug gest worse reporting for events fur ther in the past to address this con cern we lim ited our obser va tions to the two years prior to the sur vey although sen si tiv ity ana ly ses using all five years prior to the sur vey gen er ally yield sim i lar results third for users of inject ables we did not have data on when women received an injec tion rel a tive to when she reported dis con tin u a tion although we did include a threemonth lag in our sen si tiv ity ana ly ses fourth owing to data lim i ta tions we could not dis tin guish between method type for inject ables and iuds we note however that in lowresource set tings many iuds are cop per rather than hor monal and some inject ables are for mu lated to pro vide con tra cep tion for one or two rather than three months while dmpa which pro vi des three months of pro tec tion remains the most com mon type of inject able in lmics there is some var i a tion in the inject able mix across set tings although this is not welldocumented fifth because inter view ers could record only one con tra cep tive method per month dis con tin u a tion of mul ti ple con tra cep tive meth ods is not pos si ble to mea sure reports of using tra di tional meth ods like absti nence and with drawal may also suf fer from poor reli abil ity com pared with use of hor monal meth ods sixth the dhs data we used do not include infor ma tion on regu lar sex ual activ ity part ners and other mea sures that could influ ence fecundability measures of peo ples under ly ing fecun dity or pro pen sity for infer til ity were also not pos si ble to esti mate seventh we did not include mea sures of sex ual vio lence and inti mate part ner vio lence in our study even though prior research sug gests that these expe ri ences may influ ence health out comes includ ing sti trans mis sion a final lim i ta tion is that we can not val i date two key assump tions of this study that womens desire to become preg nant fol low ing con tra cep tive dis con tin u a tion was contraceptive method use and return of fecundity sta ble over time and that women were actively try ing to become preg nant over the expo sure period as noted in prior research shortterm changes in preg nancy inten tion have been welldocumented in sev eral con texts and preg nancy ambiv a lence is also com mon conclusion many women in lmics either do not use con tra cep tion or discontinue con tra cep tive meth ods for fear that con tra cep tion will inhibit their future fer til ity although return of fecun dity is acknowl edged in the who medical eligibility criteria for contracep tive use con tra cep tive coun sel ing pro to cols and tools used in lmics may not include nuanced infor ma tion about return to fecun dity fol low ing dis con tin u a tion even though this remains a com mon con cern among women furthermore although the who mec discusses poten tial effects of inject ables on return to fer til ity there is no men tion of other revers ible meth ods our novel find ings on the con tra cep tive implant in par tic u lar war rant increased atten tion within the fam ily plan ning com mu nity while we rec og nize that the pres ent anal ysis has lim i ta tions we hope our study prompts fur ther research on this his tor i cally overlooked topic ultimately our results indi cate that delayed return to fecun dity after discontinu ing some hor monal meth ods is a com mon expe ri ence in lmics pro vid ing what we believe to be some of the first multicountry evi dence to val i date womens lived experi ences from these regions contraceptive coun sel ing pol icy and pro grams there fore should con sider inte grat ing this infor ma tion to pro vide a fuller pic ture of the range of timetopreg nancy expe ri ences fol low ing con tra cep tive dis con tin u a tion espe cially for inject ables and implants while infor ma tion about poten tial declines in fecun dity is just one cri te rion that may influ ence womens con tra cep tive use indi vid u als have a right to this knowl edge so that they can make informed choices ■

one of the most com mon bar ri ers to using effec tive fam ily plan ning meth ods is the belief that hor monal con tra cep tives and con tra cep tive devices have adverse effects on future fer til ity recent evi dence from highincome set tings sug gests that some hor monal con tra cep tive meth ods are asso ci ated with delays in return of fecun dity yet it is unclear if these find ings gen er al ize to lowand mid dleincome pop u la tions espe cially in regions where the inject able is widely used and pres sure to bear chil dren is sig nifi cant using repro duc tive cal en dar data pooled across 47 demographic and health surveys we find that the unad justed 12month prob a bil ity of preg nancy for women attempting preg nancy after discontinuing tra di tional meth ods con doms the pill and the iud ranged from 86 to 91 the 12month prob a bil ity was low est among those who discontinued inject ables and implants with approx i ma tely 1 out of 5 women not becom ing preg nant within one year after dis con tin u a tion results from mul ti var i able anal y sis showed that com pared with users of either peri odic absti nence or with drawal users of the pill iud inject able and implant had lower fecundability fol low ing discon tin u a tion with the larg est reduc tions occur ring among women who used inject ables and implants these find ings indi cate that womens con cerns about poten tial shortterm reduc tions in fecun dity fol low ing con tra cep tive use are not unfounded

list of tables table 1 ron stall for their time and support throughout this project i am extremely grateful for their mentorship in and outside of the classroom and for the opportunity to learn from their knowledge and experience their suggestions and guidance helped steer this study down the path of success i would like to thank drs nina markovic beth nolan and martha terry for their generous funding for the project without which the study could not have been to this scale i would also like to thank the mothers of the study who selflessly took the time to complete an uncompensated survey to help an unknown student while most likely juggling work and children hundreds of business organizations and individuals posted flyers sent emails and shared the study link to which i am incredibly grateful without their help the study would not have succeeded i would like to extend a special thanks to the editor of the new england newspaper bay windows for donating advertisement space which recruited a large portion of the participants i would also like to thank tanya disney pallavi jonnalagadda jason chiu and the students and faculty of the university of pittsburgh statistics consulting lab for their time and x help with the data analysis as well as for their patience with my endless questions and short deadlines furthermore id like to thank catherine boothby for her help designing the study logo lastly but most importantly i would like to thank my family and friends for their unconditional support love and encouragement i am especially thankful for my wonderful partner l fusco who stood by me through setbacks aggravation and countless hours of missed activities due to my dedication to this project i love you all xi 10 introduction over 17 million americans suffer from depression each year depression however does not affect all americans equally women experience higher rates than men do and research indicates that lesbian women may suffer more than heterosexual women do nevertheless depression can be variable over the life course so it is important to determine when individuals are most at risk and which factors are most influential if specific time points or risk factors can be determined prevention efforts can be directed upon those and depression levels may be reduced or eliminated the postpartum period defined as the 12 months proceeding childbirth has been extensively studied for incidence of minor and major depressive episodes postpartum depression is common and affects nearly 20 of mothers to some degree lesbian mothers appear to be especially susceptible to ppd there are numerous reasons why lesbian women likely experience higher rates of ppd than heterosexual women first a personal history of depression is the most significant risk factor for ppd which disproportionately affects lesbian women second low social support is a risk factor of ppd studies have found that lesbian women report weaker family ties whether it be the result of geography or discrimination furthermore lesbian women report less support for childbirth from gay and lesbian friends these are important because support from family and friends can protect against depression third high amounts of stress and low social status are risk factors for ppd research indicates that lesbian women experience institutional and medical discrimination this discrimination may reduce the social status of lesbian women create high levels of stress and discourage victims from seeking treatment the evidence suggesting that lesbian women experience higher rates of ppd than heterosexual women is especially salient since onethird of lesbian women give birth maternal depression can adversely affect the health of children and significant others children and significant others demonstrate more internalizing behaviors such as depression and anxiety children also experience more externalizing behaviors such as conduct problems and hyperactivity than do children of nondepressed mothers research has found that almost onehalf of lesbian women want children nearly 80000 foster and adopted children live with lesbian gay and bisexual parents and two million lgb individuals would like to adopt despite these findings researchers have not determined the risk or prevalence of ppd in lesbian women or have identified theories or treatment for maternal depression in lesbian women the first aim of this project is to determine the prevalence rate of depression in a sample of selfidentified lesbian women with at least one child less than 18 years of age the second aim is to investigate minority stress and determine if higher levels of social support reduce the effects of gay stress on depression symptoms finally recommendations for future research will be proposed background several studies have evaluated maternal mental health in lesbian women some studies indicate that lesbian mothers are not at a higher risk for depression compared with heterosexual women caution must be taken however when interpreting these results first lesbian women experience unique risk and protective factors that may influence depression expression differently than for heterosexual women second although these studies were groundbreaking and extremely important they contain numerous limitations making a definitive judgment about depression impossible the contemporary families study examined maternal mental health in both homosexual and heterosexual women these researchers however utilized a convenience sample which consisted of predominantly caucasian welleducated and wealthy participants which are characteristics that can protect against depression the researchers also indicated that the children of lesbian mothers reported significantly more contact with nonfamilial adults than the children of heterosexual mothers this finding suggests that these lesbian women had larger support systems which potentially buffered them against depression the san francisco bay area families study found no significant maternal mental health problems in a sample of 37 families however they did not include a heterosexual comparison group without a comparison group it is difficult to make accurate judgments about outcome correlations between heterosexual and homosexual mothers furthermore over 90 of the sample was caucasian and most possessed the protective characteristics of higher education and affluence finally the small geographically homogeneous sample was a significant limitation preventing the detection of a true difference and generalizability of findings the national lesbian family study was a longitudinal study that followed lesbian families with a child conceived by donor insemination this inclusion requirement alone may have biased study results since it is not known how donor insemination could affect study outcomes in addition the study only measured mental health on one criterion whether or not women had sought counseling although this may reveal some information about mental health it does not detail depressive symptomology or its relationship to lesbian motherhood including additional measures of depression would have likely provided a better indication of maternal mental health the avon longitudinal study of parents and children was an extensive study that included a representative sample of lesbian mothers results indicated that lesbian mothers were more likely to seek psychological treatment than heterosexual mothers were but no more likely to endorse symptoms of depression although it is not known why these mothers sought treatment seeking help is generally an indication of impairment consequently further investigation into this finding is necessary to determine if it is predictive of depression caution must be taken furthermore because this study was conducted in the london lesbian gay bisexual and transgender individuals in the united kingdom enjoy more rights and benefits than those in the united states as a result although there may be similarities this is not an equal comparison and researchers may discover different outcomes if the study were to be conducted in the us ross et al examined perinatal depression among lesbian and bisexual women they included a heterosexual comparison group but the sample was burdened by privileged demographics geographic conformity and a small sample size similar to the studies reviewed above nevertheless they found higher mean depression scores among the lesbian and bisexual mothers and concluded that although additional research is necessary lesbian and bisexual mothers may have higher rates of depression than heterosexual mothers do thus the need for research has changed we now need to explore if when and why depression affects lesbian mothers researchers need to examine if factors such as social support general stress and minority stress influence rates of depression among lesbian mothers method the relationships and depression in childbearing lesbian moms study was developed to explore depression and minority stress the first aim of the study was to determine the prevalence rate of depression in a sample of selfidentified lesbian women with at least one child less than 18 years of age we hypothesized that lesbian mothers would experience higher rates of depressive symptoms than reported among presumed heterosexual mothers in addition we hypothesized that lesbian mothers with at least one child who is birth to 12 months of age would experience higher rates of depressive symptoms than lesbian mothers would without a child who is 012 months of age the second aim of the study was to investigate minority stress and determine if higher levels of social support reduce the effects of gay stress on depression symptoms we hypothesized that social support would protect lesbian mothers from the negative effects of gay stress thereby reducing depressive symptoms this analysis was guided by the minority stress model the minority stress model predicts that minority stress can negatively affect psychological health but social support can mediate those effects therefore following this model will allow us to examine if there is a relationship between minority stress social support and maternal depression minority stress has been defined as culturally sanctioned categorically ascribed inferior status social prejudice and discrimination the impact of these environmental forces on psychological wellbeing and consequent readjustment or adaptation in this study we classified gay stress as the source of minority stress as research indicates they are independent stressors participants in order to participate in this study women had to be at least 18 years of age have children living in the household and identify as lesbian or gay or have sex with women only bisexual women were not specifically targeted because research indicates that individuals who are bisexual often suffer from higher rates of depression anxiety and general stress than individuals who are homosexual or heterosexual furthermore they report less social support and poor integration into the gay community onehundredsixtynine individuals responded of them 131 met criteria for study participation recruitment mailed recruitment recruitment packets included detailed information about the study on university of pittsburgh letterhead and a color flyer the flyer had tabs at the bottom for participants to detach the tabs included the study name and the web address recruitment packets were mailed to 406 businesses organizations and professionals in the towns cities and boroughs of hampshire county massachusetts windham county vermont dekalb county georgia and tompkins county new york these counties were chosen because according to census data they are among the top us counties with a high percentage of lesbian residents furthermore massachusettes and vermont had marriage equality whereas georgia and new york did not during the study period however new york passed marriage equality nevertheless zip code data indicated that participants from all over the country and one from outside of the country took part in the study so there was little utility in comparing data from massachusettes and vermont to georgia and new york limited resources restricted the studys range therefore in order to obtain a significant sample size the mailed recruitment was concentrated to these areas the mailing was conducted during the month of may 2011 places that specifically cater to or serve the lgbt community were initially identified for the mailing after those were exhausted libraries community centers childcare centers freecare clinics midwifery and parenting services obstetricgynecological offices newspapers wic offices colleges and universities health departments lgbtfriendly religious organizations coffee shops and restaurants were targeted twentynine packets were returned by the post office labeled as undeliverable emailed and online recruitment in order to save on postal expenses 321 additional professionals business and organizations that serve the counties were sent a recruitment packet by email nintynine followup reponses were received nearly 100 were positive and indicated that the recipient would hang the flyer or include it in their next enewsletter or eblast a radicle moms study facebook page was created and advertisement space was purchased on facebook filters were set so the advertisment would target parents who were between the ages of 18 and 60 years the advertisement included the name of the study a color picture and a 20 word description the estimated reach was 263 million people it was displayed 532005 times the advertisement was clicked on 109 times however it was not possible to determine if those clicks resulted in a completed survey on average the price of each click was one dollar and cost prohibitive for this project as such it was only displayed from june to september 2011 in addition to many newsletters internet forums online classified advertisements and newspapers bay windows the largest provider of lgbt news in new england placed a study advertisement banner on their website free of cost individuals who clicked the banner were taken to the consent page of the study the banner was very effective for recruitment 17 of participants reported learning about the study through the banner advertisement when prospective participants logged onto the survey site they were given information about the study specifically they were informed of the risks benefits confidentiality of data and contact information of the researchers they were also told that they would not be compensated for their participation if they chose to proceed they were presented with three screening questions the screening questions asked if they were at least 18 years of age had at least one child living in the household and identified as lesbian or gay or as having sex with women only individuals who satisfied the screening requirements were invited to complete the survey those who did not satisfy the screening requirements were not permitted to view or complete the survey a surveymonkey control feature prevented individuals from accessing the site after they were disqualified or had submitted the survey procedure measures in addition to questions about basic demographic information participants were given a series of standardized instruments the questionnaires were selected based on their published high validity and reliability scales demographic information participants were asked for their age raceethnicity highest level of education employment status income and physical health status they were also asked if they were currently in a relationship and if so the longevity of that relationship participants were additionally asked for the number age and sex of each child if the child was conceived while in heterosexual or homosexual relationship and if the child was biological adopted or her partners child in order to evaluate a history of depression participants were asked if they have ever been diagnosed or treated for depression from a health care professional and if one of their firstdegree relatives had ever been diagnosis or treated for depression finally for tracking purposes participants were asked for their zip code and how they learned about the study social support social support plays a significant role in health for pregnant women social support is especially important for sexual minorities as a result it was critical to assess the level of social support in the study sample the multidimensional scale of perceived social support is a 12item questionnaire that utilizes a 7point likert scale with a subscale for family friends and significant other zimet et al labels a romantic partner as a significant other rather than spouse indicating that this is a suitable instrument for sexual minorities higher scores on the mspss indicate greater social support psychometric properties were demonstrated by zimet et al coefficient alpha reliability for the family subscale was 087 reliability for the friends subscale was 085 and reliability for the significant other subscale was 091 internal reliability and validity were also confirmed by research that included a sample of pregnant women depression the shortened form of the center for epidemiologic studies depression scale was chosen as a measure of depression symptoms the short form includes ten questions instead of 20 as in the original version the short form significanlty reduced the number of questions that the participants had to answer a critical factor to consider when participants are not compensated scores range from zero to 30 a score of ten or more is generally recognized as a cut point for clinically significant number of depressive symptoms cronbachs alpha for this form is 075 the cesd has been successfully used with other pregnant childbearing and lgb women and therefore the preferred screening instrument gay stress the measure of gay stress was develped to examine minority stress experienced by gay men and lesbian women mogs is a 60item questionnaire that examines stress in the following areas family reactions family and partner general discrimination hivaids misunderstanding sexual orientation conflict violence friends and family visibility public visibility and work discrimination the questions asked about hivaids were eliminated due to time restrictions and their limited utility for this project higher scores indicate higher levels of gay stress relability for the coefficient is strong and ranges from 072 to 090 general stress in order to differentiate between minority stress and general stress the perceived stress scale short was administered the pss4 contains four items which are rated on a fivepoint likert scale the pss4 is significantly reduced from the orginal 14 items thus saving time for the participants higher scores indicate a higher level of percieved stress the reliability coefficient for this instrument is 072 results a frequency analysis descriptive analysis correlation analysis and multiple linear regression analysis were conducted frequency statistics for participants demographic characteristics are listed in table 1 descriptive statistics including mean standard deviation and range are shown in table 2 complete data for the cesd was obtained from 95 participants one participant with missing data however reported a significant number of depressive symptoms and was included in the analysis only participants who answered at least three questions on the pss4 at least 47 questions on the mogs and at least 11 questions on the mspss were included in the analyses mean substitution was used for missing data the prevalence rate of clinical depression for this study was 84 fifteen participants reported having a child aged birth to 12 months results indicate that none of these participants were suffering from clinically significant levels of postpartum depression correlations between the variables were examined and are listed in table 3 social support was negatively correlated to gay stress r 40 p 001 depressive symptoms r 41 p 001 and general stress r 30 p 003 depressive symptoms were positively correlated to general stress r 65 p 001 and gay stress r 27 p 007 gay stress was also positively correlated to general stress r 19 p 044 multiple linear regression analysis was used to examine the effect of general stress gay stress and social support on depressive symptoms due to the possibility of confounding factors we controlled for age income educational attainment employment status health status personal history of depression familial history of depression relationship status and length of relationship race was not included in the model since the sample included little racial variability responses of unsure for familial history of depression were coded as 05 although the model was unchanged if they were included with either the yes or no responses the overall model was significant r 2 550 f474 p 001 due to the high degree of correlation between mogs mspss and pss4 each was examined in a separate regression model controlling for the demographic factors listed above gay stress significantly predicted depression symptoms b 05 t 240 p 019 gay stress also explained a significant proportion of variance in depression symptoms r 2 34 f 232 p 010 social support significantly predicted depression symptoms b 15 t 393 p 001 and explained a significant proportion of variance in depression symptoms r 2 41 f 344 p 001 general stress also significantly predicted depression symptoms b 80 t 600 p 001 and explained a significant proportion of variance r 2 51 f 536 p 001 none of the demographic factors for which we controlled were statistically significant in any of the models stepwise regression analysis was also conducted and results indicated that after controlling for demographic factors general stress was the most significant predictor of depressive symptoms b 85 t 561 p 001 r 2 51 f 3144 p 001 after controlling for demographic factors and general stress social support was the next and final significant predictor of depressive symptoms b 09 t 233 p 023 r 2 55 f 543 p 023 discussion researchers have not determined the risk or prevalence of postpartum depression among lesbian women nor identified theories or treatment for maternal depression among lesbian women if when and why depression affects lesbian mothers needs to be examined once known maternal partner and child morbidity may decrease the first aim of this study was to determine the prevalence rate of depression in a sample of selfidentified lesbian women with at least one child less than 18 years of age we hypothesized that lesbian mothers would experience higher rates of depressive symptoms than reported among presumed heterosexual mothers the second aim was to investigate minority stress and determine if higher levels of social support reduce the effects of gay stress on depression symptoms we hypothesized that social support would protect lesbian mothers from the negative effects of gay stress thereby reducing depressive symptoms in this study 84 of participants endorsed sufficient symptoms to indicate a current episode of clinical depression the national rate of depression for us women varies from 26 to 139 depending on age and location additional research indicates that the rate for us mothers is 102 ertel et al found that the rate varied considerably among the sample of note being aged 35 years or more having a college degree being married having fulltime employment and having the highest income significantly reduced the rates of depression the depression rate for this sample of lesbian mothers is similar to rates for us women and mothers since depression is an enormous public health burden this finding exemplifies the need for future research and treatment targeting this population the majority of the women in this study were older and enjoyed high incomes a college education and fulltime employment which according to ertel et al were among the characteristics of women who reported the lowest levels of depression in their research with us mothers this suggests that lesbian mothers at large may actually experience higher rates of depressive symptoms nevertheless with nearly 10 of the sample experiencing an episode of clinical depression in the past week additional research with lesbian mothers is critical an additional aim of this study was to examine postpartum depression however only fifteen participants reported having a child aged birth to 12 months although results indicate that none of these participants were suffering from clinically significant levels of postpartum depression the sample is too small to draw meaningful conclusions an important finding of this study was that almost 40 of the participants reported a previous diagnosis of major depressive disorder the lifetime prevalence rate for us women is 207 this survey did not collect information about the age that the women were diagnosed so it is unknown if the women were childbearing at the time of the diagnosis regardless this finding indicates the dire need to target lesbian women with interventions to reduce depression the second aim of the study was to investigate minority stress and determine if higher levels of social support reduce the effects of gay stress on depression symptoms we hypothesized that social support would protect lesbian mothers from the negative effects of gay stress thereby reducing depressive symptoms a correlation analysis indicated that women who reported lower levels of social support reported higher levels of gay stress depressive symptoms and general stress social support independently predicted depressive symptoms when demographic characteristics were included in linear and stepwise regression analyses this finding is not surprising and is supported by previous research that identified low social support as a significant risk factor for poor health outcomes it signifies the importance of social support in this minority population and suggests that increasing social support alone may decrease depressive symptoms or the prevalence of gay stress correlation analyses indicated that women who reported higher levels of general stress experienced lower levels of social support and higher levels of depressive symptoms and gay stress when demographic factors were included general stress independently predicted depression in linear and stepwise regression analysis these results are expected and correspond with previous research although additional supporting evidence is needed these findings suggest that targeting lesbian mothers with general stress reduction interventions may decrease their level of depression symptoms correlation analysis indicated that women who reported higher levels of gay stress reported lower levels of social support as well as higher levels of depressive symptoms and general stress which agrees with the minority stress model when demographic factors were included gay stress was independently significant in linear regression analysis to predict depression gay stress however was not a significant predictor of depression in the stepwise regression analysis thus although this study has limitations that prevent generalizability results of the stepwise regression analysis provides evidence that the minority stress model may need to be adapted or perhaps discarded to understand depression more fully among lesbian mothers as a result not only is additional research needed to test this model but new theory is also needed to guide future research consequently if and when evidencebased theories successfully predict depression among lesbian mothers interventions can be developed to target and reduce depression symptoms among mothers limitations this study has a number of limitations a primary limitation is that the participants identities and eligibility could not be verified additional limitations include sampling bias selection bias volunteer bias and measurement bias also limitations result from the lack of a comparison group lack of geographic diversity and the possibility that other confounding factors unknowingly affected the results including the possible impact of participation by the timing of hurricane irene participants were recruited anonymously and online without the ability to verify identity it is not possible to confirm eligibility of the participants or the accuracy of their responses while it is possible that ineligible individuals completed the survey without financial compensation there was little motivation to do so furthermore the survey included three screening criteria and required 1520 minutes to complete thus due to the lack of incentive it is not likely that ineligible individuals would have taken the time to complete it the majority of the sample was caucasian well educated employed fulltime had household incomes in the higher income brackets and were 31 years or older thus indicating sampling bias and a nonrepresentative sample of lesbian mothers that may be suffering from depressive symptoms ertel et al indicates that being at least 35 years of age having a college degree being married being employed fulltime and having a high income were protective factors against depression the majority of the participants in this study had most of these protective factors thus it is possible that these mothers experienced artificially lower rates of depressive symptoms than did women of the national average sampling bias may have also been present since participants learned about this study by seeing a flyer at a local business organization or professional by seeing an advertisement in an lgbt newsletter or on facebook or by hearing about it from a friend religious leader or coworker most of these recruitment sources indicate social connections andor involvement in the lgbt community thus these participants are likely to enjoy larger amounts of social support than others who are more isolated or lacking community involvement consequently these recruitment methods may have missed a large and important portion of the target population while every effort was made to recruit diverse women selection bias may have affected the sample recruitment flyers were sent to hundreds of business and organizations of varied demographics however the flyer frequently had to be approved by higher management or the board of directors thus the final distribution decision was theirs organizations and businesses that did not specifically cater to the lgbt population may not have believed that the survey suited their organizations mission furthermore the stigma and fear of reprisal attached to the status of sexual minorities may have prevented some individuals from displaying the flyer volunteer bias may have affected the sample there is a dearth of research with sexual minority samples highly educated women may be aware of this and thus be more willing to participate likewise these participants may be researchers themselves and know the importance of expanding the research base with lesbian women furthermore the lack of compensation may have been a deterrent for lowincome participants individuals with lower incomes may have been experiencing financial andor time constraints that prevented them from completing the survey items from mogs were mistakenly not randomized thereby introducing measurement bias the questions were categorized by family friends work etc investigation of the questions provided no indication that the results would have been significantly different if randomized furthermore retesting with a small sample did not change the results although it is not possible to determine if this error affected survey results mogs was the least significant predictor of depression symptoms thus if anything the results were overly conservative additionally the findings for social support and general stress were significant even if gay stress was removed from the analysis this study did not include a heterosexual comparison group the rate of depression was compared to the national rates of depression which was determined using different methods and instruments however due to the validity and reliability of most standard instruments it is unlikely that these varied collection efforts significantly affected the results nationally reported rates of depression include all women including sexual minorities therefore if these minorities have increased rates of depression their inclusion may have artificially inflated the national average nevertheless since the population of sexual minority women is small this bias is likely to be insignificant the lack of geographic diversity among the participants is also a limitation the majority of the data were collected from residents of the east coast thus those individuals may have unspecified risk or protective factors that significantly influenced the results this and the small sample size indicate the need for a large geographically diverse study population additionally unknown factors may have influenced participation or responses obtained from this study introducing unidentified confounding for example hurricane irene may have affected study participation and responses due to its significant damage to the east coast in august of 2011 however an examination of participation dates and zip codes indicates that only eight surveys were collected from the affected zip codes after the hurricane although it is not possible to determine if those participants were personally affected the surveys were completed within four months of the hurricane thus it seems unlikely that individuals directly affected would have completed an uncompensated survey furthermore a regression analysis was conducted without the eight participants and there was no difference in the significance level of the model it is also possible that the response rate was affected by hurricane irene twentyfour surveys were completed before the hurricane in the affected zip codes whereas only eight were completed afterward however recruitment efforts began in may 2011 thus it is expected that participation would taper off as the areas became saturated with flyers therefore the effect of the hurricane on the response rate was likely minimal future research direction although only a portion of the study population endorsed evidence for a current major depressive episode nearly 40 have a personal history treatment andor diagnosis of depression from a health care provider since a personal history of depression is a risk factor for additional major depressive episodes effectively recognizing and treating depression in this minority population may help to reduce future morbidity and possibly mortality for the sufferer in the next section barriers for recognizing and treating depression will be explored and recommendations for future research will be proposed barriers to identifying and treating depression barriers to identifying depression and developing treatment programs are widespread and exist on a national organizational and individual level these barriers are common for many women and mothers however additional unique barriers exist for lesbian women and mothers the federal government acts as a national barrier since it fails to recommend universal ppd and maternal mental health screenings without a strong united national voice identification the most basic and easiest part of treatment can be disjointed and maternal depression may remain undiagnosed and untreated lesbian women and mothers experience additional national barriers the lack of federal benefits and marriage equality prevents lgbt individuals from domestic partner benefits and tax benefits program such as consolidated omnibus budget reconciliation act family medical leave act flexible spending accounts and health savings accounts do not apply to couples in domestic partnerships some employers however do provide some benefits to samesex couples nevertheless the benefits package is often subject to taxes not imposed on heterosexual couples regardless in instances where individual employers provide samesex partner benefits some individuals report not using those benefits for fear of coming out at work other physicians in the study indicated that they did not feel they had a clearly defined protocol or the education to accurately diagnosis depression furthermore incongruent care and poor communication between physicians were cited as further complications for diagnosing and treating depression in addition to the organizational barriers that affect heterosexual women many lesbian women experience discrimination from the medical community which may significantly affect mental health diagnosis and treatment intake paperwork often fails to recognize samesex relationships and clinical training often omits lgbtspecific issues consequently research indicates that some lesbian women report anxiety in sharing their sexual orientation with their health care provider for fear that it may affect their care furthermore some lgbt individuals avoid seeing physicians who are not specifically lgbtfriendly which may cause delays in treatment or failure to receive specialty care due to a lack of providers a number of individual barriers affect the diagnosis and treatment of depression in women during focus groups one group of researchers found that many mothers did not feel comfortable talking to their doctors about their depressive symptoms some even feared that their doctor would report them to social services if they revealed the extent of their problems other women indicated that they did not know where to seek help or what treatment was available on the other hand women in a different study refused treatment medication specifically for fear of physical addiction or adverse health consequences for their breastfeeding infants individual barriers unique to lesbian women are interrelated with national and organizational barriers two barriers are repeatedly reported the first is that lesbian women often choose not to use health care services due to negative past experiences resulting from homophobia the second is the financial burden of health care usually due to the lack of health insurance these barriers combined with those common to heterosexual women such as lack of knowledge about illnesses and treatments indicate that additional research and efforts targeting lesbian women is dire understanding barriers may allow programs to be adapted specifically for lesbian mothers for example the financial burden of treatment indicates the need for a lowcost intervention research indicates that online cognitive behavioral therapy depression treatment programs are efficacious costeffective and acceptable to users some research has been conducted using online treatment programs with lesbian women and provides evidence that they may be a promising option for this population regardless since lesbian women are at an increased risk of depression and the consequences of depression are widespread additional theories and research are essential conclusion strong evidence suggests that lesbian women suffer from greater rates of depression than do heterosexual women however existing research offers conflicting findings about depression outcomes much research indicates that lesbian mothers are at no higher risk for developing depression or poor mental health outcomes than their heterosexual counterparts these findings however have limitations that do not account for unique risk factors that may influence the expression of depression in this population since depression affects morbidity of the patient and others including partners and children it is critical to know prevalence rates of depression as well as unique risk and protective factors that may influence symptoms among lesbian mothers the first aim of the radicle moms study was to determine the prevalence rate of depression in a sample of selfidentified lesbian women with at least one child less than 18 years of age we hypothesized that lesbian mothers would experience higher rates of depressive symptoms than reported among presumed heterosexual mothers onehundredthirtyone eligible participants completed an anonoymous internet survey results indicate that 84 of the sample reported clinically significant levels of depressive symptoms this rate is similar to that of us women and mothers however limitations of the sample such as privileged demographics suggest that women in the lesbian mother population at large may experience significantly higher rates of depressive symptoms regardless nearly 40 of the participants reported a previous diagnosis of major depressive disorder which is almost double that of the national average for us women the second aim of the study was to investigate minority stress and determine if higher levels of social support reduce the effects of gay stress on depression symptoms we hypothesized that social support would protect lesbian mothers from the negative effects of gay stress thereby reducing depressive symptoms correlation analysis indicated that women who reported higher levels of social support did have lower levels of gay stress and depression symptoms multiple regression analysis provided an independent link between gay stress and depression as well as social support and depression a high level of general stress was also a significant predictor of depressive symptoms although additional supporting evidence is needed these finding suggest that targeting lesbian mothers with interventions to decrease general stress or gay stress or to increase social support may reduce depression symptoms as illustrated with this study understanding the causes of depression can be very challenging however treating it can be similarly difficult these challenges stem from many national organizational and individual level barriers some that are unique to lesbian women integrating knowledge of these barriers with the findings from the radicle moms study indicates that an online program may be a possible treatment option for lesbian mothers suffering from depression other research has already begun exploring this option lgbtadapted online programs may overcome the financial burden of treatment provide a supportive community for mothers and decrease gay stress experienced from the medical community regardless in order to reduce negative health outcomes for lesbian mothers and their families further research and theory development on the risk and protective factors of depression is critical website or include it in a newsletter eblast listsrv blog mailing or similar posting or even send it to someone else who may be able to help little is known about lesbian mothers i hope that this study will allow us to better understand lesbian motherhood and in the future develop support or treatment for mothers who need it in order to be successful though i need the largest sample possible your support and assistance would be greatly appreciated thank you appendix c recruitment flyer the radicle moms study a graduate student at the university of pittsburgh is conducting a research study to learn more about mood and social support among lesbian mothers you are eligible for this research study if • you are 18 years or older and identify as lesbian • have a child who is under 18 years of age you can be single partnered or married if you decide to take part in this study you would have to fill out an online survey in which we would ask you • general background information • questions about your relationships life experiences and mood the study will take no more than 15 minutes and can be completed online at your convenience you will not receive payment for this study your participation is voluntary and completely confidential

millions of americans are diagnosed with depression each year costing billions of dollars consequences of depression are detrimental to the sufferer and can affect children and significant others exemplifying the public health significance of this illness little is known about depression among mothers who identify as lesbian even though they may be at an increased risk the first aim of the relationships and depression in childbearing lesbian radicle moms study was to determine the prevalence rate of depression in a sample of selfidentified lesbian women with at least one child under 18 years of age the second aim was to investigate minority stress to determine if higher levels of social support reduce the effects of gay stress on depression symptoms recruitment efforts targeted counties in two states that had marriage equality and two that did not a comprehensive survey including standardized depression and stress scales were utilized for assessments onehundredthirtyone selfidentified lesbian mothers responded via an anonymous internet survey results indicate that 84 of the sample reported clinically significant levels of depressive symptoms however limitations of the sample such as privileged demographics suggest that women in the lesbian mother population at large may experience significantly higher rates of symptoms after controlling for demographic factors separate multiple regression analyses were conducted to examine the relationship between depression and social support gay stress and general stress results show that each

introduction healthy aging 1 a process in which functional health is a key driver is shaped by a broad set of interrelated sociocultural economic and health carerelated factors 2 3 4 5 many older adults with functional difficultiesincluding challenges with everyday activities like grocery shopping dressing or using the toiletaddress these longterm care needs and maintain their independence in the community using uncompensated support from family and friends or in some cases supplemental formal care 67 however functional difficulties and use of supportive services for racial and ethnic minorities can differ greatly from those of white people leading to divergent aging experiences in the united states 8 9 10 11 12 13 14 although black or hispanic older adults are at heightened risk for having functional difficulties they receive less formal care than white people 1011 compared with their white counterparts they have shorter primary care visits 15 less annual face time with physicians 16 and fewer days in hospice 17 while simultaneously experiencing longer hospitalization 18 postacute rehabilitation stays 19 and in some contexts greater use of homeand communitybased services 20 while the causes of differences in care quantity are multifactorial and contextual 21 they are posited to include policymodifiable factors such as discrimination access to care barriers and other systemic causes 101122 the myriad of recent us health policies that are believed to have reshaped longterm care 23 may have differentially altered the health of communitydwelling older adults changing the prevalence of people with functional difficulties and how functional needs are addressed across racialethnic lines one potential policy impact is through medicaid expansion under the 2010 affordable care act which was associated with increased access to formal care for lowincome adults under 65 years 2425 a recent study found that expansion was associated with an observed 44percentagepoint increase in any longterm care use and a 38pp increase in home health use 22 however black and hispanic individuals may have been especially affected given lower baseline insurance coverage compared with white people 2627 as a counter example although acas expansion of medicaid home and communitybased services promoted access to communitybased formal care broadly 28 it may have been more beneficial to white as opposed to black or hispanic individuals given that white older adults are more likely to reside in communities with more formal care supply 13 this dynamic of overall but disparate increases in care use may have been furthered under the acas balanced incentives program which offered states over 2 billion in enhanced medicaid matching funds to expand homeand communitybased care while the policy was associated with a 3 increase in daily caregiving in bipadopting states likely due to shifts from nursing to community care it disproportionately benefited caregivers with higher incomes 29 this disparity may result from more challenges for lowerincome caregivers associated with social determinants of health 29 beyond medicaid expansion several of medicares alternative payment programs may have also impacted longterm care use for instance both of the bundled payments for care improvement initiative and medicare shared savings program have reduced costly postacute care use the bpci was associated with 04 and 07 reductions in skilled nursing facilities and inpatient rehabilitation facility care and a 02 increase in home health agency services 30 the mssp has been associated with fewer discharges to facilities rather than home and shorter snf stays and home health episodes 3132 given the substitutability of formal and family care particularly for lowerincome individuals changes in postacute care use could shift the distribution of formal and family care use 33 34 35 for instance golberstein et al 34 found that a 1unit relative decrease in the use of home health services results in a more than a halfunit relative increase in informal care hours this effect was most pronounced among lowerincome families who may not have adequate resources to privately purchase formal home care and therefore are likelier to replace costlier care with more family care hours moreover if program participants avoid higherrisk and costlier patients this could have implications for differences in needs and care by race and ethnicity yet few studies have examined the evolution of longterm care demands and use among older adults and in particular formal and family care patterns in the context of these broad policy shifts 7 in particular how largescale and widely varying policy changes with potentially opposing effects have collectively affected persons of white black and hispanic racialethnic backgrounds is unknown coe and werner 36 for instance examined the prevalence of people with unaddressed functional difficulties among communitydwelling older adults in 2016 but did not examine changes over time or by race or ethnicity van houtven and colleagues 7 examined care support receipt trends from 2004 to 2016 between white black and hispanic individuals who were 65 or older with multiple functional difficulties however these findings elide potential policy effects on younger older adults that are expected given policies like medicaid expansion moreover little is known about shifts on the quantity of care support for functional difficultiesan important dimension for potential inequities we aimed to provide a nationally representative picture of unaddressed functional difficulties and corresponding care support among white black and hispanic communitydwelling older adults in the united states from 2008 through 2018 we used 6 waves of data from the longitudinal health and retirement study to proxy for functional difficulties we used respondents reported need for help with activities of daily living or instrumental adls a lack of care support for a specific functional difficulty was based on respondent report of no receipt of either formal or family care for their corresponding functional difficulty next we measured the weekly overall quantity of hours of care received by people with any functional difficulty summed across all functional difficulties for each population we estimated the prevalence of people with any functional difficulties people with functional difficulties lacking corresponding care support and weekly hours of family and formal care received by people with any functional difficulties to explore potential impacts of access to insurance on disparities namely medicaid before and after expansion and medicare we reconducted analyses for populations with incomes below and above eligibility thresholds to the medicaid program and for populations under and over age 65 years data and methods data and variables we used the rand hrs longitudinal file 37 a cleaned version of hrss core data to examine hrs waves 2008 through 2018 the hrs is a national biennial panel survey of americans over the age of 50 and their households that includes data on sociodemographic characteristics functional difficulties and help received for each functional difficulty 38 our sample consisted of communitydwelling individuals aged 55 years or older in waves 2008 through 2018 of the hrs who were nonhispanic white nonhispanic black or hispanic we restricted the sample to individuals ages 55 years or older because the hrs refreshes its survey population with cohorts ages 51 and older every 6 years with only adults 55 years or older consistently included in each wave prevalence of people with any functional difficulties we considered people as having any functional difficulty if they having any difficulty with at least 1 of 11 activities due to health or memory problems or if they did not or could not do at least 1 of those activities 7 the recall period was the last 2 years or since the last survey wave these activities were 6 adls representing selfcare activities and mobility and 5 iadls representing household activities prevalence of people lacking care support for functional difficulties we categorized a person as someone lacking care support if a respondent or proxy reported at least 1 adl or iadl difficulty for which no corresponding assistance was received during the past month assistance was evaluated as support from a family or formal caregiver or through the use of relevant equipment following approaches taken in prior literature 36 given the substantial needs among communitydwelling individuals who can perform tasks with some difficulty we chose to identify difficulties that were unsupported rather than a failure to complete a specific functional task the former offers a broader portrait of community need than the latter and should be interpreted accordingly average quantity of care per person per week we calculated average weekly care hours summed across all 11 adl or iadl activities by formal and family care type that individuals with any functional difficulty reported having received during the past month formal care hours included care from an organization an institution employee a paid helper or a health care professional family care hours included uncompensated care from family and friends analysis we compared the riskadjusted prevalence in people with functional difficulties and corresponding care support of white black and hispanic people in the past decade to avoid discounting differences in outcomes that result from cumulative raceand ethnicityrelated disadvantages including physical health and access to and use of health care 3940 we limited risk adjustment to age age squared sex marital status and children for each descriptive statistic we estimated 95 cis adjusted for survey weighting in pooled analyses we combined all survey waves to estimate the following for white black and hispanic individuals prevalence of people with any functional difficulties prevalence of people with functional difficulties lacking corresponding care support and average weekly hours of each of family and formal care the prevalence for a specific group was calculated by dividing within each population the number of people with the outcome by the total sample size for prevalence estimates and we included data from all respondents for weekly hours of care we included data only from respondents with at least 1 functional difficulty to evaluate insurance coverage differences that could explain care support disparities we calculated prevalence rates by poverty and age 41 we chose 138 of the fpl because the aca extended medicaid eligibility to adults with incomes up to an effective fpl threshold of 138 42 we chose 65 years as a cutoff because medicare which impacts access to insurance and health care services primarily enrolls americans over age 65 in crosssectional trend analyses we used repeated crosssections instead of pooled data trend analyses were otherwise identical to pooled analyses for further clarity we showed main results separately for adl and iadls robustness checks first given ambiguities in the characterization of functional limitations and care support we adopted an alternative method to categorize whether a person lacked care support this approach allows that individuals may report functional difficulty even with the use of assistive equipment 43 this alternative approach yields a higher prevalence of people lacking care support but similar betweengroup patterns second we examined trends in the prevalence of people with functional difficulties receiving any care support as a way to situate our findings within the existing literature we found results consistent with findings by van houtven and colleagues 7 suggesting no differences in the receipt of any care between white and black and hispanic individuals these results demonstrate that binary measures can belie important divergences in care support third we examined trends in the number of functional difficulties among people with any difficulties we used the number of functional difficulties as a proxy for disability level 44 changes in disability levels over time were not statistically significant but patterns suggest potential decreased severity in the period after the aca results from 2008 to 2018 the prevalence of older people with any functional difficulties was higher for black and hispanic than white populations pooled estimates show that 35 health affairs scholar 2023 1 18 there was little evidence that these betweengroup differences diminished over time the prevalence of black and hispanic people with any functional difficulties was over 30 in each of the survey waves which was consistently 15 times greater than the corresponding prevalence among white people similar to functional difficulties there were betweengroup differences in corresponding care support with 205 of black and 201 of hispanic compared to 124 of white people who lacked corresponding care support for at least 1 reported functional difficulty again these differences across groups were persistent over time next focusing on people with any functional difficulties we examined the quantities of family and formal care support overall and across waves while all groups received substantial family care amounts white people received an average of 123 compared to 173 weekly family care hours among black people and 204 among hispanic people in contrast average weekly formal care hours were statistically indistinguishable at 16 hours for white 18 hours for black and 21 hours for hispanic people trend analysis results suggest for all groups respective decreases and increases in family and formal care although these estimates were modest imprecise and did not indicate strong patterns or decreases in gaps between groups when examined by income and age patterns were generally similar to our main approach except for people in poverty the prevalence of lowerincome people lacking care support was consistently high over time and higher than for those aged 65 and older but rates were statistically indistinguishable between white black and hispanic populations conversely the overall prevalence was lower among higherincome individuals but disparities were observed with higher rates for blacks and for hispanics discussion in this nationally representative study we found that throughout the period from 2008 to 2018 the prevalence of black and hispanic older people with functional difficulties and lacking corresponding care support was consistently around 50 higher than that of white people more than 30 of older black and hispanic compared to 20 of older white people had 1 or more difficulties with functional tasks involving selfcare mobility or household activities onefifth of black or hispanic compared to just over onetenth of white older adults lacked corresponding care support these gaps persisted despite 4065 greater amounts of family care and similar amounts of formal care among black and hispanic compared to white people for lowerincome individuals the prevalence of unaddressed functional tasks was consistently high across all racialethnic subgroups our findings imply that collectively recent us health care reforms were not associated with reductions in racialethnic gaps in functional health and care needs prior analyses have documented large differences in functional support across racialethnic groups for instance 15 and 21 of black and hispanic compared to 9 of white individuals ages 70 years and older have unaddressed selfcare or mobility needs 45 edwards and colleagues 43 estimated a 22 higher prevalence of people lacking care support among black compared to white older women with cognitive impairment during the period 20002014 our investigation confirms these racialethnic differences as well as their persistence into the period after the acas implementation together these findings suggest that the gaps were resistant to broad policy changes even though clinical and longterm care expansion under medicaid and novel payment systems in medicare might be expected to predominantly affect those with the least access to highquality clinical and supportive services with no evidence of gains over time for lowerincome populations eligible for medicaid expansion together these findings suggest that the gaps were resistant to broad policy changes even though clinical and longterm care expansion under medicaid and novel payment systems in medicare might be expected to predominantly affect those with the least access to highquality clinical and supportive services crosspressures of the programs may have had a cancelling effect for instance medicaid expansion could have increased formal home health care while potentially lowering the use of family care even as the bip shifted care back from formal to family care the findings also reveal persistent unaddressed difficulties among lowerincome individuals that surpass those of older age groups regardless of race this suggests critical needs in the future that were not addressed despite widespread incentives for improved care access in medicaid despite the greater prevalence of people with functional difficulties and more difficulties per person hours of formal care received by black and hispanic older adults only modestly increased in the postaca period these small changes in formal care receipt are in line with other literature showing an approximately 4pp increase in the likelihood of any formal longterm care use among older adults following medicaid expansion 724 while our study was not designed to assess causal implications of medicaid expansion or other policy changes our descriptive findings showed no evidence of shifts across groups in the prevalence of people lacking care support among lowincome households from before to after the aca despite marginal increases in formal care thus to close racialethnic gaps more concerted and broadly targeted policy efforts to direct and tailor formal care equitably are still needed family care typically outside the scope of health care reform remained the dominant care type among black and hispanic people with functional difficulties the higher levels of family care received by black and hispanic relative to white older adults could be due to differing cultures of family and formal caregiving in the presence of functional needs 9104647 as an example the notion that family wellbeing is more important than that of the individual among some hispanic caregivers has been posited as 1 reason for the low use of formal home care 4849 this heavy reliance on family care could also reflect continued struggles faced by racialethnic minorities in accessing highquality formal care for instance the 2022 national healthcare quality and disparities report shows that black and hispanic people had worse outcomes than white people for the majority of accesstocare measures 50 moreover racialethnic minorities tend to be overrepresented in lowquality nursing homes and home health agencies 5152 which may decrease the appeal of formal over family care 10 the more limited use of nursing home care may further explain the persistently higher prevalence of functional need among communitydwelling racialethnic minorities and resulting equity issues in unaddressed needs other potential factors explaining discrepancies in family care use are the opportunity costs which are higher for higherversus lowerincome families or greater care needs due to social determinants of health 29 how such significant reliance on family care among racialethnic minorities affects disparities in care support is unclear on one hand extensive use of family care among racialethnic minorities may reduce the prevalence of people lacking care support potentially mitigating inequities on the other hand family care may be an imperfect substitute for formal care especially as severity of needs increases 53 alternative payment models that disincentivize the use of institutional postacute and other formal care are increasingly prevalent 5455 potentially increasing the prevalence of communitydwelling people with functional difficulties and raising pressures on family care 56 for racialethnic minorities who are already particularly more likely to have lower household and community resources than white people these systemic changes exacerbate concerns about the adequacy of family care in meeting growing care support needs 57 finally heavy reliance on family care by racialethnic minorities may introduce inequities for caregivers in the future 58 since caregiving often comes with mental physical and financial hardships 59 60 61 future work should examine how formal and family care can be leveraged to decrease populationlevel differences in functional difficulty paying particular attention to how needs are being addressed across disparate groups limitations our study has several limitations first we used repeated crosssections in trend analyses without adjusting for multiple observations per person while consistent with approaches in prior literature 7 it may not represent the true degree of statistical uncertainty second while the hrs collects race and ethnicity data only black and hispanic individuals are oversampled leading to small samples for other racial groups therefore by focusing on groups with larger samples our study does not capture experiences of other populations limiting the policy implications of our findings third the 2018 hrs had skippattern issues that prevented some respondents from being asked adl questions 37 although the hrs imputed the missing data there may still be missing data bias 62 fourth our measure of unaddressed functional limitations does not capture unmet need for assistance with adl iadls the hrs does not ask respondents whether they were unable to complete a task due to lack of assistance or whether despite receiving help they remain unable to complete the task for this reason our estimates may overstate unmet need and instead offer broader evidence of incompletely addressed needs however any resultant bias is likely consistent over time and should not vary by race and ethnicity conclusion even with largescale policy changes brought forth by the aca this descriptive analysis provided evidence that black and hispanic older adults living in the community were still more likely than their white counterparts to experience functional difficulty and lack care support lowerincome individuals in particular showed evidence of substantial needs unaddressed by caregivers despite a greater prevalence of people with difficulties as well as more difficulties the quantity of formal care used by black and hispanic older adults did not meaningfully increase relative to white people in a period that included multiple health care reforms that could impact longterm care use our descriptive analyses should encourage policymakers and health groups to systematically identify understand and address policymodifiable disparities supplementary material supplementary material is available at health affairs scholar online conflicts of interest the authors have no conflicts of interest to declare please see icmje form for author conflicts of interest these have been provided as supplementary materials

unaddressed functional difficulties contribute to disparities in healthy aging while the affordable care act aca is believed to have reshaped longterm care little is known on how it has collectively altered the prevalence of older adults with functional difficulties and their use of family and formal care this study uses nationally representative data from the health and retirement study 20082018 to describe racialethnic differences in the prevalence of communitydwelling older adults who had difficulty with but lacked assistance for selfcare mobility and household activities before and after the aca individuals with functional difficulties accounted for about onethird of black and hispanic individuals compared to onefifth of white people the prevalence of black and hispanic people with functional difficulties lacking corresponding care support was consistently 15 times higher than that of white people racialethnic differences disappeared only for lowincome households where unaddressed difficulties were uniformly high while formal care quantity was similar black and hispanic people with functional difficulties received nearly 50 more family care than white people these gaps between white black and hispanic older adults were persistent over time these findings suggest that racialethnic gaps in aging needs and supports remain despite major health care reforms in the past decade

introduction this paper examines the topic of chronic disorders of consciousness from a legal perspective our intentions underlying this deceptively simple opening statement however require some elaboration what do we mean by these key phrases chronic disorders of consciousness and legal perspective the phrase chronic disorders of consciousness is an umbrella term referring to severely braininjured patients in prolonged comas vegetative 1 or minimally conscious states 2 the second term a legal perspective requires a little more unpacking legal scholarship is now a already have been imagined for the paper offers an empirical analysis of the legal consciousness of the family members of patients with chronic disorders of consciousness legal consciousness an admittedly confusing term in the context of this paper about disorders of consciousness is a term of art within the sociology of law 9 that is much wider in its focus than the medical conditions explored in this paper legal consciousness comprises societys constructions of legality the cultural characterisations of legality that are common currency and drawn upon when as individuals and groups we make sense of everyday life 10 to study legal consciousness is to study the background assumptions about legality that structure and inform routine thoughts and actions 11 an empirical focus on legal consciousness then like much legal research involves an enquiry into the role of law in society but not law as expounded by the courts or legal personnel rather law as constructed by society in various cultural narratives of legality as they are sometimes described 12 this paper accordingly focuses on the images of law that were drawn upon and invoked by family members when negotiating the situation of their relatives with chronic disorders of consciousness including in some cases the ending of their lives in this way we present a study of law in the everyday lives 13 of ordinary people enduring extraordinary circumstances thus offering a distinctly sociological contribution to the question of how law matters in this particular domain of social life the paper proceeds in four stages first to provide some background and context we offer a brief overview of the legal regulation in england and wales of the treatment care and ending of lives of patients with chronic disorders of consciousness secondly we give an introduction to our data set and describe the research methods used to obtain it thirdly we present our research findings and fourthly we then discuss them from the perspective of legal consciousness before concluding by exploring the wider implications of our analysis for this field of medical care and considering what research agenda they suggest the law the treatment of patients with chronic disorders of consciousness is like all medical treatment subject to the standards of care developed in the general law of 9 see eg m hertogh a european conception of legal consciousness rediscovering eugen ehrlich 31 j legal stud 455 s silbey after legal consciousness 1 ann rev l soc sci 323 m kurkchiyan perceptions of law and social order a crossnational comparison of collective legal consciousness 29 wis intl l j 102 10 se merry getting justice and getting even legal consciousness among workingclass americans a sarat the law is all over power resistance and the legal consciousness of the welfare poor negligence 14 more specifically however treatment decision making is governed by legislation dealing with situations in which individuals lack the capacity to make decisions for themselves the mental capacity act 2005 is the statute in force in england and wales that sets out a legal framework for determining mental capacity and for decision making on behalf of those over 16 years old who lack the capacity to make decisions for themselves 15 patients with catastrophic brain injuries leading to disorders of consciousness clearly lack such capacity and under the act the senior clinician with treating responsibility therefore becomes the decision maker for such patients the only exceptions to this would be the rare circumstances 16 in which a patient has elected in advance to refuse consent to certain treatments by way of a legally valid and applicable advance decision 17 or the patient has granted a health and welfare lasting power of attorney to someone so that they can give or withhold consent to treatments 18 or the court has appointed a welfare deputy with the power to give or withhold consent 19 20 contrary to popular belief 21 then the term next of kin has no legal status in england and wales and does not grant any decision making power over an incapacitated patient family members although not the responsible decision makers must however be given the opportunity for involvement in decision making regarding their loved ones care and treatment clinicians have a duty to consult with the patients family in order to inform decisions in the best interests of the patient 22 although most medical treatment decisions can be taken simply as a result of discussions between the clinicians and family and friends the decision making process is more involved in relation to serious medical treatment 23 including the withholding or withdrawal of artificial nutrition and hydration 14 see generally ma jones medical negligence 15 lack of mental capacity is defined in ss 2 and 3 16 currently only 4 of the population of england and wales reports having made an advance decision and only 4 reports having appointed anyone as their health and welfare lasting power of attorney in g v e 2010 ewca 2512 j baker elaborated the principle underpinning the statutory provisions regarding deputies the words of s16 are clear they do not permit the court to appoint deputies simply because it feels confident it can but only when satisfied that the circumstances and the decisions which will fall to be taken will be more appropriately taken by a deputy or deputies rather than by a court bearing in mind the principle that decisions by the courts are to be preferred to decisions by deputies 17 mental capacity act 2005 s 24 18 ibid ss 911 note however that under s 11 an attorney can only refuse lifesustaining treatment if the grant of the power of attorney expressly provides for this 19 ibid s 16 20 ibid s 20 21 albeit wrongly 48 of people believe that they have the legal right to make medical decisions on behalf of an adult family member who lacks capacity to make decisions for themselves 22 did not know whether they had this legal right or not only 22 answered correctly that they did not have this right from a patient in a permanent vegetative state all such decisions must be brought to the court of protection for an exercise of its declaratory power under the act 24 under s 15 the court of protection may make declarations as to the lawfulness or otherwise of any act done or yet to be done in relation to a person who lacks capacity the issue for the court in such cases is strictly speaking whether it is in the patients best interests to give treatment rather than to withhold or withdraw treatment given that the jurisdiction of the court is to grant treatment consent where the patient is incapable of doing so himherself if the treatment is not in his best interests the court will not be able to give its consent on his behalf and it will follow that it will be lawful to withhold or withdraw it 25 the crucial test of best interests 26 is not defined in the act rather the act gives a checklist of factors that must be considered when working out what is in a persons best interests 27 in addition to clinical considerations these include taking into account the patients prior expressed values wishes and beliefsfor example what the patient would have wanted for himherself this is why consultation with family is essential to inform any best interests decision the role of families as defined by the act is to provide information about the person before the loss of capacity his or her character beliefs values and what his or her wishes might be about treatment and care decisions this information contributes to the courts 28 best interest decision but does not determine it in a fairly recent 29 judgment 30 even a united family view that the relative would not want to be kept alive in a minimally conscious state was insufficient to tip the balance in favour of withdrawal of treatment when set against other factors including the value of preserving life which weighed particularly heavily mental capacity the research project the research reported here is part of a larger ongoing project conducted by the yorkcardiff chronic disorders of consciousness research centre we draw here on a data set of more than 50 family members who have experience of a catastrophically braininjured relative in a chronic disorder of consciousness ethical approval for the study as a whole was obtained from the universities of york and cardiff ethics committees indepth semistructured audiorecorded interviews were carried out by celia kitzinger and jenny kitzinger and then transcribed and anonymised before being shared with other members of the research team 31 participants were recruited through advertising via braininjury support groups and websites and through social networks through contacts made after giving formal presentations about our research and via care homes and snowball sampling the study subsequently received nhs approval and we were also able to recruit via consultants although all interviews took place off nhs premises interviews were mostly onetoone but occasionally in pairs interviewees were mostly parents siblings spousespartners and adult children of the patient most patients were currently either pvs or mcs the recruitment methods used clearly do not result in a sample representative of all families with severely braininjured members although the pool of interviewees 32 shows considerable variation in terms of age gender ethnicity and cultural and economic capital 33 we can make no claim as to the representativeness of our sample in relation to the sampling frame equally as a purely qualitative study we can make no claim as to the distribution of various legal consciousness narratives amongst those with relatives with chronic disorders of consciousness nor do we claim that legality was the dominant theme of our interviews interviews were often quite long and involved discussion of many issues indeed in some interviews issues of legality were not canvassed positively at all but although the study of legal unconsciousness as it were could be as important and revealing as that of consciousness 34 our focus here is on the interviewees who positively communicated perceptions of legality this permits us to discover the significance of legal consciousness for the thoughts and actions of these interviewees in relation to their relatives this kind of grounded analysis in turn allows us inductively to hypothesise about the potential significance of legal consciousness more widely in this domain findings that can be tested and refined in further work in other words our data set allows us to build theory about the potential significance of law for chronic disorders of consciousness given how little research 31 further anonymising became necessary at the point at which presentations and publications were prepared the challenges of avoiding jigsaw identification of participants across our publications and of maintaining the confidentiality of those whose stories may also be in the public domain following court hearings and media interest is discussed in b saunders c kitzinger and j kitzinger anonymising interviews for data sharing the practical research ethics of protecting participant identities european sociological association conference turin italy 2013 32 for more information about interviewees represented by the sample see ibid exists with families of these patients and that this analysis is the first to explore legal consciousness in this field we believe that the theorybuilding in this paper is a very important step the conduct and analysis of the interviews that gives rise to our findings followed the broad methodological trend within legal consciousness work 35 where possible the direct questioning of interviewees about law was avoided instead the focus was upon the characterisations of legality that emerge naturalistically in the ways in which participants discuss their lives and actions generally or certain topics specifically thus our interviewees in discussing the situation of their relatives with chronic disorders of consciousness and the approaches taken to their care treatment and death revealed their assumptions about legality assumptions that informed their views and actions it is these assumptions aspects of broader cultural narratives of legalitythat are the focus of our analysis it is to this analysis that we now turn research findings the clearest and perhaps most obvious finding from our data one no doubt that can be confidently projected inductively on to all those who find themselves in these circumstances is that the experience of a relative suffering a severe brain injury is a shocking one that propels family members into a state of great uncertainty neurology is a complex field of medicine beyond the ken of most laypeople as in many fields of medicine family members found themselves initially entirely dependent on the expertise of medical staff for example one interviewee kim noted that when we started this i was such an innocent and if somebody had said to me right do we operate or dont we do we put him into intensive care or dont we i wouldnt have actually known i was very much in the hands of the professionals another interviewee gill expressed a similar sentiment you rely on these people who are at the top of their fields to make these decisions and so you trust them gills statement about the inevitability of initial trust reflects a common assertion within the broader sociological literature on trust the medical system with which family members find themselves having to engage is in giddens terms an expert system 36 perhaps indeed the expert system par excellence it is opaque and confusing for most laypeople trust in the medical knowledge and expertise of trained staff is the antidote to the initial sense of uncertainty felt by families 37 as sztompka has noted in relation to the role of trust in contemporary society more often than ever before we have to act in the dark as if facing a huge black box on the proper functioning of which our needs and interests increasingly depend trust becomes an indispensable strategy to deal with the opaqueness of our social environment without trust we would be paralysed and unable to act 38 however this initial trust can be shortlived indeed such was the case for a number of our interviewees there are we suggest several features associated with chronic disorders of consciousness that reduce the likelihood of initial trust in medical expertise enduring undiminished for a start there are the limits of medical expertise in relation to severe brain injury and associated levels of uncertainty about outcome in the early time period from the outset clinicians may thus explicitly inform families of the limits of medical knowledge about and ability to intervene in severe brain injury making comments such as time will tell and we have to wait and see secondly medicine may be implicated as a cause of the disorder of consciousness over time there may also be concerns from family members about what care and rehabilitation can be provided or what options are available to relieve suffering and distress or indeed to allow death 39 another distinct feature of disorders of consciousness that may have a profound implication for trust in medical expertise is the fact that patients have little or no ability to communicate about anything they may be experiencing this means that family members become involved in interpreting nonverbal signs as part of the wider process of deciding how best to care for the patient and what is in the patients ultimate interests and of course family members draw from their longterm and intimate knowledge of their relative including their sense of what their relative would have wanted knowledge that medical staff do not share in a significant reversal of the trustexpertise dynamic many of the family members we interviewed felt that they were the experts about the patients experiences of treatment and care and that the medical staff should trust them not the other way round 40 gill for example who above noted her initial trust in the medical staff caring for her partner oscar very poignantly described her ultimate lack of trust in the staffs understanding of him it was really bugging me that they were just sedating him and not actually going to the root of the problem and because they were saying we are neurology nurses we know seizures when we see them and i said you may know neurology patients and you may know seizures but i know oscar and hes not having seizures likewise sarah raised this issue in relation to her family members treatment a young man supposed to be vegetative 38 p sztompka trust a sociological theory p 13 39 the fact for example that death for a permanently vegetative patient may only be possibleallowed via the withdrawal of artificial nutrition and hydration is one potential source of tension between family members and care providers 40 in this way our interviewees individual assertions of expertise match similar communal assertions arising from organised politicalsocial movements see eg s epstein impure science aids activism and the politics of knowledge they would do all of these things but not look at ricky and see that he was in pain because oh he cant feel painand when they tell you that and you know that youve seen it you think my god how can youagain youre back to what your nightmares are made of how can you trust youve got to entrust them with them and youve got to walk away and leave them sarahs statements point to the intimate relationship between trust and risk another key theme in the sociology of trust trust is usually depicted as a strategy for managing risk 41 however the flipside of this dynamic as we can see here is that where trust diminishes one is left with the sense of risk where family members no longer trusted medical staff to fully understand their relative our interviewees perceived their ongoing care as a source of risk risk that their best interests would not be promoted and that avoidable suffering would be endured perhaps inevitably this often became a source of tension between family members and clinicians it is in the negotiations of these tensions that we gain our first insight into the significance of legal consciousness the first of three key images of legality that form part of different legal consciousness narratives becomes apparent in this context law as sword a key theme to emerge from our data set is that family members felt embattled in relation to the care of their relatives many felt they had to fight to achieve what in their view was best for their loved ones hugo for example described a process of struggle in relation to his wife its been a long long battle trying to find the right thing i wont say all the things get resolved but generally its made a bit better it is a long daily process of just making sure that everything is okay likewise elspeth described the difficulties her family experienced in trying to secure her brothers transfer to another hospital where they felt his needs would be better catered for thats how we got into st peters hospital basically its from resources and arguing and bullying basically just by not letting up and then also by having friends who are doctors who knew someone who knew someone it is important to note that most interviewees experienced the medical system as a powerful one and many perceived themselves as having a comparative lack of power in relation to it some interviewees indeed felt belittled by their experiences tracy for example expressed this sentiment forcefully i sit here im like a witch sitting here and now what can i do next how do i handle these people they are dreadful they are so precious they are so territorial they are so because you see they think were dog shit equally elspeth in discussing her anger about her familys struggle for the care of her brother expressed her sense of not having been respected int do you think any of that anger was legitimate as opposed to just expressing pain are there people you ought to have been angry with elspeth angry at doctors who didnt listen to us and treated us like idiots yeah angry at doctors for not listening however as we saw above in relation to elspeth some interviewees despite their frustrations felt they had the resources skills and determination to challenge decisions that were being made by medical staff but others turned to law in order to redress the power imbalance tracy for example sought legal assistance when she felt that medical staff were not being sufficiently open with her about what had caused the minimal consciousness of her partner trevor i phoned the solicitors and they said to me it sounds like either there was a mistake made or maybe they did everything they could and were just really really unfortunate but when you get him out of estridge hospital get his records send them down to me and ill look at them and ill tell you what the story is likewise gill expressed her faith in law to mitigate a power imbalance in her case she was worried that lifesustaining treatment might be denied to her badly injured partner and turned to the law to try to prevent this you can take disagreements about care decisions to your lawyer you can get your lawyer involved i tell you what that put them on edge i said im just going to go and run this past my lawyer do you know like i was feeling threatened so i was using her as my power for people like gill and tracy legality acts like a sword against the power of the medical system locked in a struggle over the welfare of their relatives law can be turned to in order to alter power relations and influence decision making about treatment and care gills decision to phone a human rights organisation for legal help suggests a perception of law as a weapon of justice and as representing some kind of higher normative order likewise when tracy described her turn to law as way of trying to prevent poor treatment happening to other patients in the future legality is being imagined as a means of combatting unfairness and injustice in the medical system yet tracys interview displays some ambivalence about the nature of legality as a weapon suggesting it can be something of a doubleedged sword she additionally framed her turn to law not as a way of promoting general fairness or respect for human rights but rather merely as a way of securing damages under the law of negligence so that she could pay for better care for her partner trevor equally she contradicted her earlier concern for the situation of future patients my brother in law karl hes a lovely fellow but he tends to get emotional and he was saying this is a dreadful situation theres people out there who need this information and i was going yeah karl thats for another day okay lets concentrate on trevor i dont give a fuck about those other people to be quite honest right now here the image of legality albeit temporarily and perhaps to a limited extent is disconnected from justice and becomes merely a powerful means to an end law is less an expression of a collective justice and more a tactical weapon to be wielded instrumentally in a personal struggle law as shield both gill and tracy were speaking to the interviewers within a year or two of their partners initial injury and both believed that the partner would recover from their chronic disorder of consciousness and were fighting to keep them alive and to secure the conditions that would help them improve not all of our interviewees however shared this belief a number of them believed that their relatives disorder of consciousness was irreversible and that it was in their best interests to die for some of these interviewees the wait and see period was long over and they no longer hoped for recovery as the means of release but saw death as the only way forward 42 here at least for some legality could act as a shield lillian and kim were two such interviewees both had applied to the court of protection in england and wales for a declaration that it would be lawful to have artificial nutrition and hydration withdrawn from their relative resulting in their deaths for both the fact that this decision was being made by a court was highly significant and helped to protect them from feelings of responsibility lillians relative had suffered severe brain injury after an operation before that operation he had written a letter expressing his desire to refuse lifesustaining treatment if he was rendered incapable of making a decision for himself however this letter did not meet all the criteria necessary to be compliant with the requirements of an advanced decision under the mental capacity act 2005 43 nonetheless the court of protection in part informed by this letter made a declaration that it was lawful to allow artificial nutrition and hydration to be withdrawn the courts jurisdiction to decide this was highly significant to lillian i think the fact that hed written what he wrote helped you cope with it in your head because otherwise it would feel like it was more your decision if the court of protection wasnt there to say well we are making the ultimate decision and this is what we decide i would always feel that it was me whod actually chosen to do it almost feeling that youd sentenced them to death so the court of protection has shielded me from that experience kim expressed similar sentiments in relation to the court of protections decision about her son kim if you make a decision to end a life and then somebody changes their mind if you dont have a court ruling for it then the ensuing recriminations could destroy a family whereas if youre thinking we decided this was a good idea it then went through due process of law and it was looked at by someone who had no emotional involvement at all then it takes the guilt out of it int did it feel like it was the courts decision not yours ultimately kim exactlyyes and thats what i was told youre not deciding to end your sons life you are posing a question that the judge will then answer for you here the image of legality encapsulated in the court of protections jurisdiction is one of impartiality no emotional involvement as kim put it both kim and lillian were relieved to be able to pass this lifeanddeath decision up to a higher decision making forum in relation to both kim and lillian the image of law as a kind of shield was invoked in relation to their own feared sense of individual responsibility however kims reference to due process of law connects with a wider sense of law as a shield that was also evident in our data in other interviews the benefits of due legal process were referred to in relation to society protecting its members from reckless decision making in relation to those with chronic disorders of consciousness here legality is an impartial and appropriate form of authoritative collective regulation that merits compliance and respect a number of interviewees displayed considerable deference to formal state legality in this regard jim is one such example jims interview is of particular interest because his sister who had been diagnosed as being in a permanent vegetative state had been killed by his mother after delays in the legal process of being granted permission to withdraw artificial nutrition and hydration a doctor appointed by the official solicitor to give a second opinion on jims sisters condition had raised the possibility that she might be in a chronic minimally conscious state rather than in a permanent vegetative state when that last report was produced by doctor smithers that clearly was going to delay proceedings further it was clearly not reaching a conclusive situation because doctor smithers report was just going to kick it all into touch again so then my mother had reached some decision in her mind and she borrowed someones insulin and there was a hospital car that was adapted for taking a wheelchair you can borrow it and sign it out and you have to have somebody else with you a third person to look after them in the back of the car but she didnt fill in the form or ask for anyone else to come along she just went and asked for the keys and they gave them to her she was so well known there and its a failure of procedure but anyway she took the car took her home and they were both found dead later on that day yet despite jims support for his mothers decision he was nonetheless very deferential to legality these are momentous decisions that need to be done by a disinterested authoritative and experienced party if you have a legal system you cant have people taking the law into their own hands i still support the fact youve got to have a system youve got to stick to it the deferential approach that jim displayed towards legality can be significant for other family members contributing to decisions about whether and how to allow their relatives to die john is one such example john and other members of his family had asked the nhs trust to apply to the court of protection for a declaration that it would be lawful to withdraw artificial nutrition and hydration from his wife who was in a permanent vegetative state he was critical of the fact that his wifes consultant had not made the possibility of this legal process known to him he had learned about it instead from a television programme at the time of interview the court hearing had been provisionally scheduled for a couple of months time once involved in the application process however his sense of it was that it was a procedural formality with a foregone conclusion int what do you think will be the outcome of the case do you have any sense of whether it would be approved or not john well i think it will be because the official solicitors involved so i think the legal bods will get together and theyll say its a no contest this and theyll just nod it through one reason why it might be a little more protracted than normal is they want to hit it on the bounce in that they dont want it to go to court and then come back and more work to be have to be done in johns view the decision to allow a dignified end to his wifes life had taken too long and he acknowledged the role of law in lengthening that process of course when you get the legal people involved everything then slows down for whatever reason weve got all the reports from the senior clinicians and then the legal people have got to put that into legal speak to present it to the court it might take quite a long time before it gets heard by the judge itll be a year since we started the process and itll be four years since shes been in this state so its taken five years yet despite the fact that the court of protection proceedings that caused further delay to his wifes death was a legal requirement 44 and despite this process being a matter of nodding it through he was still deferential to legality and was content to see due process complied with fundamentally i think it should go to court at the moment the clinicians know what the law says so they abide by it which means that we have to go through this long protracted process there need to be safeguards and safety checks not all our interviewees however displayed this kind of deference to law in light of its role in protecting society from reckless decision making for others law was not a shield in this sense but rather was an illegitimate barrier to ending what they perceived to be their relatives indignity or suffering like jims mother above some of our interviewees were willing to subvert the legal process it is to these data that we now turn law as barrier within our data set in addition to deference towards legality there was also conversely considerable scepticism towards the legal regulation of the ending of patients lives death can only be allowed through the withdrawalwithholding of treatment that may in some circumstances include the withdrawalwithholding of artificial nutrition or hydration however where a patient has a diagnosis of being in a permanent minimally conscious state rather than permanent vegetative state the courts have not so far been willing to grant permission for the withdrawal of artificial nutrition and hydration 45 in this context some of our interviewees expressed a willingness to kill their relative themselves either because they thought a court would not allow their relative to die andor because they viewed the legally permissible route of anh withdrawal to be intolerable and lacking in compassion but for such people the act of killing would not involve taking the law into their own hands as jim above put it rather it would be a legitimate subversion of legality because of its illegitimacy in this context this orientation towards legality involves an external and critical stance rather than showing deference to law because of its authoritative status in regulating collective matters some interviewees observed law from the outside as it were and critiqued it for its normative failures this was expressed in terms of law failing to meet acceptable moral standards elspeth for example discussed the situation of her brother ian who had been diagnosed as mcs although ian eventually died of natural causes prior to this elspeth had been planning to kill him elspeth he was in so much pain breathing really difficult and i said ian i just wish there was something i could do and he again leant out and looked at me and to me that meant there is something you can fucking do and it just it suddenly became really clear that thats what we had to do is to help him do that and when we went to see the lawyer and it basically looked impossible to win a case for anh withdrawal having rationalised it and realised that this was the best thing for him i was personally wanting to take his life illegally int but youd have faced a prison sentence airedale nhs trust v bland elspeth yeah but that would be not as bad as his sentence if we know that something is the right decision to do then it wouldnt be something id question massively afterwards indeed for elspeth not only was the law morally wrong in relation to the ending of her brothers life it was an inappropriate intrusion into this domain there needs to be an option somehow i mean obviously you cant just be hey hes mcs lets off him but i dont think it should be a legal thing i think it should be down to the doctors with the carers and it should be a multidisciplinary thing i dont think it is a legal matter a similar scepticism towards legality was expressed by sarah like jim her family member had been killed by another relative unlike jim however sarah showed little deference towards the law in this regard indeed she had been willing to do the same i always said i dont think itd be wrong but i am not going to let that system get hold of me i couldnt deal with prison i mean id end up probably killing someone else as well and be truly a murderer in some cases they say its wrong what mary did well morally it isnt wrong and i dont care what the law says sarahs reference to being truly a murderer suggests that from her perspective formal legality has only a contingent relationship to justice the legal category of murder is only true when it corresponds to a higher normative order where it doesnt then the law lacking legitimacy in this respect can be ignored and subverted discussion what should we make of these different images of legality identified from our interviews two potential preliminary objections to our analysis should be anticipated and countered before the discussion ensues first it is tempting perhaps to view our analysis not as one of law itself but rather as one of attitudes to law one quick response to such a concern would be to note that attitudes to law the focus of much sociolegal work over the years 46 are as worthy of study within the legal academy as legal doctrine itself however the deeper point of the legal consciousness literature is that if we are concerned with the rule of law in society we cannot avoid examining how legality is constructed by society for the societal constructions of legality away from the formal sites of law law in everyday life in other wordsconstitutes the rule of law in an important sense as ewick and silbey have noted in an interview about their legal consciousness research the law is what people do about the law we said that peoples engagement with the law in their lives was an ongoing construction of relations law was just a flavor to any social relation so in order to understand the rule of law we had to find its place in ordinary social relations so the question was not only what do people do it was also what is the rule of law 47 the study of legal consciousness therefore is as much the study of law as is the study of legal doctrine in this way our paper makes a novel contribution to our wider understanding of how law matters in the care of those with chronic disorders of consciousness secondly it might be objected that an analysis of individuals attitudes and actions does not sustain the claim that we are studying legal consciousness narratives as such societys constructions of legality our response here is that although individuals have attitudes attitudes are not individual orientations towards legality are social rather than individual the contribution of the legal consciousness literature has been to highlight the ways in which legality is socially constructed in society and such constructions are not infinite the work of both ewick and silbey 48 and halliday and morgan 49 contends that the constructions of legality within society are limited and capable of structured analysis it is important to stress again at this point that our aim in this paper is to build theory about the significance of legal consciousness for the thoughts and actions of families going through this situation we use our data to make links between the wider body of literature on legal consciousness and the experience of having a relative with a chronic disorder of consciousness by interrogating our interviews for images of legality we can open up a dialogue between this data and broader legal consciousness theory and in turn legal consciousness theory applied to and tested in our data can deepen our insights into the experience of responding to the severe brain injury of a partner spouse offspring parent or sibling what we will show in the following section is that the images of law as sword shield and barrier can be interpreted meaningfully through the lens of existing legal consciousness theory and in light of these connections we can hypothesise about the wider role of legal consciousness in this domain of social life legal consciousness theory ewick and silbey proposed an influential typology of legal consciousness narratives as they put it separate characterisations of law in society which they suggested are drawn upon and reproduced in a routine fashion in commonplace lives 50 they name these three narratives according to the characteristic orientation towards law implicit in the narrative before the law with the law and against the law each narrative has a double face as it were representing both a characteristic individual response to law and a cultural schema that make sense of law at a structural level standing before the law captures an image of law as ensuring collective fairness equality and justice playing with the law by way of contrast is a story where law is a morally neutral game that can be played to individuals advantage if they are clever enough and have the right resources being against the law tells yet another story of law where it is the expression of brute power exercised unpredictably and resisted by individuals where cracks in that power appear halliday and morgan 51 have recently mapped ewick and silbeys typology on to a broader analytical framework derived from mary douglas gridgroup cultural theory 52 ewick and silbeys three narratives correspond largely to three of the four cultural biases suggested by douglas however this mapping exercise revealed that a fourth narrative corresponding to the fourth cultural bias in douglas scheme is missing from ewick and silbeys account of legal consciousness halliday and morgan applied the fourth cultural bias to the topic of legal consciousness in a study of radical environmental activism within this narrative of legality state law is similarly regarded as illegitimate and oppressive but is resisted and subverted in a collective effort to alter the power structures that legality imposes existing scholarship on legal consciousness then offers us four core cultural characterisations of legality 53 before the law with the law against the law collective dissent our suggestion is that the images of legality revealed in our data are rooted in these four cultural narratives before the law the image of law as both a sword and a shield connects largely with ewick and silbeys before the law narrative of legality the idea of law being a powerful weapon of justice to counteract and call to account the failings of the medical system is part of the story of law as a general objective and impartial power 54 as ewick and silbey put it gills sense that formal law was protective of human rights and tracys instinct to invoke law to protect the interests of others correspond to the story of law as a reified system of justice as ewick and silbey noted individuals decisions to mobilize the law thus often involved the crucial interpretive move of framing a situation in terms of some public or at least general set of interests 55 this same interpretive move is seen in the image of law as a shield protecting society from reckless decision making about the ending of lives despite johns criticisms of the slowness of the legal process in relation to his wifes case and despite jims sympathy for his mothers killing of his sister both portrayed court of protection proceedings as an essential system for collective protection the court of protection offered safeguards and a demonstration that the issue would be dealt with in a balanced way and represented disinterestedness authority and experience in their view the court was the proper place for decisions about the ending of lives in this narrative of legality law deserves respect and compliance from deferential subjects against the law yet in contrast to the deferential orientation of subjects invoking the before the law narrative the image of law as an illegitimate barrier connects with ewick and silbeys against the law portrayal of legality where the power of law is resisted in contrast to tracys and gills faith in the normative qualities of legality whereby it can protect relatives needs or prevent doctors from doing the same again to others the interviews with elspeth and sarah reveal considerable scepticism towards it in this domain for them given the courts reluctance in the case of w v m and others 56 to permit withdrawal of anh in relation to a minimally conscious patient the requirement of legal proceedings was a problematic obstacle to and unwelcome intrusion into the resolution of their families suffering as such the demands of due legal process did not merit compliance or respect but rather invited avoidance and resistance the legal thing thats whats made me most angry ive got absolute contempt for this legal system and despite the power of law to criminalise and punish indeed perhaps because of it we saw such an act of resistance in the action of jims mother in her dual mercy killingsuicide as ewick and silbey have noted resistant acts are almost always opportunistic dependent upon a crack or opening in the face of power t hese acts are often practiced to escape rather than change a structure of power 57 jims mother identified such a crack in the face of power allowing her to take her daughter out of the hospital unaccompanied and thus to administer a lethal dose of insulin and in killing herself with her daughter jims mother performed the ultimate act of escaping laws power albeit at the cost of her life with the law although we suggested above that the image of law as a sword is part of the before the law narrative it can also connect with ewick and silbeys with the law narrative of legality as we saw in relation to tracys interview here formal law is disconnected from justice and is portrayed simply as a resource that may be harnessed tactically for individual gain tracys ambivalence about the character and promise of law hints at this more instrumental and profane story of legality in the midst of a harrowing and lengthy struggle with a powerful medical system it is not hard to imagine such a narrative of legality being invoked collective dissent the interview with sarah reveals that the act of killing a loved one may be more than an act of escape from or avoidance of laws power as was the case with jims mother sarah contrasted herself with her family member who had killed their loved one i know what a crusader mary can be she always has been she might want to make a crusade of this issue with ricky but i dont i mean im not saying i dont but not with my life in prison thank you i could not have dealt with them getting hold of me so i wouldve done it sneakily whereas sarah was inclined like jims mother to escape the power of law others may act in order to change the power of law in this domain for the benefit of all those who may suffer similarly in this contrast between sarah and mary we can see a glimpse of halliday and morgans fourth narrative of legal consciousness what they call collective dissent 58 here the authority of state law is rejected and critiqued in the name of some kind of group interest the act of killing a loved one then may be prefigurative or be part and parcel of a wider collective voice of dissent against the power of law in this domain conclusion this paper has offered a sociolegal analysis of chronic disorders of consciousness like other aspects of society that have been studied through a legal consciousness lens we have demonstrated the pertinence of legal consciousness theory for legal study in this field if as legal scholars we wish to understand the significance of law for the treatment of those with chronic disorders of consciousness then we must study legal consciousness as much as we study legal doctrine but what are the wider implications of our analysis for this field of medical care and what research agenda do they suggest it is trite to stress that law surrounds and permeates this field from above as it were the law seeks to regulate who gets to make treatment decisions when patients lack capacity further when it is thought that the withdrawal of treatment may be in the patients best interests the law ultimately reserves that judgement for itself from below the law is invoked by individual family members to protect their relatives interests and to call to account a powerful medical system one of the main insights of our analysis is that the power of law to achieve these objectives depends on legal consciousness and it is the legal consciousness of two key groups who stand either side of the injured individualfamily members and health professionals that is central here in relation to family members our data revealed that legal consciousness can undermine the capacity of law to control endoflife decisions they could equally undermine its capacity to support empower or vindicate family members who feel aggrieved about the medical treatment provided to their relatives the key questions here are about the conditions under which different narratives become salient for family members at key moments individuals will not sustain a single narrative in relation to all aspects of their lives we should expect people to display a certain amount of incoherence in their legal consciousness 65 equally individuals will not sustain a single narrative over time we should expect a certain amount of inconsistency in this respect although the reasons for individual orientations towards law may be complex and in some situations beyond full explanation the impact of key events or interventions will in many situations be capable of analysis what role for example do legal advisors or advice networks have here equally what potential do support groups have to foster a collective sense of agency to try to alter the power structures of law in this domain and how might such a sense of agency be lost some social movements such as the civil rights movement in the usa have been successful in challenging the power structures of law 66 equally some movements in the health domain have been successful in challenging the domain of medical expertise 67 however at the same time as halliday and morgan have argued 68 there is a significant empirical dynamic between the sense of collective agency within such activism and the individual sense of fatalism characteristic of the against the law narrative empirically collective initiatives and organisations are vulnerable to failure individuals who were once energised as part of a group effort to challenge the power of law can be vulnerable to shifts towards a more isolated sense of fatalism where symbolic acts of resistance rather than collective struggles are more common we should expect such in this context too but what are the particular features of this context that militate for or against collective agency longitudinal research that could reveal such dynamics would be very useful here of course our analysis of family members accounts serves to highlight an important gap in our understanding and the need to include medical staff in future legal consciousness research for when family members invoke the law against medical staff its power to influence those staff depends on their legal consciousness in what ways for example is law resisted deferred to or played with in medical decision making around chronic disorders of consciousness if staff draw upon a with the law consciousness they will probably respond tactically to the prospect of legal accountability much like a move in a game if they draw upon an against the law consciousness taking a fatalistic stance to laws power they may resist its power where opportunities arise equally they may engage in collective efforts to subvert or alter the power of law 69 it is only the before the law consciousness that will prompt a deferential approach to the demands of legality and just as in relation to families we must explore the conditions under which particular narratives become salient for medical staff what role do internal features of the medical organisation such as legal advisors and complaints processes play here in relation to external features halliday has argued that the legal compliance of public bodies may be governed through a combination of hierarchical community and market mechanisms 70 in what ways then do regulators auditors and courts shape the legal consciousness of medical staff what role do professional organisations play for example in promoting or resisting legal values as professional values 71 what capacity does the market have in this field to influence the perspectives of individual staff members and teams all of these questions are important for a full understanding of law in this important domain of life and death and everything in between

this paper addresses from a sociolegal perspective the question of the significance of law for the treatment care and the endoflife decision making for patients with chronic disorders of consciousness we use the phrase chronic disorders of consciousness as an umbrella term to refer to severely braininjured patients in prolonged comas vegetative or minimally conscious states based on an analysis of interviews with family members of patients with chronic disorders of consciousness we explore the images of law that were drawn upon and invoked by these family members when negotiating the situation of their relatives including in some cases the ending of their lives by examining legal consciousness in this way an admittedly confusing term in the context of this study we offer a distinctly sociological contribution to the question of how law matters in this particular domain of social life

of worklife imbalance group those who in the groups of worklife balance and work imbalance had significantly higher retirement planning score the life imbalance group have the same retirement planning score as the worklife imbalance but did not differ significantly in addition engagement of life and work satisfaction had significant interaction effect to retirement planning discussion according to the results employees who have worklife balance tend to have better retirement planning the government should encourage employees to actively engage in life such as domesticity social participation care cultivate interest among others higher engagement in the life domain can significantly promote employees retirement planning child and famliy studiesyonsei universityseoul03722korea2 yonsei universityseoulrepublic of korea guided by a life course perspective the purpose of this study is to examine the linkages between adult childrens outcomes for the transition to adulthood and their parents psychological wellbeing as well as whether these associations are similar for parental income regression models were estimated using data from 2596 parents whose youngest child was at least 40 years old in the 2012 klosa sons employment and marital status and daughters marital status was significantly associated with their parents levels of wellbeing moreover parents income moderated the associations between childrens outcomes and the level of their parents life satisfaction unemployed sons and single sons and daughters jeopardized the life satisfaction of their mothers with low income but not other subgroups and coresidence with sons decreased the life satisfaction of fathers with high income but not those with low income in line with how the results suggest that parental psychological outcomes regarding adult childrens circumstances may be different depending on income this study has implications for intergenerational relationships in the sociocultural context these findings also imply that parents may have different views about norms regarding the transition to adulthood depending on their economic backgrounds in sum based on the life course perspective and a stress process model this study provides a comprehensive understanding of how adult children and family structural factors may contribute to individuals wellbeing in old age the relationships between korean adult childrens outcomes and their parents psychological wellbeing m lim 1 h jun 2 1 department of thinking about the end of life when it is near a comparison of german and portuguese centenarians d jopp 1 k boerner 2 k kim 2 a butt 2 o ribeiro 3 l araujo 4 c rott 5 1 university of lausanne 2 university of massachusetts boston 3 university of aveiro university of porto cintesis 4 cintesis esev ipv 5 heidelberg university centenarians approach the end of their lives with certainty yet little is known about their thoughts about the end of life comparing centenarians from germany and portugal this study examined common thinking of and planning for the eol among centenarians and whether views on eol are shaped by cultural contexts and individual characteristics centenarians from two larger populationbased centenarian studies responded to five questions regarding their views on eol using latent class analyses we identified patterns of eol thoughts and examined differences in country and individual characteristics by the derived patterns a significant portion of centenarians in both countries reported not thinking about the eol not believing in the afterlife and not having made eol arrangements perceiving the eol as threatening and longing for death were less commonly endorsed lca identified three latent patterns of eol thoughts class 1 class 2 and class 3 the proportion of portuguese centenarians was higher in class 1 whereas the proportion of german centenarians was higher in class 2 and 3 class membership was also related to centenarians demographic social and health characteristics in sum findings indicate that despite closeness to death centenarians do not necessarily think about andor prepare for the eol given that lack of eol planning can result in poorer eol quality enhancing communication among centenarians family and health care professionals seems imperative ugandan grandparentcaregivers consequences of caregiving and quality of life in the hivaids era s matovu m wallhagen university of california san francisco in this manuscript we seek to highlight the consequences of caregiving and their impact on the health and overall quality of life of ugandan grandparentcaregivers over the past two decades the number of studies investigating grandparental caregiving provided to children affected by hiv aids in subsaharan africa has gradually increased with the sustained loss of lives due to aids older adults are continuing to bear the burden of caring for children affected by the epidemic often with very limited resources despite the acknowledgement of the elderly as the backbone and safety net of the african family in this hivaids era very limited research has been conducted to explore the impact of this burden on the caregivers mental health physical wellbeing and overall quality of life thirtytwo participants were recruited from urban and rural areas in uganda and interviewed using a qualitative approach specifically grounded theory methodology the narratives generated from the semistructured and oneonone interviews were audiorecorded transcribed and analyzed using both open and axial coding as well as reflexive and analytic memoing congruent with the methodology descriptions of physical financial and emotional caregiver burden were reported additionally our study findings uniquely explored the impact of the perceived burden on their health and overall quality of life and provided an explanatory model of the caregiving experience therefore the study findings provide a foundation upon which clinicians researchers and policy makers can design and implement effective interventions needed to improve the health and quality of life of grandparentcaregivers who among japanese employees prepares well for life after retirement k katagiri 1 t onze 2 1 kobe university 2 research institute for culture energy and life osaka gas the life expectancy of japanese people is one of the longest in the world although most japanese companies still set the retirement age at 60 through a recent amendment of the law people can continue to work until the age of 65 with different work conditions before retirement as the lifetime employment system was popular until recently and the organization culture of companies reflects a verticallystructured society the japanese are not accustomed to making plans and decisions about their careers little is known on this topic in japan this study examines those who plan well for their lives after retirement an internet survey was conducted in tokyo and the osaka metropolitan area in 2016 by the research institute for culture energy and life osaka gas the subsample consisted of 924 people aged 4080 years the result revealed that only a low percentage of people in their fifties had planned for life after retirement a logistic regression analysis was also conducted in which demographic variables social activity variables social relations and views of life were considered people who were older richer single house owners participating volunteers or those who had hobbies and valued their own way of life were more likely to have a definite plan after retirement we observed no sex difference workaholics were at a higher risk of illpreparation the study therefore implies that an active private life other than work is necessary to sustain a long life after retirement objectives increased mortality after spousal bereavement has been observed in many populations few studies have investigated the widowhood effect in a traditional culture where the economy is underdeveloped in this study we assessed whether the widowhoodassociated excess mortality exists and differs by gender and living arrangement in rural china methods the data used in this longitudinal study come from the survey wellbeing of elderly survey in anhui province which was conducted every three years between 2001 and 2015 in rural townships of anhui province excluding cases with missing values and restricting the sample to respondents who were married or widowed with adult children at baseline and in followup analyses were carried out on 2471 adults aged 60 and above cox regression was applied to examine the effects results spousal loss decreased mortality for older rural chinese and there was a gender difference in this effect analyses also show that living with adult children after spousal loss played a protective role in reducing the risk of older mens death though it tended to increase older mens mortality risk in general conclusion our findings suggest that the widowhood effect is culturespecific and spousal loss reduces rather than increases the mortality risk of rural elders in china which implies that widowhood and mortality risk of older people in rural china do gender and living arrangement make

among the negative effects of chronic diseases the selfperceptions and the selfconfidence of chronically ill persons deserve more research this study explored how such persons dealt with the physical mental and emotional changes brought about by the onset of chronic disease the specific focus here was the role of social support networks in older patients emotional coping this qualitative study was conducted in two stateowned medical institutions in the northcentral part of nigeria indepth interviews were conducted among 19 purposively selected chronically ill persons aged 50 years and over who were receiving clinical care this study revealed that except in extremely dire circumstances older people with chronic conditions preferred to keep knowledge of their conditions strictly within their close family circles it is almost a taboo to inform community members friends and religious groups about ones chronic health difficulties reasons for the need to appear healthy to others might have stemmed from the fear of being discriminated against and attempts to maintain some level of normalcy when interacting with others moreover social networks could also have a negative influence on older persons emotional wellbeing for example many of the respondents received negative comments about their physical appearances these statements resulted in participants having low selfesteem about their body images and consequently affected their participation in social activities thus the supportiveness of social networks cannot be assumed outside of close family social networks appear to be inadequately equipped to understand some of the sensitivities that chronically ill older persons struggle with

introduction background women with breast cancer are living longer and the number of survivors is increasing as the us population ages recognizing the need to address the longterm needs of cancer survivors in 2006 the institute of medicine recommended that all cancer patients receive a survivorship care plan with a summary of their treatments followup care plan and information on potential late effects selfcare and resources 1 in 2016 the american college of surgeons committee on cancer developed an accreditation standard requiring cancer care programs to provide scps to all nonmetastatic patients treated with curative intent with annual evaluation of these plans 2 however providing patients with scps is ineffective unless cancer patients understand and know how to use this information survivorship care planning programs to be distinguished from scps alone are patientcentered activation interventions providing information on recommended health care and selfcare following cancer treatment 1 scpps typically help patients understand and follow recommended care regimens and encourage healthy lifestyles scpps can meet patients information needs 3 improve communication with clinicians and improve wellbeing 4 in addition scpps need to address healthy lifestyles as most cancer survivors tend to be overweight or obese and have sedentary lifestyles 5 6 7 particularly latinos 8 and strong observational evidence links these risk factors with poorer survival among breast cancer survivors 9 physical activity interventions in particular improve symptoms and healthrelated quality of life 10 11 12 and reduce the risk of recurrence and death among breast cancer survivors 13 however clinicians rarely provide lifestyle counseling to cancer survivors despite evidence that oncologists recommendations are effective among cancer survivors 1415 nonwhite cancer survivors in particular face ongoing informational needs to address fear of recurrence and management of symptoms late effects of treatments and lifestyle changes 16 latina breast cancer survivors experience disparities in knowledge of breast cancer survivorship psychosocial health lifestyle risk factors and symptoms after treatment compared with their white counterparts 17 18 19 20 21 spanishspeaking latina breast cancer survivors especially report many unmet medical psychosocial and informational needs that affect negatively their selfefficacy for managing survivorship 22 23 24 scpps could help these women receive optimal care and manage their condition preliminary evidence suggests high acceptability of mobile health apps among latino cancer patients because of a high need for spanishlanguage information and support on disease and treatment effects 25 objectives the objectives of this mixedmethods study were to develop and evaluate the feasibility acceptability and preliminary efficacy of a culturally and linguistically suitable scpp called the nuevo amanecer survivorship care planning program for spanishspeaking breast cancer patients in public hospital settings as they approach the end of active treatment the intervention was delivered via a written scp and booklet mobile phone app and telephone coaching calls and aimed to decrease fatigue and health distress and increase knowledge and selfefficacy for managing cancer survivorship and physical activity levels methods we describe the intervention components and then methods for examining feasibility acceptability and preliminary efficacy intervention the 2month intervention comprised 4 components hard copy of an individualized bilingual scp spanishlanguage survivorship information booklet spanishlanguage mobile app called trackc with integrated activity tracker and 5 weekly health coaching telephone calls in spanish to reinforce survivorship care concepts and positive health behaviors combined these components were designed to provide a support system for womens cancer survivorship needs on the basis of social cognitive theory the individually tailored intervention was designed to improve outcomes by building selfefficacy for managing cancer using selfregulation tools of selfmonitoring goal setting and feedback 26 written spanish language survivorship care plan we adapted the american clinical society of oncology scp template 27 for lowliteracy spanishspeaking latinas simplifying the layout and translating it into spanish adaptations were based on iterative review by a latina psychooncologist 2 oncologists a bilingual oncology nurse and 3 spanishspeaking breast cancer survivors participants signed a medical release form and study personnel extracted the information from medical records to complete the scp completed scps were reviewed by the project director and the patients oncologist or oncology nurse and scanned into the patients electronic health record this written bilingual scp was given to participants at the second home visit spanishlanguage survivorship information booklet we selected the asco answers cancer survivorship guide because it was comprehensive easy to understand and available in english and spanish 28 the guide covers what to expect after active treatment including psychological physical sexual reproductive financial and workrelated challenges trackc mobile app with integrated activity tracker the spanishlanguage mobile app was designed to contain womens breast cancer diagnostic and treatment history and provide information on potential side effects healthy lifestyles and survivorship resources an activity tracker was integrated with the app to display progress toward a personalized daily steps goal we selected the fitbit zip wireless activity tracker henceforth referred to as activity tracker based on cost simplicity and availability of an application programming interface the mobile app home page contained 4 section tabs daily walks treatment followup care and managing symptoms content was based on asco treatment guidelines at the time we summarize each section briefly • daily walks information on walking and integrated activity tracker that could be synced with the app so that it displayed a history of daily steps and their average daily steps target • treatment screens for entering cancer diagnosis and treatment information that could be updated as needed and emailed to others including clinicians • followup care general followup recommendations for women with noninvasive breast cancer specific followup recommendations for those receiving radiation tamoxifen aromatase inhibitors and women experiencing premature menopause option to record pending medical appointments and receive reminder notifications • managing symptoms information on signs of recurrence treatment side effects daily exercise nutrition and cancer survivorship resources developing and testing trackc in phases we developed mockups a detailed wire frame and a prototype of the app employing usercentered testing 29 with iterative review and pretesting by 3 spanishspeaking latina breast cancer survivors a latina psychooncologist an oncologist serving ethnically diverse lowincome cancer patients and 6 bilingualbicultural study staff members the prototype was developed in english and then translated into spanish using rigorous forward translation and team reconciliation methods health coaching protocol the coaching protocol was based on evidencebased motivational interviewing and health coaching techniques which seek to actively engage patients in managing their health within their social contexts 30 the health coach encouraged use of trackc walking reporting symptoms to clinicians and calling clinicians to ask questions communication with clinicians was emphasized because of evidence that latino patients often lack the confidence to report symptoms or ask questions especially when the physician speaks a different language 3132 the health coach reinforced cancer survivorship information the health coach was a bilingualbicultural latin americantrained internist with extensive health coaching experience coaching consisted of 5 weekly phone calls with the following structure review of progress toward daily steps goal and working through any barriers daily steps goal setting for the coming week and information on a weekly health topic the 5 health topics paralleled the trackc content and included walking and nutrition breast cancer followup care signs of recurrence treatment side effects and resources and review of content from the first 4 calls the health coach used a manual but tailored the content based on participants needs study design and procedures this singlearm feasibility study was conducted between february and june 2017 with women recruited from 2 public hospitals in northern california all study materials including the app were translated into spanish using team translation and expert review and reconciliation by 6 bilingualbicultural research staff the study provided all participants with an iphone and covered the costs of the data plan participants were compensated a total of 60 for completing 2 assessments during the 2month study the same trained bilingualbicultural research associate conducted 3 scheduled home visits enrollment visit 1week visit at the end of the activity tracker runin period and final endofstudy visit this protocol was approved by the university of california san francisco and contra costa regional medical center and health centers institutional review boards eligibility and recruitment eligibility criteria consisted of selfreported spanishspeaking latina diagnosed with nonmetastatic breast cancer and within 1 year of termination of active treatment exclusion criteria included walking more than 30 min on 5 days per week or more using lists of potentially eligible participants provided by the hospital sites we mailed them bilingual initial contact letters and postagepaid refusal postcards a total of 2 weeks later women who had not returned a refusal postcard were contacted in person or on the telephone by trained bilingualbicultural ras to conduct eligibility screening ask about mobile phone usage and schedule an appointment to visit the participants home within 1 week study enrollmenthome visit 1 the ra conducted the enrollment visit at the clinic site or the participants home during which the study was explained in detail written informed consent was obtained participants signed a medical release form and the baseline survey was completed this marked the start of the 1week runin period women were provided with a masked activity tracker and instructions to wear it every day for a minimum of 10 hours per day and not to change their usual activity levels this runin period was used to establish participants baseline average daily steps and personalized goal end of 1 week runin periodhome visit 2 in this 1hour visit participants received materials and verbal instructions on the use of the written scp survivorship booklet iphone and charger with trackc app installed unmasked activity tracker and a stepbystep illustrated guide on how to use the iphone app and activity tracker devices the ra reviewed the scp survivorship booklet device guide and the individualized average daily steps goal to be achieved within 2 months women were instructed on synchronizing the tracker and mobile app at the end of every day to update the apps average daily steps graph the ra helped participants enter diagnostic and treatment information from the written scp into trackc end of studyhome visit 3 at this visit the ra conducted the final assessment and a brief satisfaction survey synchronized the activity tracker with the fitbit app to update the final daily steps data and collected the mobile phone and charger participants were allowed to keep the tracker and encouraged to continue to maintain a daily exercise routine upon returning to the office the ra logged in using the participants study fitbit account credentials and downloaded the fitbit steps data to the study computer acceptability and feasibility measures acceptability and feasibility were examined via tracking of implementation processes evaluation indicators debriefing interviews and postintervention satisfaction surveys implementation processes an electronic database was developed to track usability issues 33 this system contained data from multiple sources including phone calls from participants issues reported by the health coach daily review of the mobile app backend database ra and project director tracking forms and notes and timing of software updates for the activity tracker mobile app data were sent to the studys secure database via encrypted transmission if the mobile phone or app lost connectivity data were transmitted the subsequent time the app was connected to the internet coaching call indicators the health coach recorded attendance and duration for the 5 calls at every call women were asked how many times in the past week they had synced their activity tracker with the trackc app and checked the apps average daily steps graph and if they had experienced any problems doing this on calls 1 and 3 women were asked how difficult they found it to use the graph after every session the health coach was asked to rate how much of the material she felt the participant had understood debriefing interviews semistructured debriefing interviews were conducted with a subset of participants to ask about their study experiences and suggestions for improvement selection of women was stratified to include those who had an iphone versus other type of mobile phone or none aged 50 versus ≥50 years and from the 2 study sites a trained bilingualbicultural latina interviewer used an interview schedule that asked about their experience using the app ease of use perceived usefulness for managing their cancer and facilitating factors satisfaction survey a 5min satisfaction survey was administered at the final home visit after downloading participants activity tracker data for the study period and the final assessment the survey asked them to rate the programs perceived quality ease of use and usefulness overall quality of the app was assessed using a 5level response set of poor fair good very good or excellent ease of use was assessed by asking about the overall difficulty of using the trackc app syncing and using the treatment summary with response options of not at all hard a little hard somewhat hard quite hard or very hard perceived usefulness was assessed by asking participants to rate how useful the app and health coach were for helping them gain a sense of control over their health and how useful the app was for keeping their cancer treatment information in one place and knowing about cancer symptoms and treatment side effects to monitor response options for the usefulness ratings were not at all a little useful somewhat useful quite useful or very useful efficacy of intervention measures to assess preliminary efficacy we conducted baseline and 2month interviews using structured surveys to examine changes in symptoms knowledge and wellbeing changes in preand postintervention average daily steps count were assessed based on activity tracker data primary outcomes we measured 6 selfreported primary outcomes 2 on symptoms 3 on knowledge of cancer survivorship care and 1 on selfefficacy for managing their cancer followup health care and selfcare the 2 symptoms assessed were cancerrelated fatigue and health distress we adapted the patientreported outcomes measurement information system cancerfatigue scale which assesses the extent of fatigue and its impact on daily life over the past 7 days 34 we dropped 1 item and added 2 items from the promis cancer fatigue short form 35 felt tired when hadnt done anything and limited social activities because of fatigue the final 7 items assess 4 aspects of severity and 3 aspects of interference with daily life to assess health distress we selected 4 items from the medical outcomes study health distress scale 36 that asked how much of the time during the past month they felt discouraged fearful worried or frustrated by their health problems response options for both fatigue and distress scales were as follows never rarely sometimes often or always scale score were the mean of nonmissing items with higher scores indicating greater fatigue effects or health distress the 3 knowledge measures consisted of 2 global single item measures and 1 6item scale the 2 single items of global knowledge of survivorship care asked how true the following statements were for them you know what to expect now that your initial treatment has finished and you know how to take care of yourself after cancer the new scale assessed knowledge of followup care and ease of finding information a sample item is how true is the following statement for you you know the possible side effects of your cancer treatment response options for the 3 knowledge measures were 0not at all true to 4completely true the scale was scored as the mean of nonmissing items with higher scores indicating greater knowledge a new 8item selfefficacy for managing cancer care scale assessed confidence in ability to do what is needed to manage health care and health after cancer a sample item is how confident are you that you will be able to call your doctor if you have a question about a symptom that might be related to your cancer or treatment with response options of 0not at all confident to 4completely confident the scale was scored as the mean of nonmissing items with higher scores indicating greater confidence these new measures assessing womens sense of control over their survivorship care drew on published questionnaires 3738 secondary outcomes secondary outcomes included emotional wellbeing depressive and somatic symptoms and average daily steps as recorded by the activity tracker emotional wellbeing was assessed with the 6item emotional wellbeing scale from the functional assessment of cancer treatmentgeneral 39 scores range from 0 to 24 with higher scores indicating more wellbeing we used the patient health questionnaire 8item version to assess depressive symptoms 40 scores range from 0 to 24 with higher scores indicating more depressive symptoms we used the 6item brief symptom inventory somatization scale which assesses the extent to which they were bothered by symptoms such as faintness and dizziness pains in heart or chest nausea trouble getting their breath numbness or tingling and feeling weak 41 scores range from 0 to 4 with higher scores indicating more symptoms baseline steps were calculated as the average daily steps during the 1week runin period before the intervention start date postintervention steps were calculated as the average daily steps during the last week of the 2month study period prepost changes in average daily steps were calculated as the postintervention average daily steps minus the preintervention average daily steps analyses descriptive statistics were used to analyze sample characteristics and satisfaction survey responses debriefing interviews were transcribed verbatim in spanish a total of 3 bilingualbicultural ras independently performed content analyses of all transcripts and discrepancies were resolved through team meetings linear mixed models were used to assess mean prepost differences on primary and secondary outcomes controlling for hospital site and reporting unstandardized betas p values and cohen d as an estimate of effect size results demographic characteristics of 100 women in the sampling frame 23 enrolled in the study 17 were ineligible 17 could not be reached 7 had incorrect contact information 34 refused and 2 were deceased mean age of participants was 558 years all were foreignborn and limited english proficient most had an elementary school education or less over half were of mexican origin and all had public health insurance about half reported financial hardship in the past year and most reported a comorbid chronic condition the majority had breast conserving surgery and both radiation and chemotherapy only 1 woman reported not owning a mobile phone use mobile phone to make calls at least once a week during the last month n 14 send a short message service text message using mobile phone at least once a week during last month n 15 use mobile phone to access the internet n acceptability and feasibility implementation processes nonscheduled home visits by the ra to all participants became necessary because participants requested help with the trackc app activity tracker or phone or study staff noticed a lack of data transmission from trackc to the app backend database a total of 63 nonscheduled visits occurred during which the ra would troubleshoot technical and user issues and provide additional support and instruction most issues were related to technical or hardwarerelated problems some were related to user issues coaching call indicators coaching calls lasted on average 15 min each a total of 19 of 23 participants completed all 5 coaching calls 1 woman completed 4 calls 1 woman completed 1 call and 2 women completed no calls number of times per week that women synced their activity tracker and app ranged from 44 to 57 number of times per week that women checked their daily steps graph on the app ranged from 42 to 59 ratings of the difficulty with using the daily steps graphs at call 1 and call 3 were almost identical with most women rating it as not at all difficult a total of 3 women reported vision problems interfered with reading the app screens on the basis of the coachs ratings the number of women understanding all of the material ranged from 17 for call 1 to 20 for call 3 debriefing interviews a total of 10 semistructured postintervention debriefing interviews were conducted participants were aged 56 years on average and most were from mexico all participants reported elementary school completion or less in general participants reported positive attitudes toward the program and increased awareness of the importance of walking themes emerging from the interviews are described next perceived usefulness of intervention components participants voiced appreciation for the trackc app information about their disease treatments side effects and signs of recurrence having felt misinformed about cancer survivorship before the study all the women wanted the written scp in addition to the app version they reported feeling motivated and supported by the weekly checkins with the health coach because she provided them with tailored detailed and credible information and support helping them understand their disease symptoms and bodies and achieve their walking goal participants valued the visual and auditory instant feedback provided by the activity tracker and app for example applause received after achieving their daily goal helping them maintain a positive attitude toward walking perceived ease of use of mobile app participants described varied experiences about the effort required to navigate and use the app users with mobile phone experience found the app easy to use however 4 of 10 participants with little or no mobile phone experience expressed that use of the app required more effort and support at the beginning of the study some participants reported difficulties because of poor literacy or poor eyesight all women reported being satisfied with the apps interface fonts colors and visuals perceived benefits of intervention informants reported positive outcomes related to walking a total of 7 of 10 women reported enhanced physical health because of their participation in the study including weight loss improved digestion and bowel movements and improved sleep participants also reported improved emotional wellbeing that is decreased stress and better mood social norms a total of 3 women felt a sense of accountability because they knew their steps were being monitored by themselves and others women reported that social support and encouragement from family members and neighbors pushed them to achieve their daily goal finally several women expressed a shift from being extrinsically motivated by the app and coach to increase their walking to being intrinsically motivated because they wanted to do it for themselves illustrative quote theme and subtheme perceived usefulness of intervention components the app where you could find information you could trust you see so many things on the internet a home remedy but nothing where you feel sure that what they are telling you is true app provided credible information about healthy lifestyles side effects of treatments and signs of recurrence what motivated me to walk was wearing the pedometer to see how much i could walk in one day and that this was recorded so that i would not forget how much i had walked the day before and the day before that feedback provided by activity tracker and app graph of daily steps progress over time were motivating it seemed really important to me that when you met your goal it was as if it were saying yay you won as if you had won a prize…and i liked it visual and auditory positive feedback from the app for steps taken were motivating yes she really helps you she motivates you to walk how to take care of yourself your health what you should discuss with your doctor in case you feel something health coach provided detailed tailored information on their specific treatments and potential side efshe tells you you need to be aware of your body and report anything unusual like pain to the doctor she gives you great advice fects and followup care and motivation and support for walking setting goals helped me focusthat helped me a lot i used to not take my dogs for a walk i would let them just run around here but now i take my dogs for a walk so i can get more steps goal setting provided motivation for walking perceived ease of use of the mobile app it was a little hard but then i read the instructions that they had given me i have a cell phone but i only use it for emergencies and to communicate with my children but my cell ease of use varied with prior experience using mobile phone phone is very basic and the one i use here is more advanced but after a while i got the hang of it the button was in the corner and i would push it two or three times to get it to work you need to have more room to be able to push the button appearance fonts font size and colorswere satisfactory but a few suggested larger font and navigation buttons perceived benefits of the intervention the walking is so good i used to feel stressed very tired with no energy and it all went away at first when i started walking i would get tired but now i cant believe it after walking so much i dont get tired walking was a commitment that they made upon joining the study i would get excited when i would open the app and the stars would come out and my little boy would say well lets go walk so we can see you meet your goal and i would say yes lets go and my kids would say mami arent you going to walk today and i would answer yes go get me the cell phone they too were involved encouragement of family and friends satisfaction survey a total of 21 of 23 women completed the final assessment for a retention rate of 91 overall quality the majority of the women rated the overall quality of the app as very good or excellent the overall quality of the information received on how to use the trackc app was rated as very good or excellent by 16 women all rated it as at least good ease of use most women rated the ease of syncing the trackc app and activity tracker as being not at all hard fewer respondents reported it being not at all hard to use the treatment summary found in the trackc app usefulness regarding their ratings of the usefulness of the scpp for feeling more in control of their health all except for 1 woman rated the health coaching calls as quite or very useful and all women reported the trackc app as quite or very useful almost all women reported that the trackc app was quite or very useful for keeping their cancer treatment information in one place having information on trackc about cancer symptoms and side effects were both reported as being quite or very useful by 18 and 19 respondents efficacy of intervention primary outcomes regarding primary outcomes compared with baseline fatigue and health distress levels were significantly lower post intervention women reported significantly greater knowledge of recommended followup care and resources after the intervention selfefficacy for managing cancer followup care did not change secondary outcomes of the secondary outcomes emotional wellbeing improved significantly post intervention womens average daily steps increased significantly from 6157 to 7469 a controlling for study site and using intenttotreat analysis b adapted 7item patientreported outcomes measurement information system cancer fatigue scaleshort form possible range15 high scoremore fatigue c 5item subset of the medical outcomes study health distress scale response options of 1none of the time to 5all of the time possible range15 high scoremore health distress d new single item how true is the following statement for you you know what to expect now that your initial treatment has finished with response options of 0not at all true to 4completely true e new single item how true is the following statement for you you know how to take care of yourself after cancer with response options of 0not at all true to 4completely true f new 6item knowledge of followup care scale with response options of 0not at all true to 4completely true possible range04 high scoregreater knowledge g new 8item selfefficacy for managing cancer care scale with response options of 0not at all confident to 4completely confident possible range04 high scoremore confident h emotional wellbeing scale of the functional assessment of cancer therapygeneral possible range024 high scorebetter emotional wellbeing i patient health questionnaire 8item scale possible range024 high scoremore depressive symptoms j brief symptom inventory somatization scale possible range 04 high scoremore symptoms k calculated as the average daily steps during 1week runin period before intervention start and last week of the 2month study period discussion principal findings this study sought to develop and test the preliminary acceptability feasibility and efficacy of a multicomponent breast cancer scpp designed for spanishspeaking breast cancer survivors the intervention consisted of a bilingual individualized written scp a spanish language survivorship information booklet a mobile app called trackc with an integrated activity tracker and health coaching calls we found preliminary support for the program with significant 2month improvements in fatigue health distress and emotional wellbeing and increased knowledge of recommended followup care and average daily steps women reported checking their daily steps graph about 5 times per week and the majority indicated the app was not difficult to use the majority of women rated the quality of the app as very good or excellent participants were motivated by the visual and auditory instant feedback provided by the activity tracker and app in qualitative debriefing interviews most women indicated that the app and coaching were useful for giving them a sense of control over their health that the app provided a useful place for storing cancer and treatment information in one place and that the scpp resulted in increased physical activity weight loss and improved digestion and sleep these results are consistent with similar studies that have demonstrated preliminary satisfaction with or interest in mobile phone appbased survivorship information among latina 42 or nonwhite cancer survivors 43 lessons learned although women were receptive to the scpp overall we learned a number of lessons first women preferred receiving both the mobile and written versions of their bilingual scp so a mobile app alone might not suffice further customization of scps to include breast cancer typespecific information for example hormone receptor status would be helpful we were able to provide this level of customization via the health coaching but this level of customization of the app exceeded the budget of this pilot study but could be addressed in future studies we did not anticipate the extent of technical issues involved in maintaining communication between the trackc app the activity tracker api and the database management api unanticipated updates in the apis of the activity tracker or database management system necessitated unscheduled home visits to install these updates as participants often did not know how to do this women sometimes forgot to wear the activity tracker or sync their trackc app and tracker a small number of women with limited mobile phone experience low literacy or vision impairments indicated some difficulty in navigating the app thus the app would need to be further tailored and tested to meet their needs for some women with limited iphone or mobile phone experience individualized assistance in learning how to use apps was needed for example knowing how to swipe to advance to next screen required repeated reinforcement regarding the design of the app in the future we would enlarge and centrally position the button used to sync the app and activity tracker app as suggested by some women limitations this study has limitations as a feasibility study we did not include a control group and the sample size was small as the study was conducted in northern california with mostly mexican women results may not generalize to other regions or latino national origin groups in addition because this was a multicomponent intervention we are not able to isolate the relative effects of each of the components finally we experienced a high refusal rate much higher than in our prior studies with women from the same population so the final sample may be not be representative of spanishspeaking latinas in our region notably this study coincided with a period of increasing immigration raids and heightened fear in local latino communities in our study one of the most common reasons women gave for refusing to participate was fear that they would be tracked by immigration officials via the fitbit wearable device implications mobile phones offer promise as an excellent delivery mode among latinos because of their widespread use of webenabled phones to access the internet 254445 mobile app interventions can be adapted for those with visual or auditory impairments and low literacy supplemental training and telephone health coaching can be provided to those with limited experience using mobile phones and to sustain levels of mobile app use for many vulnerable populations mhealth approaches alone may not suffice and more personal and intensive delivery modes will be needed some segments will prefer not to use mobile apps conclusions our pilot study results support investment in testing of smart phone and health coaching sccps among spanishspeaking latina breast cancer survivors additional research employing usercentered testing can identify the appropriate combinations of delivery modes and intensity of scpps for vulnerable subgroups of cancer survivors harnessing technology to address the needs of these groups ensures equitable access to its potential health benefits related to selfcare and longterm cancer survivorship outcomes xsl • fo renderx

background spanishspeaking latina breast cancer survivors experience disparities in knowledge of breast cancer survivorship care psychosocial health lifestyle risk factors and symptoms compared with their white counterparts survivorship care planning programs scpps could help these women receive optimal followup care and manage their condition objective this study aimed to evaluate the feasibility acceptability and preliminary efficacy of a culturally and linguistically suitable scpp called the nuevo amanecer new dawn survivorship care planning program for spanishspeaking breast cancer patients in public hospital settings approaching the end of active treatmentthe 2month intervention was delivered via a written bilingual survivorship care plan and booklet spanishlanguage mobile phone app with integrated activity tracker and telephone coaching this singlearm feasibility study used mixed methods to evaluate the intervention acceptability and feasibility were examined via tracking of implementation processes debriefing interviews and postintervention satisfaction surveys preliminary efficacy was assessed via baseline and 2month interviews using structured surveys and preand postintervention average daily steps count based on activity tracker data primary outcomes were selfreported fatigue health distress knowledge of cancer survivorship care and selfefficacy for managing cancer followup health care and selfcare secondary outcomes were emotional wellbeing depressive and somatic symptoms and average daily steps results all women n23 were foreignborn with limited english proficiency 13 57 had an elementary school education or less 16 70 were of mexican origin and all had public health insurance coaching calls lasted on average 15 min each sd 34 a total of 19 of 23 participants 83 completed all 5 coaching calls the majority n17 81 rated the overall quality of the app as very good or excellent all rated it as at least good women checked their daily steps graph on the app between 42 to 59 times per week compared with baseline postintervention fatigue b26 p02 cohen d04 and health distress levels b36 p01 cohen d03 were significantly lower and knowledge of recommended followup care and resources b41 p03 cohen d05 and emotional wellbeing improved significantly b142 p02 cohen d03 selfefficacy for

introduction covid19 has emerged as a global health emergency and posed a great threat to almost all countries and regions it affects all segments of the population especially the patients of covid19 the impact is far beyond merely physical concerns previous studies have shown that the pandemic has led to psychological problems among patients healthcare workers and other caregivers patients infected with covid19 not only suffered from illness but also had mental health problems due to viral infection and worries about aftereffects perceived stigma is prevalent among covid19 survivors and healthcare workers in covid19 designated hospitals which has an interrelated bearing on their mental health in post pandemic era most patients of covid19 have been discharged the mental health of those who had recovered from covid19 and been discharged from hospital deserve more attention during their rehabilitation these patients were isolated during treatment and had limited freedom and communication with the outside world thus their negative emotions cannot be alleviated in a short period of time rd may have a more serious sense of loneliness and repression as well as a higher level of psychological pressure in the aftermath and the longcovid period they may experience depression anxiety fatigue posttraumatic stress disorder and neuropsychiatric syndromes poor mental health condition will impact ones social behaviors and cognitive functions as a result rds mental health should be attached much importance rds mental health condition might affect their perceived covid19 stigma perceived stigma is ones personal feelings about the stressors and his projection of the feelings on others from the patients perspective they might feel being stigmatized if their mental health condition was poor covid19 rd are at high risk of ptsd partly because of their near death experience delirium and icurelated trauma during the covid19 experience they might have uncontrollable thoughts about the experience and their image in others mind which would increase their perceived stigma perceived stigma might also in turn predict ptsd depression is another prevalent mental issue among covid19 rd rd with depressive symptoms might be more sensitive and pessimistic to the negative attitudes from the community which makes them feel more stigmatized emotions besides to contain the spread patients are required to stay in close isolation during treatment and reduce their movement after discharge which may lead to feelings of loneliness and fear of discrimination thus increasing their perceived stigma peace of mind is important for them to manage stressful situations as well as avoid the irresistible but unwanted impulses resilience is not a linear path toward happiness but a combination of behaviors that encourages individuals and communities to persevere and move forward confronting difficult situations higher level of resilience might decrease the risk of developing psychological distress and suppress suicidal thoughts and insomnia resilience might be influenced by job stress perceived stress and mindfulness and be promoted by brief resilience interventions based on positive psychology thus with higher level of peace of mind and resilience patients will control their emotions better and be less sensitive to the negative attitudes from others which might result in lower sense of perceived stigma from the societys perspective low perceived social support may also lead to perceived stigma among covid19 rd perceived stigma might in turn increase the mental problems among rd and be detrimental to their mental health recovery therefore the stigma among covid19 rd may have a certain impact on the whole population the perceived covid19 stigma in rd could be evaluated by a modified 12item hiv stigma scale which contains 4 subscales to measure personalized stigma disclosure concerns concerns about public attitudes and negative selfimage however this scale has no cutoff point which makes it hard to precisely evaluate the stigma among rd clinical psychiatric interviews are usually regarded as the gold standard for diagnosis and the criterion for determining cutoff points of screening tools however the identification and diagnosis of cases with perceived covid19 stigma has not reached a consensus additionally the characteristics and prevalence of perceived covid19 stigma among rd and its psychosocial influencing factors remain elusive currently most previous studies focused on the recursive effect of perceived stigma on mental health without considering the possible vicious circle between mental health and perceived stigma among rd while according to the theory of socioecological model one is not a passive recipient of life events but a key role in constructing and modifying the living system it is therefore important to explore the influencing factors of perceived covid19 stigma among rd the specific objectives of current study are to identify the characteristics of perceived covid19 stigma in rd using latent profile analysis to explore the psychosocial influencing factors of perceived covid19 stigma in rd and to determine the cutoff point of the stigma scale using roc analysis for further evaluation and application which may help healthcare professions and policymakers to deal with the increasing stigma and control the pandemic effectively methods study design and participants the crosssectional study was carried out among previouslyinfected covid19 patients in jianghan district from june 10 to july 25 2021 extracted from the electronic medical records of the jianghan district health bureau a total of 3059 covid19 patients met the inclusion criteria and were eligible for the study for they were infected with the original sarscov2 strain and were diagnosed between december 10 2019 and april 20 2020 when they were receiving clinical reexamination 1601 covid19 survivors were invited to complete a questionnaire survey on their mental health status and 1541 of them who finished the survey were included in the study all investigators and support staff in this study were trained according to the same protocol and required to have an educational background in medicine or public health from june to july 2021 the online structured questionnaire was distributed to those who had a history of covid19 infection and had been discharged all participants digital informed consent was obtained to ensure their voluntary participation an online survey platform redcap was used to disseminate the selfadministered electronic questionnaires and digital consent to the target population stigma the short version of covid19 stigma scale is a 12item scale that is employed for evaluating the perceived stigma of patients of covid19 during the past 2 weeks the scale was reviewed by several experts in the field and was approved to use in this population each item is scored on a likert scale of 14 higher total scores indicate greater stigmatization in this study the cronbachs alpha of the instrument was 0936 posttraumatic stress disorder the impact of events scalerevised is a 22item scale aimed at screening posttraumatic stress symptoms in adults or older people the items of this instrument are rated on a 5point likert scale from 0 to 4 the iesr contains three dimensions measuring intrusion avoidance and hyperarousal respondents rate their degree of distress during the past 7 days after they have identified a specific stressful life event that occurred to them a total score equal to or above 35 can be regarded as positive ptsd symptoms this instrument has been proven valid and reliable among chinese covid19 patients in this study the cronbachs alpha of the instrument was 0965 anxiety the generalized anxiety disorder questionnaire consists of 7 items that are rated on a 4point likert scale from 0 to 3 it was developed for measuring the severity of generalized anxiety symptoms during the past 2 weeks the scores of the instrument range from 0 to 21 a cutoff score of ≥ 5 is recommended for considering significant anxiety symptoms this instrument has demonstrated to be reliable and valid among the chinese population in this study the cronbachs alpha of the instrument was 0951 depression the patient health questionnaire is a 9item questionnaire that is used for screening and monitoring depression of varying degrees of severity during the past 2 weeks the items of the phq9 are rated on a 4point likert scale ranging from 0 to 3 the total score is utilized to assess the degree of depression of participants with scores of ≥ 5 indicating depression this instrument has been validated among various chinese populations in this study the cronbachs alpha of the instrument was 0914 sleep disorder the pittsburgh sleep quality index consists of 18 items and is used to measure an individuals quality of sleep during the past 2 weeks it contains seven components including subjective sleep quality sleep latency sleep duration sleep efficiency sleep disturbance use of sleep medication and daytime dysfunction and each component is a 4point likert scaled from 0 no difficulty to 3 severe difficulty the total scores range from 0 to 21 and a cutoff score of ≥ 6 is recommended for considering certain sleep disorders this instrument has been validated among chinese population in this study the cronbachs alpha of the instrument was 0784 fatigue the fatigue scale14 is a 14item scale aiming at measuring the severity of fatigue during the past 2 weeks the items of this instrument are rated on a 2point scale of 01 the fs14 contains two dimensions measuring physical fatigue and mental fatigue respectively higher total scores of the 14 items indicate a higher level of fatigue this instrument has been proved valid and reliable among chinese in this study the cronbachs alpha of the instrument was 0845 resilience the resilience style questionnaire consists of 16 items that are rated on a 5point likert scaled from 1 to 5 it is used to measure the level of an individuals resilience during the past 2 weeks higher total scores of the 16 items indicate a greater ability to recover from negative events this instrument was developed and validated among the chinese rural leftbehind adolescents and nonlocal medical workers in this study the cronbachs alpha of the instrument was 0975 social support the level of perceived social support of the participants was measured by two items including emotional support and material support during the past 2 weeks the items were how much support can you obtain from familyfriendscolleagues when you need to talk or to obtain emotional support and how much support can you obtain from familyfriendscolleagues when you need material support and each item was 11point likert scaled from 0 to 10 in this study the cronbachs alpha of the instrument was 0819 peace of mind the peace of mind scale comprises a total of 7 items rated on a 5point scale ranging from 1 to 5 and is used for measuring the peace of mind during the frontiers in public health 04 frontiersinorg past 2 weeks higher total scores indicate a more peaceful mind this instrument has been validated among chinese population in this study the cronbachs alpha of the instrument was 0874 statistical analysis descriptive analyses were performed to describe the participants demographic characteristics clinical characteristics the condition of perceived stigma and potential influencing factors in the absence of an accurate and precise reference standard lpa has been widely employed to identify the symptom characteristics and to further calculate and determine optimal cutoff points of assessment instruments lpa is a personcentered statistical method that employs latent profile model to divide population into multiple profiles and it focuses on identifying latent subpopulations within a population based on a set of continuous variables despite the possible arbitrariness for lpa in determining the number of class members due to its semisubjective properties the misclassification rate is relatively low and it could produce more reasonable results compared with some other classification approaches generally in lpa individuals assigned to the latent profile that represents the lowest level of symptoms or risks are regarded as noncases and others are considered cases hence lpa was conducted to identify the characteristics of perceived covid19 stigma among rd robust maximum likelihood estimation was employed to estimate the parameters the lomendellrubin and the bootstrap likelihood ratio test were performed to compare the model fit improvement between models with k classes and k1 classes significant p values indicated a better model fit with k classes the optimal number of classes was evaluated by the entropy akaike information criterion bayesian information criterion the adjusted bayesian information criterion and the interpretability and definition of classifications where an entropy value≥080 represented adequate quality of classification lower aic bic and abic values indicate better model fit and the turning point of the scree plot for the abic could suggest an appropriate number of classes after the selection of optimal model and definition of classifications chisquare began with the full set of demographic and clinical characteristics ptsd anxiety depression sleep disorder fatigue resilience social support and peace of mind to evaluate their associations with different characteristics of perceived covid19 stigma statistically significant variables in the univariate analysis were further used for stepwise multinomial logistic regression analysis adjusted odds ratio and the corresponding 95 confidence intervals were calculated to assess the regression model results receiver operating characteristic analysis was conducted to determine the optimal cutoff value for the csss the area under the roc curve sensitivity specificity and youdens index value were employed to evaluate the performance of classifiers and youdens index value was used to identify the optimal cutoff value sas94 and mplus83 were utilized to conduct all the analyses with level of significance determined at a 005 value of p results demographic characteristics among the 1541 people who finished the survey questions 1297 questionnaires were enrolled in the data analysis as illustrated in table 1 over half of the participants were male and were less than or equal to 60 years old the majority of the participants were from urban areas and married most of the participants had an income for 2020 less than 60000 china yuan and had an education level as senior high school or below a small percentage of participants lived alone used alcohol no less than 2 times per week and were current smokers the covid19 patients were clinically classified into four categories asymptomatic mild moderate critically severe a significant proportion of the participants had no experience at icu had never received psychological or emotional counseling during hospitalization and had never received psychological or emotional counseling before infection just under a half of participants stayed over 20 days in hospital and had no complication most of the patients perceived good or moderate mental health status during hospitalization stigma and related psychological factors the 12item cssss total scores range from 12 to 48 with higher scores indicating a more stigmatizing attitude the mean score in this study was 2804 the mean scores of fatigue peace of mind resilience and social support were 638 2470 5682 1425 respectively the prevalence of ptsd anxiety depression and sleep disorder were 165 288 379 and 471 respectively latent profile analysis latent profile models with onetofiveclass solutions were specified and the fit indices of the 5 models are displayed in table 3 the entropies of all classifications were above 09 the lmr and blrt test were all statistically significant the aic bic and abic decreased with the increase of class number and the scree plot of abic flattened out after the 3class model taken together considering the model fit parsimoniousness and interpretability of the classes the 3class model was selected as the optimal model for the current sample the distribution and conditional means of items of csss on each class in the 3class model are illustrated in figure 2 and table 4 in the 3class model the average latent class probabilities for most likely latent class membership demonstrate reasonable classification and good distinction given the conditional means of items on each class we define class1 as low perceived covid19 stigma group class2 n 663 influencing factors of perceived covid19 stigma of rd the result of univariate analysis showed that female older age being married low family income living with other people low education level having complication perceiving worse mental health status during hospitalization ptsd anxiety depression sleep disorder and fatigue were positively associated with perceived covid19 stigma while resilience social support and peace of mind were negatively associated with perceived covid19 stigma among rd these variables were further employed in stepwise multinomial logistic regression analysis with the low perceived covid19 stigma group as a reference the result of stepwise multinomial logistic regression analysis showed that older age living with other people anxiety and sleep disorder were positively associated with moderate perceived covid19 stigma while higher educational level was negatively associated with moderate perceived covid19 stigma female older age living with other people anxiety and sleep disorder were positively associated with severe perceived covid19 stigma while higher educational level social support and peace of mind were negatively associated with severe perceived covid19 stigma among rd receiver operating characteristic analysis to identify the optimal cutoff value of csss for screening perceived covid19 stigma among rd participants assigned to the low perceived covid19 stigma group in lpa were defined scree plot of change trend of adjusted bayesian information criterion as noncases and those assigned in moderate perceived covid19 stigma and severe perceived covid19 stigma groups were defined as cases the roc curve was then plotted for the total score of csss using the binary outcome with an auc value of 9996 indicating a good predictive capacity for perceived covid19 stigma the diagnostic criteria and indices are illustrated in table 8 the optimal cutoff value was ≥ 20 where the sensitivity specificity and youdens index value were 0996 0982 and 0978 respectively discussion the crosssectional study employs lpa to assess the characteristics of perceived covid19 stigma among rd and analyzes its psychosocio contributing factors perceived stigma of rd was divided into three categories in this study we measured the demographic characteristics and some possible psychological predictors of perceived covid19 stigma generally older age living with other people anxiety and sleep disorder were positively associated with moderate perceived covid19 stigma while higher educational level was negatively associated with moderate perceived covid19 stigma female older age living with other people anxiety and sleep disorder were positively associated with severe perceived covid19 stigma while higher educational level social support and peace of mind were negatively associated with severe perceived covid19 stigma among rd the cutoff point of the stigma scale was determined at 20 using roc analysis this study classified covid19 rd into three groups according to the stigma level low perceived covid19 stigma moderate perceived covid19 stigma and severe perceived covid19 stigma group only 128 of rd were categorized into the low perceived covid19 stigma group which indicated the lowest levels of stigma and reported the lowest level of psychological risk factors the majority belonged to the moderate perceived covid19 stigma compared with the low perceived covid19 stigma group anxiety and sleep disorder were positively associated with moderate perceived stigma similar to previously published studies anxiety was a major risk factor for stigma in a study that evaluated the depression and anxiety symptoms among 174 patients who recovered from symptomatic covid19 infection in saudi arabia the stigma scores were significantly associated with higher scores on anxiety some other studies on people living with epilepsy dementia and cancer patients also demonstrated that anxiety is one of the psychosocial determinants of perceived stigma therefore mitigating the anxiety symptoms is essential to decrease the stigma among rd emotional regulation mindfulness and experiential techniques are possible solutions to improve social anxiety disorder symptoms rd could also try exercise yoga and meditation which were proven to have modest positive effect on assisting their anxiety alleviation hospitals and communities should assess the anxiety level of covid19 rd to detect anxiety as early as possible for rd the society should be less hostile to rd it is necessary for social media to refute false information strengthen the information guidance of social media and output positive information so as to avoid the anxiety mood in origin our study also found that sleep disorders is a determinant of moderate perceived stigma in rd previous studies showed that 295 of the covid19 hospitalized patients had sleep disorders poor sleep quality was associated with stigma cognitive behavior therapy is aimed at treating insomnia by avoiding behaviors and thoughts that might develop into sleep disorders rd with sleep disorders could use this method on their own to improve their sleep quality effective programs based on the therapy could also be embedded in smartphones to assist their sleep promotion process in addition progressive muscular relaxation is an effective way to help covid19 patients feel less anxious and have better quality sleep the receiver operating characteristic curve of the csss for screening perceived covid19 stigma the severe perceived covid19 stigma group reported three more risk factors compared with moderate perceived covid19 stigma group including female gender insufficient social support and peace of mind female gender is a risk factor of longcovid syndrome and tend to have a higher proportion of physical and psychological symptoms than male because of the more severe illness and torment they suffered they might find it difficult to maintain a good mentality toward the stigmatized attitudes a low perceived level of social support prevailed during the pandemic due to the shutdown of many places like schools markets and workplaces to avoid transmission of the virus rd facing such conditions may arouse a sense of isolation and vulnerability which would cause severe stigma perceived social support and use of adaptive coping strategies were found to affect individuals psychological adjustment and resilience interventions like inperson interview supportive psychotherapy and positive attention would improve their social support and could be considered widely promoted peace of mind might increase ones self awareness and attitude toward the surroundings and indirectly reduce the sense of being stigmatized a previous study on female patients with schizophrenia also identified that enhancing peace of mind will help reduce stigma level our study determined 20 as the cutoff score for csss by lpa and roc analysis which may guide future epidemiological studies on covid19 stigma the cutoff value is instructive for clinical practice in covid19 rd mental health promotion hospitals are suggested to collect stigma information of discharged patients and carry out relevant psychological intervention for patients whose scores exceed 20 although our team have analyzed the same population in advance and explored the prevalence and influencing factors of anxiety and depression in rd a further analysis in this study provided insightful observations from a different perspective this study enriched our knowledge on the association between mental health and perceived stigma among rd and provided possible suggestions for the authorities and the society to reduce perceived covid19 stigma in the future however it has several limitations first this crosssectional study has its inherent limitations for it contains no dimension of time to support a causal relationship second the study was conducted more than 18 months after the covid19 patients were discharged which may cause recall bias third convenience sampling may decrease the representativeness of the population fourth stigma contains two factors namely public stigma and selfperceived stigma in this study we only mention the latter further studies should measure stigma more comprehensively in a representative sample conclusion this study provides an insightful result of the prevalence and influencing factors of perceived stigma among rd in wuhan stigma among covid19 rd could be divided into 3 groups low perceived covid19 stigma moderate perceived covid19 stigma and severe perceived covid19 stigma group based on the cutoff value we explored the high proportion of perceived stigma level highlights the importance of solving the stigma and discrimination problem for its impact on personal and community wellbeing therefore it is essential to mitigate the psychological problems and reduce the perceived stigma level of rd as part of the response toward the covid19 pandemic psychological interventions on anxiety sleep disorder and social support are suggested to alleviate mental health problems and stigma among this population additionally this study discovered the precise cutoff value for csss which provides a valuable tool for screening perceived stigma among future covid19 patients and can be used to identify the patients in noosed of tailored interventions data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement the studies involving human participants were reviewed and approved by the ethics review board of the institute of pathogen biology chinese academy of medical sciences and the research ethics committee of the hospital the patientsparticipants provided their written informed consent to participate in this study publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

background perceived stigma has greatly influenced the life quality of the covid19 patients who recovered and were discharged rd hereafter it is essential to understand covid19 stigma of rd and its related risk factors the current study aims to identify the characteristics of perceived covid19 stigma in rd using latent profile analysis lpa to explore its psychosocial influencing factors and to determine the cutoff point of the stigma scale using receiver operating characteristic roc analysis

introduction the emergence of covid19 has a highly complex impact on human life it takes a quite long time to find a vaccine for the viral system that attacks the immune and respiratory systems the virus eventually becomes a pandemic the impact changes the entire order of human life includes the economic itself in the early time of the virus emergence the world economic system begins collapsed almost none of countrys economic system survives due to the effects of the pandemic the international monetary fund has recorded a global economic loss with approximately 12 trillion us dollars in addition covid19 caused a decreased economic growth rate up to 6 as well as global unemployment rate that reached 79 this illustrates how complex and large is the impact of the presence of the virus the outbreak of the pandemic has caused great impact to the world economy affecting micro firms small and medium enterprises and large companies the pandemic has disrupted the original study and job search plan arrangement of college graduates and the employment difficulty of college graduates has been aggravated the garment industries in bangladesh have also been affected leading to social and economic losses the pandemic has caused an unprecedented negative impact on peoples lives and the worlds economy including the stock market as a developing country indonesia also experienced the impact of the virus originated from wuhan china to minimize the spread of the virus indonesia implemented several policies such as limiting the entrance access of foreign tourists a largescale social restriction providing incentivessubsidies and other various economic political and sociocultural policiesthe general director of taxes at the ministry of finance noted that there were 3 major impacts of covid19 in indonesia namely the declining purchasing power of the people uncertainty over the end of the pandemic so as to weaken investment in business and business activities and the global impact of the pandemic caused importexport commodity prices to fall the covid19 has impacted all aspects of economic life especially tourism trade and investment however the problem in the economic sector is related to crowd such as tourism event exhibition and malls the supporting business such as mass transportation ticketing hotels seasonal tradesouvenirs etc businesses that cannot implement physicalsocial distancing a tertiary product business whose sales depend on public savings as well as supporting businesses various efforts have been made to minimize the impact of the covid19 pandemic in the sector of economics the government must work hard to restore the economy various economic recovery policies carried out by the indonesian government include the provision of social assistance to the poormen tax relaxation and other policies the global and widespread impact of covid19 requires collaboration between public involvement and service providers the government cannot work alone the facts prove that none of countries is ready and able to anticipate the impact of the covid19 pandemic also the community cannot be allowed to survive by himself without the support of government policies in this situation collaboration and cooperation between civil society and government become a necessity peoples behavior or attitude is the key to this pandemic it means that collaboration between the government and the community is required to minimize the impact of the pandemic the government cannot rely solely on structural policies besides the government needs to accept and develop policies culturally in nature his affirmation is that social capitalbased policies need to be pursued and developed in building national economic resilience value culture motivation form of cooperation networks in the community must be optimized to facilitate and assist government in overcoming the complex impacts of the pandemic the implementation and development of policies based on social capital in building national resilience becomes the focus of this study the relationship between social capital and economic policy is quite relevant at least policies based on social capital in the community can ease people to believe and accept these policies social capital can also be a source of social clarity and optimism in dealing with the complex and prolonged impact of the pandemic we conducted a study in bantul regency special region of yogyakarta wiith an area of 50685 km 2 locates between 07º440408º0027 south latitude and 110º1234110º3108 east longitude bantul regency is one of the regencies in the special region of yogyakarta similar to other regions this regency also experiences the impact of the covid19 pandemic to anticipate the impact of the pandemic the government in bantul issued a regents instruction number 31instr2021 regarding policies on trade activities the trading activity stipulated by regents instruction include traditional markets supermarkets grocery stores culinary centres food stalls restaurants cafes street vendors hawker stalls pharmacies drug stores etc based regents instruction concerning trading activity is valid from october 19 to 1 november 2021 the daytime for traditional market was restricted to 0600 pm while the nighttime was restricted to 0900 pm with a maximum capacity of 75 similarly supermarkets grocery stores and other similar markets that sold daily necessities were also restricted to 0900 pm with a maximum capacity of 75 the impact felt by the community was a decrease in income due to restrictions on community activities and market operations it was known that 90 of bantuls economic support was small and medium enterprises therefore this study examined how social capitalbased national resilience policiesefforts were developed in bantul regency during the covid19 pandemic method this study was descriptive qualitative research with a case study approach conducted around august to october 2021 qualitative research begins by using assumptions and theoretical framework that forms on a social problem data will be collected through semistructured interviews with small business owners community leaders and government officials in bantul regency the sample will be selected through purposive sampling and data saturation will be used as a criterion for sample size determination data analysis will involve coding and theme development to identify patterns and themes in the data we collected data through interview and documentation the validity of the data was checked using source triangulation source triangulation uses different information data therefore we compared the results of interviews on research subjects and compared the results of interviews with the contents of documents related to the research to make a concluding idea results and discussion social capital social capital is an important concern in every empowerment and problem solving in the community it is essential when social capital becomes popular and wellknown in social studies community empowerment based on social capital is an important key in overcoming all problems in the community the important concept of social capital stems from the assumption that it is impossible for individuals to deal with their problems because individuals are socially powerless in addition social capital is also considered as an alternative to the failure of development viewed from the point of view of economic development therefore individuals must share a network cooperate and help one another this concept is called as social capital simply social capital affirms that relationship is essential social capital is not capital in general economic terms many experts had attempted to decipher the definition of the term conceptual and theoretical ambiguity and confusion are found in social capital according to hanifan social capital is highly broad in the form of will fellowship mutual sympathy and social interaction of individual and family groups that make up social communities the affirmation is that everything needed and is constructive in building and strengthening social relations or communities is categorized as social capital fuyukuma also emphasized that social capital can be defined simply as a set of informal values or norms that are shared among group members that enable them to cooperate with one another the difference is that fukuyama emphasizes the importance of trust in strengthening social capital for him trust is a lubricant so that the organization can run well in line with previous opinion bhandari and yasunobu argue that the term social capital is highly complex and broad social capital is a collective asset in the form of norms values beliefs trust networks social relationships and shared institutions that facilitate cooperation and collective action for mutual benefit however social capital will only be useful and beneficial if it is applied in social relation and interaction otherwise social capital will not have any impact on the community social capital is essentially neutral and depends on community members in the community therefore social capital requires human capital although social capital is considered good and constructive social capital can also be destructive and not useful not even a few experts doubt about the meaning and role of social capital many studies have proven that social capital is positive in various peoples lives in the field of crime social capital is considered to have an impact on crime rates likewise in the economy social capital is considered to contribute to investing less incash and more in inventory using more checks having higher access to institutional credit and reducing the use of informal credit beside that social capital has been impacted by the pandemic in various ways studies have shown that community decisionmaking during the pandemic is influenced by social capital including trust social norms and social networks the use of information and communication technologies has also been effective in maintaining social capital at the individual level during the pandemic governments have mobilized social capital to support their efforts during the pandemic but this does not always lead to positive resource mobilization the pandemic has also reshaped social capital with an increase in emotional intensity and length of conversations but a decrease in the frequency of meeting alters corporate benevolence has been found to have a positive impact on social capital during the pandemic with companies with larger firm size higher leverage higher institutional ownership and higher esg rankings more likely to donate covid relief the utilization of social capital in community development or empowerment is important in dealing with the impact of the covid19 pandemic the use of social capital is urgently needed so that the impacts of the pandemic can be minimized and the governments workload can be assisted especially in building national resilience this is because social capital serves as a useful framework for successful development and policy formulation and it is closely related to poverty reduction in the case of pandemic a study of ronnerstrand concluded that social capital is strongly correlated with the acceptance of a immunization social capitalbased economic resilience bantul has local wisdom values as social capital that can be developed according to samsuri yogyakarta has local wisdom in the context of economic resilience management such as the philosophical value of hamemayu hayuning bawana the moral teachings of mustard greget sengguh ora conceit and the spirit of golong gilig hamemayu hayuning bawanameans is the obligation to protect maintain and foster the safety of world it is also concerned with working for the community rather than fulfilling personal ambitions while the moral teachings of mustard greget sengguh ora micah mean concentration enthusiasm selfconfidence humility and responsibility in addition golong gilih is the spirit of unity between humans and their god as well as the fellow human beings the government of bantul implements an economic resilience policy based on social capital normatively to minimize the spread of the covid19 while maintaining the communitys economy the government issued a regent instruction number 31instr2021 related to trade activity policy several policies are the exemptions of user fees for traders and a 50 reduction in user fees the fund revolving policy is a program of borrowing funds from the government for traders in the communitys market the visible social capital is about how the government builds trust cooperation between the government and community organizations as well as government and society the involvement of community organizations is realized through collaboration between the government and the association of indonesian market traders for bantul imogiri and angkruksari and semampir area this form of cooperation is a form of trust another collaboration with the community is cooperation between bantul regency government and gojek in increasing msme income through digital payments the association of indonesian market traders in bantul imogiri and angkruksari and semampir area played an important role in the success of public policy appsi acts as a mediator between the government and the community especially market traders appsi facilitates traders through training programs or workshops advocacy programs or complaints about any problems related to the market even appsi attempts to find out an alternative capital assistance for traders who do not receive assistance from the government the traders try to get this assistance by collecting certificates facilitated by appsi there were around 200 business certificates collected then appsi at semampir market brought these certificates to the subdistrict office the value of social capital that appears in the national resilience policy in bantul regency is the high value of cooperation and trust between the government and the community this is in the policy of providing a fund revolving assistance for market traders by the government a fund revolving is given to traders worth 1 million for each trader with a return system traders with a loan have to pay in installments of 10 thousand rupiah perday until it is paid off overall the traders are cooperative and responsible on average all traders payreturn somehow trust is one of the important indicators in the success of social capital as emphasized by fukuyama in contrast to market traders the modern franchise networked market and the nonfranchise networked modern market have received less attention from the government there is almost no assistance or involvement from local governments for alfamart business ventures or other types of modern franchised stores the economic resilience of bantul regency was successful or stable even though at the end of 2019 to early 2020 where covid19 had spread in indonesia this fact can be seen from the poverty rate released by the central statistics agency in 2021 strictly speaking this has not seen the economic data for 2021 which has entered the second semester of the period where the impact of the covid19 is more affecting however the data released depicts bantuls economic data for oneyear where covid19 has spread in indonesia with all its policies and impacts with these data the data on the depth of poverty between 2019 and 2020 was relatively stable qualitatively there was a correlated influence between the policies of the bantul government and the social capital base described previously capitalbased economic policies have long been emphasized researched and considered to connect one another local economic growth should benefit from binding and bridging social capital bonding social capital consists of closedties in small and cohesive communities policies based on social capital are constructive or positive as long as they are empowered social capital can be a solution so that anxiety and social rifts do not occur due to the impact of the covid19 policies based on social capital are relatively easy to accept and understand by the public the implementation of policies that involve organizations or communities in the community as part of social capital is able to bridge and facilitate the objectives of the policy because the valuesorganizationscollaborations involved in public policy are not new or strange to the community this creates trust and acceptance from the community therefore social capital in the community supports and helps the effectiveness of government performance tavis argues that social capital may be linked to government performance because it increases the level of political sophistication and facilitates cooperation in society as well as helping people to better voice their policy demands the involvement of appsi within the policies against the covid19 in bantul regency is a form of utilizing social networks in the community this facilitates socialization as well as making it easier for the community to express their aspirations to the government thus social capital affects the communitys response to covid19 in the form of a facilitator as well as a leading point of policy compliance the development of policies or public policies based on social capital have long been pursued at the same time it is an alternative and a new breakthrough that development is not always viewed from an economic viewpoint social capitalbased policies are considered as an alternative when economic development is only the best way as evidence that not all of these economic developments were successful thus it is important to create a new concept or approach based on social capital as an alternative the important emphasis of social capital is the community should be able and have a potency and opportunity to improve and empower themselves this potency is actualized in the form of cooperation norm belief and value that live and are maintained because humans or society should always interact with the environment and their problems another awareness is that the individual is socially helpless so that there is no choice but to build cooperation and sharedvalues to create social capital in the community social capital is also potential and neutral it actually requires the involvement of other parties for optimization in hemingways terms social capital also requires human capital in strengthening human capital the role of the government and community organizations in providing facilities and services is highly required otherwise the existing social capital may not be lifted and become part of public policy even worse social capital can also have a destructive impact the role of the bantul regency government in optimizing cooperation or social networking is manifested in the 2013 regents regulation concerning modern shop business permits in the regulation the establishment of modern shops must take a certain distance from traditional markets in addition modern shops are required to build partnerships with micro and small businesses in the form of marketing partnerships provision of place of business product acceptance and equity participation conclusion social capital plays an important role in the success of policies taken by bantul regency government in dealing with the covid19 the policy taken is the regents instruction number 31instr2021 related to policies concerning trade activities restrictions on social activities market operating hours and the provision of capital assistance to traders the values or social capital involved in the economic resilience policy in bantul regency are the values of cooperation trust and the use of social networks or communities in the community namely indonesia market traders association especially in imogiri area semampir market bantul market and angkruksari market appsi acts as a facilitator and mediator between the community and the government in conveying aspirations criticisms and advices to the government the success of this social capitalbased policy can be seen in the publics compliance or acceptance of the policies implemented by the bantul regency government besides it can also be identified through data on the depth of poverty in bantul economy metrics which has relatively lasted one year of the covid19 pandemic released by the central statistics agency for bantul 2021 finally this study merely investigated four markets in bantul regency so that the research needs to be expanded especially by using quantitative research approach to provide comprehensive data

this study purposed to examine social capital in economic resilience in bantul regency during the pandemic

introduction according to the national alliance to end homelessness over 500000 people are homeless on any given night in the us 1 other reporting strategies indicate that as many as 1725 million youth under age 25 years are homeless or unstably housed on any given night in the us 2 3 4 individuals who experience homelessness are at greater risk of acquiring or transmitting hiv compared with people in stable housing 5 with hiv prevalence rates among the homeless being nine times higher than in the general population 6 despite this those who experience homelessness have dramatically limited access to hiv prevention programs particularly preexposure prophylaxis and nonoccupational postexposure prophylaxis two promising biomedical hiv prevention strategies homeless youth are less likely to enroll in hiv prep trials with one study reporting that only 1 of hivnegative participants were prescribed prep 7 in prep trials fewer young adults have enrolled than older adults 8 and uptake 7 and adherence were lower in those with unstable housing 9 homelessness is associated with several hiv risk behaviors such as having condomless sex and multiple sexual partners which contribute to disparities in sexual health outcomes for example condomless sex is a prevalent hiv risk behavior among individuals experiencing homelessness in studies of homeless men over twothirds of participants reported having condomless sex in the past six months 10 and each additional sex partner has been found to be associated with an increase of more than two times the odds of engaging in condomless sex 11 in a sample of both male and female sexually active homeless adults approximately 76 reported having condomless sex 7 among younger homeless populations 60 reported condomless sex during their last sexual encounter 12 among heterosexual homeless men the strongest predictors of condom use were attitudes about condom use selfefficacy for condom use partner type and partner communication about condom use 13 in addition having multiple sexual partners and depression were found to be associated with consistent condom use 10 predictors of condom use among homeless women include condom efficacy and their perceived risk of getting hiv for example women who believe they have low hiv susceptibility are less likely to have condomless sex 14 yet in other homeless adult samples hiv susceptibility operationalized as worry about getting infected with hiv or aids was not found to be significantly associated with condom use 11 while researchers have identified several common predictors of condom use among various homeless subgroups the relation between other factors such as hiv risk perceptions current age age at onset of sex and first period of homelessness remains unclear other hiv risk behaviors such as having multiple sexual partners and concurrent sexual partners are prevalent among homeless populations including exoffenders and streetinvolved youth 1516 in a study of homeless men from los angeles 17 almost 40 reported multiple concurrent sex partners ie having sex with more than one person around the same time which is a known risk factor for hiv 18 finally sexually active homeless individuals reported more sex partners in their lifetime and in the past 12 months with an unknown hiv serostatus partner compared with hiv housed adults 19 subgroups of homeless individuals report high rates of sexual risk behaviors including females young adults under 25 years old sexual minorities and those with early sexual debut 2021 homeless women are more likely than homeless men to engage in sexual risk behaviors such as having condomless sex with casual partners and having multiple partners 22 23 24 25 26 homeless youth are 612 times more likely to become infected with hiv than housed youth with prevalence rates as high as 13 2728 homeless youth have earlier sexual debut are more likely to have multiple partners trade sex for food shelter money or substances and use substances before sex and are less likely to use a condom or contraception than stably housed youth 20 29 30 31 32 33 lesbian gay bisexual transgendered and questioning homeless persons have a higher risk of hiv than heterosexual individuals among a sample of homeless lgbtq young adults 17 reported a diagnosis of hiv 33 as well lgbtq homeless youth experience higher rates of sexually transmitted infections than homeless heterosexual youth 34 finally both males and females who had sex before age 13 years were more likely than nonearly sexual initiators to have multiple sexual partners during their lifetime and to engage in condomless sex 35 multiple risk factors for engaging in sexual risk behaviors have been identified among homeless populations however less is known about differences in sexual risk behaviors according to current age as many studies of homeless youth do not compare youth to older adults in the same sample less is known as well about the age of homelessness onset as a potential independent risk factor despite findings suggesting that age of onset is correlated with other risk behaviors such as substance use with a younger age at the onset of homelessness being associated with a higher incidence of substance use 36 an oakland california based study found that among homeless adults 50 years old those who first became homeless before age 50 reported higher rates of substance use than those with a later age of homelessness onset 37 while research demonstrates that age at the onset of homelessness is associated with substance use little is known about the relation between age at the onset of homelessness and sexual risk behaviors in a broader sample of homeless adults and young adults purpose in this study we examined the prevalence of sexual risk behaviorshaving condomless sex a new sexual partner and multiple sexual partnersamong sexually active homeless adults in oklahoma city ok usa in addition we assessed the relations between hiv risk perception age at sexual debut age at the onset of homelessness current age and sexual risk behaviors we hypothesized that those who were younger than 25 years and those who experienced homelessness at an earlier age would report more sexual risk behaviors and that those with low perceived hiv risk would report fewer sexual risk behaviors methods data and sample from julyaugust 2016 participants were recruited through flyers posted at six different homeless shelters in oklahoma city ok usa to be enrolled participants must have been 18 years of age or older receiving services at the targeted shelters and had a minimum 7th grade english literacy level based on a score of 4 or higher on the rapid estimate of adult literacy in medicineshort form 38 after the screening and informed consent process each participant was given a questionnaire to complete on a tablet computer which enabled the participant to see survey items on the screen and hear the questions being read aloud via headphones participants took about 1 h to complete the survey and were compensated for their time with a 20 department store gift card the institutional review boards at the the university of texas health science center the university of houston and the university of oklahoma health sciences center approved this study a total of 648 participants were screened for inclusion in the parent study thirtyfour participants were excluded because they did not meet the reading level criteria realm literacy score four eligible people chose not to participate a total of 610 adults were enrolled and completed study measures over the 12 day data collection period across 6 shelter sites an additional 21 participants were not literally homeless and therefore were excluded from the analysis of the sexually active participants none had missing data on any of the sexual risk behavior measures however 3 participants were excluded for having missing data on independent variables and 4 additional participants were excluded for missing data on the covariates the final analytic sample for this study included 460 homeless and sexually active participants the subsample of sexually active participants in this study differed from those excluded who were not currently sexually active the sexually active participants were younger minority race and had less than a high school degree the sample for this study also demonstrated more moderate to severe stress and were more often diagnosed with alcohol or substance use disorder compared to the not sexually active participants from the parent study measures dependent variables condomless sex participants were asked how often they had vaginal or anal sex without using a condom in the past 12 months participants who responded that they had sex without using a condom less than half of the time about half of the time not always but more than half the time or always were coded as having condomless sex while participants who responded that they never engage in sex without a condom were coded as always having sex with a condom new sexual partner to determine if a participant had a new sexual partner participants were asked did you have any kind of sex with a person that you have never had sex with before in the past 12 months multiple sexual partners participants were asked to report the number of people they had any kind of sex with in the past 12 months responses were dichotomized to 4 or more partners or fewer than 4 to align with the literature on multiple sexual partners and allow for comparisons with other studies and populations 716 sexually transmitted infection participants were asked if a health care professional had ever told them they had genital herpes genital warts human papillomavirus or hpv gonorrhea chlamydia or syphilis independent variables the independent variables included in the model represented sexual activity and hiv risk perceptions homelessness and age characteristics stress and substance use hiv risk perceptions participants were asked to rate their perception of their hiv risk from 0 to 5 39 participants who responded as somewhat at risk moderate risk or high risk were coded as high perceived risk while participants who responded as low or no risk were coded as low perceived risk age characteristics participants reported their age at their first sexual encounter this variable was dichotomized to either 14 years or ≥14 years of age to align with sexual initiation surveys 40 participants reported their age at the onset of homelessness which was dichotomized as 25 years or ≥25 years to align with the literature on homeless youth that often includes youth 25 years old and younger 4142 participants also reported their current age which was dichotomized as 25 years or ≥25 years covariate measures the regression models included various characteristics that may influence participants sexual risk behaviors in addition to hiv risk perceptions and age characteristics covariates included sex marital status education raceethnicity history of sexually transmitted infections and sexual orientation the fouritem perceived stress scale was used to assess perceived stress 43 items were summed and responses were grouped into two groups moderate to severe stress and low stress 4445 participants were also asked if they had ever received a diagnosis for alcohol or substance use disorder analytic plan descriptive and logistic regression analyses were conducted using stata version 240 statistical software bivariate analyses assessing the relation between sexual risk behaviors and individual factors were conducted using chisquare tests three covariateadjusted logistic regression models were conducted one for each sexual risk behavior standard errors were adjusted to account for the lack of independence of observations as participants were clustered within the shelter location where they completed the survey 46 results sample characteristics participants were predominantly ≥25 years old male single white and heterosexual and most had at least a high school diploma this sample approximates the age and sex of the homeless population surveyed in the oklahoma city pointintime count in 2016 47 regarding the prevalence of sexual risk behaviors in the past 12 months 53 of the participants reported engaging in condomless sex 35 had a new sexual partner and 12 had multiple sexual partners eightynine percent of participants perceived themselves to be at low risk for hiv seventyone percent of the participants initiated sexual activity at 14 years or older most participants were ≥25 years old at the onset of homelessness and had been homeless for an average of 171 ± 264 years additionally 22 report a positive sexually transmitted infection history the results of the bivariate analyses are shown in table 1 having low perceived hiv risk was independently associated with lower prevalence of all three sexual risk behaviors an early sexual debut was associated with having condomless sex but not with having new or multiple sexual partners in the past 12 months experiencing first homelessness at 24 years or younger and current age of 24 years old or younger were associated with greater odds of having condomless sex a new sexual partner and multiple sexual partners in the past 12 months early sexual debut was also associated with having low perceived hiv risk being female being married having less than a high school diploma and being a racialethnic minority homelessness onset at 25 years old was associated with having low perceived hiv risk currently being 24 years or younger having completed less than a high school diploma and being a racialethnic minority currently being younger than 25 years old was associated with being lgbtq no significant associations were found between the age characteristics and perceived stress or alcohol and substance use disorder diagnoses 47 36 hiv human immunodeficiency virus lgbtq lesbian gay bisexual transgender questioning significance of chisquare tests between each sexual risky behaviors and each characteristic is denoted by p 005 p 001 p 0001 regression analyses predictors of condomless sex in the covariateadjusted models low perception of hiv risk was associated with 73 lower odds of engaging in condomless sex in the past 12 months being female married and having a sexually transmitted infection were respectively associated with a 110 283 and 107 higher odds of having condomless sex predictors of having a new sexual partner low perception of hiv risk was associated with 71 lower odds of having a new sexual partner in the past 12 months being younger than 25 years was significantly associated with 265 higher odds of having a new sexual partner being married was also associated with 55 lower odds of having a new sexual partner while having a diagnosis of alcohol or substance use disorder was found to be associated with a 49 higher odds of having a new sexual partner in the past 12 months predictors of having multiple sexual partners low perception of hiv risk was associated with 77 lower odds of having multiple sexual partners in the past 12 months being younger than 25 years was significantly associated with 108 higher odds of having multiple sexual partners in the past 12 months experiencing homelessness before 25 years old was associated with 80 higher odds of having multiple sexual partners in past 12 months additionally identifying as lgbtq was associated with 123 higher odds of having multiple sexual partners in the past 12 months while a diagnosis of alcohol or substance use disorder was found to be associated with a 32 lower odds of having multiple sexual partners in the past 12 months discussion among a crosssectional sample of sexually active homeless adults from an understudied region in the southwestern united states we examined the prevalence of recent sexual risk behaviors including having condomless sex new sexual partners and having multiple sexual partners in the past year we found lower rates of condomless sex than have been found in other studies of homeless adults 710 we also found that the proportion of individuals who had condomless sex new sexual partners and multiple sexual partners in the past 12 months was higher among those younger than 25 years old than among those 25 years and older this aligns with the literature that homeless youth have significant sexual health risks and high prevalence of sexual risk behaviors 19 29 30 31 32 findings from this study add to the literature on sexual risk behaviors among homeless populations by comparing homeless youth and older adults within the same sample and suggesting that the age at the onset of homelessness is an important independent risk factor to consider when addressing sexual risk behaviors even after controlling for current age in contrast to other studies that have found no significant association with perceived hiv risk and sexual risk behaviors 11 in this sample we found that having low hiv risk perception was associated with significantly reduced risk of having condomless sex a new sexual partner and multiple partners in the past year this may be related to the participants ability to accurately conduct a selfassessment of their hiv risk behaviors ie those with low risk behaviors conclude they are at low risk for hiv and therefore report low hiv risk perceptions sex marital status ever having an sti sexual orientation and alcoholsubstance use disorders were found to be significantly related to sexual risk behaviors females reported more condomless sex which aligns with the literature among homeless populations 2233 however in contrast to the literature fewer females reported having multiple sexual partners 22 23 24 26 as expected being married was found to be significantly associated with reduced odds of new sexual partners and increased odds of having condomless sex this aligns with the literature that has revealed lower condom use among steady sexual partners and may be related to low hiv risk perception among those having sex within established relationships 48 those reporting ever having an sti had increased odds of condomless sex and those who identify as lgbtq had increased odds of having multiple sexual partners we also found that while having a diagnosed alcohol or substance use disorder increased the odds of reporting a new sexual partner in the past 12 months it decreased the odds of having multiple sexual partners this suggests that it may be important to also screen for substance use and assist with access to substance abuse treatment in conjunction with hiv risk prevention counseling particularly among homeless persons with early homelessness onset study strengths include the novel analysis of age at the onset of homelessness and current age as potential factors contributing to sexual risk behaviors among a large sample of both younger and older homeless adults there are several limitations of this study the sample was collected in one understudied southwestern region of the united states therefore the results may not be generalizable to other homeless adult populations this sample was predominantly ≥25 years old white and heterosexual which does not approximate the demographics of many other homeless populations this study is also limited by reliance upon selfreport data and the crosssectional design thus we can interpret associations but not causation from these data the sample represents only homeless adults interfacing with shelter services because this study was not designed to include street outreach to homeless adults disconnected from service providers the sexual health risk factors may be an underrepresentation of all homeless adults both connected and disconnected from service providers such as shelters and dropin centers the lower prevalence of sexual risk behaviors may also reflect the older age of the sample as homeless youth report higher prevalence of sexual risk behaviors 9 as well multiple analyses were conducted which increases the risk type 1 errors finally participants recruited for this study were from homeless adult vs homeless youth serving organizations conclusions current age and age at the onset of homelessness should be considered in planning sexual health programs and hivsti prevention interventions among homeless populations social service and healthcare providers should consider screening homeless adults for the age at the onset of homelessness as a gauge for sexual risk behaviors youth experiencing homelessness and those who experience early homelessness engage in more hiv risk behaviors than older homeless individuals and those who first experience homelessness later in their adult life to effectively scaleup hiv prevention among homeless youth health and social systems should increase access to free hiv prevention counseling that includes linkages to care and patient navigation refs promoting condom use and hiv prevention strategies including prep and npep and providing free condoms hivsti screening and treatment in locations that are easily accessible by public transportation author contributions all authors conceived and designed the survey instrument michael s businelle and darla e kendzor collected the data diane santa maria daphne c hernandez and katherine r arlinghaus analyzed the data all authors contributed to the writing of the paper

while hiv disproportionately impacts homeless individuals little is known about the prevalence of hiv risk behaviors in the southwest and how age factors and hiv risk perceptions influence sexual risk behaviors we conducted a secondary data analysis n 460 on sexually active homeless adults from a crosssectional study of participants n 610 recruited from homeless service locations such as shelters and dropin centers in an understudied region of the southwest covariateadjusted logistic regressions were used to assess the impact of age at homelessness onset current age age at first sex and hiv risk perceptions on having condomless sex new sexual partner s and multiple sexual partners ≥4 sexual partners in the past 12 months individuals who first experienced homelessness by age 24 were significantly more likely to report condomless sex and multiple sexual partners in the past year than those who had a later onset of their first episode of homelessness individuals who were currently 24 years or younger were more likely to have had condomless sex new sexual partners and multiple sexual partners in the past 12 months than those who were 25 years or older those who had low perceived hiv risk had lower odds of all three sexual risk behaviors social service and healthcare providers should consider a younger age at homelessness onset when targeting hiv prevention services to youth experiencing homelessness

where social media is very useful for everyone to communicate and spread information to the public the social media that is very popular with people of all ages is tiktok tiktok has many uses ranging from creating video content to spreading information or news even tiktok can be a place to make money if we create content that many people like 3 however tiktok can also harm its users if it is not used wisely for example tiktok is used by its users especially teenagers to judge content if they dont like it they will even give a negative comment on the content which will have an impact on basic ethics therefore the researcher wrote this article to discuss the consequences of using tiktok for in the contemporary generation which will affect their ethics in real life 4 and with the development of the times it makes it easier in various fields especially in modern communication with these advances in modern technology making developments in the communication arena continue to grow one of which is the emergence of the android device which facilitates and accelerates both work and remote communication then came various new applications such as social media networking platforms 5 tiktok is a mobile app that makes it easy to create short videos it doesnt even require a lot of equipment the only is mobile support these videos made from it doesnt even need editing in august 2018 music was added to this app and it started to be used all over the world chinese video sharing is a social networking service owned by byte has a company called dennis isaac 6 tiktok is a social media that has millions of users around the world historically tiktok was created by zhang yiming in september 2016 it allows users to create videos creatively with backsong and filter options tiktok is a social media platform that allows users to create short videos easily and its idea derives from previous apps named douyin 7 currently tiktok has become a common social media platform used by youth around the world before now tiktok was only used by persons who wanted to exist in the cyber world and listen to music but recently tiktok has been commonly used by persons either for business politics or by those who want to be celebrities the existence of tiktok as a popular social media is influenced by the global pandemic tiktok is a short video on social media that has both positive and negative values 8 one of the negative impacts that parents must watch out for on their children is pornographic content or the use of sexy or impolite clothing 9 for example in midfebruary 2020 the tiktok video went viral because of the immoral scene of a couple of teenagers doing scenes like husband and wife which was recorded by a colleague who was dancing without realizing it 10 this incident is one of many cases so it is necessary to supervise children and teenagers in using smartphones especially the tiktok application the instant gratification and viral hit to a tiktok users video are what has allowed the app to continue its popularity teens look to this app as a source of external validation and rely heavily on its use to provide what they believe is total happiness 11 social media has become an important need for the community this fast and advanced era make people complacent with the ease and convenience of social media currently tiktok social media videosharing application is available on smartphones social media tiktok is an online media with its users can easily participate share and create content including blogs social networks wikis forums and the virtual world 12 the use of tiktok by the contemporary generation can develop meaning and selfawareness due to continuous social interaction between users 13 during the pandemic children experienced moral degradation which was influenced by the use of gadgets one of which was the tiktok application which contained various content that became a problem if the content viewed or imitated did not reflect something that could be seen and imitated which hurt morals of youth a lot of young adults use the tiktok application which harms them and those nearby 14 the social media tiktok is a medium for selfexpression providing entertainment and information enlarging social networking and developing the creativity of its users however tiktok is frequently showing behavior contrary to islamic religious values only to be popular phenomena on tiktok such as dancing and swaying by showing some body parts that identify as pornography as reported by online media kompascom on 24 february 2020 with the titlefakta video tik tok berlatar adegan mesum pelaku umur 14 tahun terlibat prostitusi online 15 islam plays a central role in the lives of muslims even in their usage of social media the lives of muslims ought to be holistically guided by the islamic principle of social engagement 16 allah has spoken of the believers about upholding the teachings of islam allah says those that turn to allah in repentance that serve him and praise him that wander in devotion to the cause of allah that bow down and prostrate themselves in prayer that enjoin good and forbid evil and observe the limit set by allah so proclaim the glad tidings to the believers 17 this marks the importance of using social media ethically other than social media usage the tiktok ecosystem needs to be conducted in an ethical manner for ethical usage of the social media platform to take place effectively this is because behavior that is not by norms and religious values that can harm the morals of tiktok users are found in the platform therefore it is important to understand morals morals is defined as behaviors possessed by humans both praiseworthy morals and despicable 18 considering some social phenomena on tiktok usage in the community then this study aims to overview social media tiktok in islamic perspective literature review explained that the tiktok application is an application that can make users create a video that lasts approximately 30 seconds to 3 minutes with different music the tiktok application is a social networking site used in the system for uploading a video by the application user which is then given to other users tiktok is the most prominent and trendy application among young people 19 tiktok is now used to foster selfconfidence and become a place of popularity and selfpresence that causes other peoples interest the will is identical to someone who has narcissistic behavior the influence of the use of social media itself is very diverse with both positive and negative impacts selfish behavior is acculturation showing itself excessively narcissism means a persons willingness to show that he is superior by feeling that he has potential that exceeds others to get more attention and praise 20 the existence of this tiktok someone cannot be separated from selfish behavior which can ultimately become arrogant selfperception the form of tiktok application is now used excessively which causes narcissism among youths particularly females ironically some of these females apply this by showing themselves revealing their genitals when swaying by wearing sexy clothes so that the behavior attracts the attention of others who are watching 21 explained that islam has regulated human life as well as possible 22 from the point of view of islam the glorious quran is a source of law and a source of knowledge filled with lessons wisdom and examples on how a believer is to his life most importantly as it relates to social engagements 23 tiktokers are individuals or people who carry out activities to create unique and exciting video content on the tiktok application that makes the user known and therefore has many followers because of the exciting and inspiring content created by these individuals at the transitional age adolescents have begun to 17 quran surah attaubah 9112 18 have specific interests such as interest in selfappearance adolescents try to be able to look as attractive as possible to get recognition and attractiveness 24 tiktok also allows users to create short music videos a study by ridgway clayton looks at social media from a different perspective and focuses on the direct effects of social media use on body image as it affects women folk this study examined social media platform users that promoted their body image for satisfaction either through selfie posts encountering the risk of social mediarelated conflicts and negative romantic relationship consequences 25 another research with a more direct effect explored the impacts of social media on the body image of youth the results demonstrated that while using social media the youth particularly female felt pressured to lose weight look more attractive or muscular and change their appearance to become attractive 26 according to ajao bhowmik zargari social media is being used to spread false news and other immoral acts it was established that twitter instagram facebook tiktok linkedin snapchat etc sites that have a presence in muslim societies are also useless and are very much filled with dirtiness these sites are being misused by a lot of blogs to spread unwanted behaviors to the cyber27 method the methodological survey was utilized in the conduct of this research there are a variety of ways to collect data for surveybased research the most popular of which are interviews and questionnaires however the primary data used for research is obtained through the interview methods finding and gathering reference materials that are relevant to this research is the first of three processes the researchers adopted when putting this piece together secondly several interviews have been conducted analyzed and elaborated to fully understand the intersections of this essay thirdly the researchers conclude the research by giving a highlight and the outcome of the research for further study result and discussion a islam and morality the goal of islamic moral values is to govern human behavior within muslim communities to encourage and regulate such behavior for the advantage of society as a whole and its members and to ensure that each person has a happy afterlife to prepare followers of the lord whom islam explained and made clear the road of virtue for it seeks to unify human characteristics behavior and activities therefore all islamic moral values of individuals like honesty tolerance compassion love and soulfighting as well as communal ones like selffeeling duty and calling for islamare intended to promote and safeguard the welfare of both the individual and the community according to islam morality is the set of virtues and good behavior that a person possesses to uphold societal harmony foster peace and defend it against vices like enmity indecency lust and so on the quran declared prophet muhammad to have the best manners and he was shown as an example of a decent person to the rest of humanity since he had embraced these virtues to such an extent in the glorious quran allah states you have indeed in the messenger of allah a beautiful pattern for anyone whose hope is in allah and the final day and who engages much in the praise of allah28 islam undoubtedly commands muslim ummah to uphold the moral principles of islam which are the only thing that bind them together a muslim has a duty to treat nonmuslims as well as other muslims with honesty tolerance keeping ones word generosity mutual aid and manliness a peaceful society must first create and maintain moral principles which are so crucial that the prophet muhammad stated i have been sent to bring the moral values to perfection 29 as a universal text the quran speaks to all people not only muslims its plethora of moral lessons is evidence that it speaks to all people everywhere always the moral principles outlined in the quran apply to nearly every facet of life including being modest when walking being truthful when conducting business being kind and responsible to ones parents caring for plants and animals and being a good neighbour by upholding kinship above all must properly care for and keep spouses and children imam ghazali stated that morality symbolises a kind of high point deeply ingrained in the soul from which different human actions flow naturally effortlessly and without the need for prior thought he says this place is considered morally beneficial if it leads to good deeds in the context of the shariah and common sense on the other hand the source of a negative deed is referred to as a disastrous moral source 30 b dawah essentially dawah has two dimensions external and internal external dawah is to invite nonmuslims to islam and teach them about islamic beliefs and practices internal dawah is to teach muslims about aspects of islam 31 dawah is a fard kifiya if there are individuals within a community inviting people to dawah then others within the community are relieved of the obligation if noone in the community issues the invitation the sin falls on every individual within that community 32 a person who performs dawah is known as a dai although their effectiveness will vary according to their ability all dai should be at the very least familiar with the basic teachings of islam 33 technical meaning of dawah it has two broad applications in this context the first is with the meaning of islam as a religion and the message sent to prophet muhammad that is the true call of worship to allah alone and to be far from polytheism it is the comprehensive principle for the behavioural act of mankind as well as the establishment of rights and commandments the second meaning is the extensive spread of islam and the message of allah to the people 34 in the quran almighty allah says instructing the believers and guiding them to the successful way of calling to the path of allah invite ibn taimiyah sees dawah as belief and having trust in allah calling to the word of testimony with full identification of good application of the teaching of islam which includes consideration of the five compulsory daily prayers giving out of zakat fasting the month of ramadan pilgrimage to the holy house of allah as well as to believe in allah his angel his books his messengers day of resurrection after death good and bad destiny and to worship allah as if you are seeing him 36 shukri ahmad muwaffaq defined dawah as motivating people over doing good deed and keeping away from evil attitude by bringing the people out from the darkness of kufr to the light of islam 37 as a career dawah should be carried out practically and verbally by a knowledgeable and qualified scholar and to be in accordance with the legitimate methods and strategies in line with the circumstances of those to be invited at anytime and anywhere c unmarried muslim women and unethical behaviours on tiktok tiktok have become a breeding ground where muslim youth in nigeria showcase and displayed immoral acts to the wide world to see this aspect diagnosed the behaviour of some unmarried muslim women on tiktok particularly as it relates to northern nigeria an indepth interview in relation to the views of some concerned social media users that relates the ugly behaviour of some of these women on the tiktok application have been captured below to isa idris lukumbogo who avers that the way he understands tiktok social media communication tool from its inception is a music and video sharing site which has not given room for censoring and for that it allows teens to make 33 ibid 34 arrawi muhammad abdurrahman addaawah islamiyyah dawatun alamiyyah dar alqaumiyyah 1965 35 quran surah annahl125 36 ibn taimiyyah abu alabbas ahmad alhirni mjmoo fatawah shaikh alislam ibn taimiyyah taqiq bu abdurrahman bn muhammad bn qasim ibn taimiyyas library 2nd edition nd 37 shukri ahmad muwaffaq ahlalfartah wa man fi hukmihim ma dissertation kulliyatu usul aldin imam muhammad bin saud islamic university riyad dar ibn kasir beirut first edition 1988 and share immoral messages in the form of videos to the public without regard to religious morals according to isa idris lukumbogo the harm associated with tiktok about the morality of muslim youth is far more than its benefits to the ummah because before one comes across any dawah message by muslim scholars on tiktok users who navigate the platform will see a lot of videos which showcase indecency which includes nudity female dancing and showing what is not supposed to be exposed of their body 38 this act as asserted by isa idris is also found amongst some muslim youths who see it as a way of socialising and forgetting their islamic identity which is against such acts most of the muslim youths that engage in tiktok do not in any way propagate islam to the public but rather music and other unethical behaviors that do not align with the teachings of islam bullying has also become the order of the day as some of these youths have no regard for the rules of social engagement 39 this attitude by muslim youth on tiktok is a serious setback to islam and muslim ummah in general and for that there is the need by scholars to enlighten the ummah particularly the youth on the danger of engaging in such acts of immorality not only on tiktok but other social media platforms that is why in my opinion there needs to be tiktok as a social media platform because it promotes nudity pornography and other social vices munirat halilu abubakar opined that most videos by youths on tiktok that emanate from the northern part of nigeria are always about indecent activities that are geared towards the moral bankruptcy of the young generation of the youthful population in the muslimdominated society 40 at times some of the short videos by either young males or females show a lack of regard for religious teachings by most of the users who utilize it to spread their thoughts through the short video messages they send via tiktok muhammad maishanu aliyu evinced that some muslim women are misusing the tiktok social media application for their selfish interest by doing what is against the teachings of islam most of these women displayed their nudity through videos and selfies which they share on the tiktok thereby accompanying it with immoral statements not only that the activities of some these tiktok users has poses a great danger to muslim ummah in northern nigeria and some of the menace include among other things destruction of good islamic moral and deviation from the good path 41 women are advertising and exposing their bodies on tiktok by way of sharing videos of themselves dancing and altering words that are unethical and affect the moral teachings of society babagana mallam abatcha harped that the behavior of muslim youths including women on tiktok in northern nigeria can vary widely as individuals express themselves differently however according to abacha there have been concerns globally particularly muslim communities about content on tiktok platforms conflicting with cultural and religious values some potential dangers of tiktok social media site for muslims in northern nigeria could include exposure to content which are been shared and posted mostly by females that go against islamic teachings privacy concerns and the risk of spending excessive time on 38 isa idris lukumbogo civil servant interviewed at nassarawa eggon nasarawa state nigeria 28 th november 2023 39 the platform which might interfere with religious obligations or other responsibilities individuals and communities need to promote responsible and mindful use of tiktok while respecting cultural and religious values 42 one of the drawbacks to tiktok most young adults often use tiktok as they wish which constantly causes negative videos to appear on this platform this can be seen as uploaded media content such as photos or videos the excessive use of tiktok allows everyone to express themselves even exploiting their bodies for pleasure or just selfexistence however …… avers that many of these young adults especially females use it to create harmful content for example a woman intends to show her body shape through her mini clothes which causes negative views this type of attitude leads to selfish behavior among females strong immoral are what some of these women propagate on the tiktok site the youth today have been abusing the opportunity provided by tiktok as a social media platform to communicate and disseminate vital messages to the world ahmad kassim harped that there are some muslim youth out there who are bound to destroy the morality of the young general through the utilization of tiktok social media platforms to display all sorts of vices to the wide world daily young tiktokers are always online with the name of becoming a celebrity or want to have many fans on social media will resort to posting videos of hisherself either singing and dancing or making indecent utterances that are not supposed to come a true muslim believers 43 some of these muslim youth consume whatever comes their way from the new media technology without recourse to islam and what it teaches and in some cases most of these youths are being sponsored by the western world help them in their agenda of destroying the islamic culture and teachings among muslim youths hajara usman elkasim asserted that it has gotten to a point where some female muslims are trading themselves like commodities in the market on tiktok with utmost disregard to the moral teachings of islam and the culture of the people of northern nigeria it has gone to a point where sexy videos and photos are posted on tiktok by muslims to become celebrities and have plenty of followers and likes on this platform in northern nigeria some unmarried women shamelessly embrace their sexuality flirt dance and lipsynch to songs on tiktok they disregard rules of gender seclusion purdah sexual modesty and middleclass feminine comportment by uploading such eyecatching tiktoks 44 the researchers asked an online business lady who had a public tiktok account with over 5000 followers if her parents knew about her tiktok dancing and public videos the tiktoker laughed and said her parents knew nothing about her tiktok activities and if they knew that they would kill her it has also been observed by the researchers some unmarried women engage in explicitly sexualized performances women also involved in covert sexualized performances for example a popular trend consisted of women making a series of innocent yet sexual facial expressions to different sounds a startled suggestive look a shy smile blowing a kiss and a petulant expression such memes channeled the trope of sexy schoolgirl and while appearing to be innocently playful were also instances of expressive sexuality women also 42 babagana mallam abatcha lecturer ramat polytechnic maiduguri borno state nigeria interviewed on 13 th december 2023 43 ahmad kassim businessmansocial media user interviewed at sokoto sokoto state nigeria 10 th november 2023 44 hajara usman elkasim student department of islamic studies nasarawa state university keffi interviewed on 12 th november 2023 uploaded funny videos and acted out entertaining scenarios and dialogues which poked fun at societal norms and engaged in crude humor in such videos women appeared confident irreverent and selfpossessed these bold performances undermined local norms of respectable femininity centered on docility tradition and respect for authority many tiktoks did reproduce heteronormativity by uncritically relaying normative ideas of feminine beauty and heterosexuality yet such sexual andor frivolous tiktoks also challenged local gender norms according to abdulrasheed ishiaku tiktok as one of the most recently used social media sites has greatly influenced the life of youth most especially women nowadays but its adverse effects can be clearly seen in some of its users particularly on unmarried women in the north part of the country where morality is regarded with high esteem due to the islamic religious teachings which have dominated the region some unmarried muslim female uses it to serve as an avenue for publicizing nudity and public abuses as well as a means of connection with other gender far and near moreover tiktok is timeconsuming and a waste of resources for many of its users 45 never in human history has our society faced a tragedy of such immense proportions and farreaching consequences as we do today regarding the unethical moral display by young women on social media particularly on tiktok unrestrained social media use has in a sense diminished our moral and cultural standards to the point that some things that were formerly considered taboo have become the norm the tendency is so concerning that dangerous precedents are being formed 46 mallam saudatu ayuba sabo also observed that these days anyone may rise from relative obscurity to the limelight and even become a celebrity by sharing a video or photo of themselves in their nudity on one or more social media sites and encouraging others to like comment and share it sometimes people will commit such an aberration in the hopes of earning partnerships with corporate entities for brand endorsement rahamat yahaya observed that part of the major problem with tiktok is that it is primarily focusing on dancing and music which are both not permissible in islam that is why one sees many girls dancing and singing on social media their videos have been viewed by millions in the world and those people watching them are not their mahram not only that most of the females who are involved in these unethical acts on the tiktok social media site do it because of the temporary fame that they have observed other tiktok users to have garnered from the platform they do not mind if the fame is temporary or not which is more likely to make a person feel isolated and do all sorts of stuff to gain the attention of people like her page on the platform 47 the negative impacts of tiktok as social media platform muslim on youth cannot be over emphasis this is because islam have dealt in total all aspects of human life be it social interaction politics and economic which also include that of morality mustapha ibrahim muluku acknowledged that despite the role of parents in instilling better morals for their children reverse have been the case with some unmarried muslim females who by all costs are emulating the social lifestyle of the western world thereby making short videos of themselves either half naked or bullying some through the tiktok 48 not only that the advent of tiktok has affected morals and caused a lot of harm to the youthful population around the world many times some of the parents are not even aware that their children are into such illicit acts this is because most of the youth hide their escapade away from their parents and as such it becomes hard for the parent to understand what they do online in addition another deviant behaviour of female tiktok users in the northern part of nigeria is an obsession with popularity this is an encouragement to own which tiktok is a trending today so they take advantage of it to gain popularity because many tiktok users are famous on social media through the content they create some other users are also interested in feeling the same way to get the popularity of tiktok users to do anything to get it whereas pursuing popularity is merely worldly a pleasure which is condemned by religion as allah says suratul hud 1516 whosoever desires the life of the world and its glitter to them we shall pay in full their deeds therein and they will have no diminution therein they are those for whom there is nothing in the hereafter but fire and vain are the deeds they did therein and of no effect is that which they used to do49 humans are commanded to have prepared for life in the hereafter by doing righteous deeds but humans who are only busy with the pleasures of this world will oppose and deny allah and his messenger the reward for them is none other than hell because of all their useless actions while in the world so humans who are only busy chasing popularity in the world are despicable morals where popularity can bring ujub or arrogant and riya even though the world is a test for humans and a place to collect good deeds for those who have ambitions to gain worldly benefits and deny the values and teachings of the quran all the time spent pursuing the world is a waste and gives a loss 50 for like the solutions provided by other tiktok users to not only pursue popularity it would be nice if tiktok users were not obsessed with popularity especially since he achieved popularity in a way that is not allowed in islam it can be understood from the response of the quran to the nondeviant behaviour of tiktok users in northern nigeria is a behaviour that must be maintained and the deviant behaviour of tiktok users in northern nigeria is a behaviour that must be avoided to avoid deviant behaviour to maintain behaviour that is under the values of this source it can be returned to the quran as a way of life to solve these problems as the response of the quran to tiktok users in northern nigeria we can see that there is also a solution in it that tiktok users in northern nigeria can practice applying some commendable morals such as practising patience in fighting lust because there are many temptations as interesting content but contains much mudarat in it the second solution is that tiktok users should maintain shame to prevent deviant behaviour in their content if shame is maintained properly then shame can be a shield for tiktok users from creating deviant content not being obsessed with the worldly is the next solution because there are still many tiktok users who are so obsessed with popularity that they produce any content without first considering the behavior displayed in the content tiktok users can practice this solution to avoid disobedience and slander so that there are no more moral deviations committed by a muslim who uses tiktok d islamic dawah as solution to the menace of tiktok in northern nigeria mustapha ibrahim muluku emphasizes the need for muslim scholars to widen the horizon of enlightening the ummah most especially during congregational prayers on the harmfulness of the tiktok social media platform and ways to make the best use of the platform and by this it will go a long way in minimizing the threat it posed to the muslim ummah 51 abu masud said the prophet once said one word of the earlier prophets to people if you have no shame you can do what you want52 it means that if humans do not feel ashamed towards allah and their fellow human beings they commit immorality conversely if the shame is still maintained they will stay away from disobedience53 thus it would be better if tiktok users in northern nigeria still have limitations in creating content maintain a sense of shame in themselves and are not trapped in the release of lust by other social media users islamic dawah has the power to transform an individual into accepting and adopting better moral values in society so the need for dawah to intensify to eradicate and bring back such persons on track for their activities not to affect other members of the muslim community in northern nigeria muslim scholars need to utilize social media for dawah activities to enlighten muslim ummah on the need to properly make use of social media for social engagement rather than using it for immoral acts that would cause the wrath of allah upon them it is also important for muslim scholars to use these platforms to remind muslim women that islam has honored them and for that they do not need to make videos of themselves dancing on tiktok for the purpose of becoming a celebrity or advertise products to the public just to get money through dawah the menace of immoral behaviour on tiktok could be reduced and through this means muslim youth particularly females will develop a clear mindset because the higher the level reminder of mankind of his duties to allah the higher of development in thinking the greater the potential to achieve a better level of moral development in everyday life although shaping the mindset of youth to morality takes time and the need for parents also to play a role to guide and checkmate the usage of their childrens activities on smartphones and through this also most of those who engages in illicit behaviours on this social media platform would reduce and will likely not spread to their younger ones parents have a major role to play in checkmating menace of tiktok among females in muslim society most especially in their homes this is because most of the parents are not aware of what their children engage in on social media platforms particularly tiktok which has become a centre where indecent activities are taken place daily by the socalled muslim females with the name of becoming celebrities it is therefore important for muslim scholars and parents to intensify efforts in correcting the illness and menace being displayed by muslim youths most especially females on social media platforms particularly tiktok conclusion this study concludes that computers and smartphone devices are now a daily necessity due to technological advances realm of modern communication the younger generation of users feels anxious and restless if they are far from their devices apart from these communication tools gadgets will be interconnected with what is called social media which tiktok falls under social media itself has many application features that attract users one of which is the tiktok application this application is one that many people like because of the exciting challenges to imitate both from curiosity and as new content material so that users keep opening it this application is so cherished by young adults particularly women who do not care about the teachings of the religion as the app allows dancing and exposure to a lot of immoral activities in other words it has been discovered that dancing is part of the phenomenon of tiktok and muslim scholars need to question it in the digital sphere most of the youth who use social media want selfexpression in their accounts which in turn leads to the breaking of islamic values among muslim ummah if there is no guidance for muslims using social media moreover there are occurrences where women who do not care about morals consider tiktok as an avenue for them to make money or gain fame in society through nude videos on tiktok

in english tiktok is a new social media site that offers a lot of features to let its users create expressive content on their own most of the users on this platform create indecent video content about dancing excessively and other immoral acts particularly by women this paper therefore aims to discuss the behavior of some unmarried muslim women on tiktok in northern nigeria it was observed that the attitudes of some unmarried muslim women on social media especially on tiktok are unbecoming and go against the moral teachings of islam as it relates to social engagement the researchers also discovered that most of the women are involved in indecent behaviors on the tiktok platform where some of these unmarried muslim females either in the name of becoming celebrities or advertising a brand for the public to see via videos that were uploaded to the platform thereby exposing their bodies to those who are not their mahram to see this study was conducted using a survey method and data were collected through indepth interviews the researchers therefore recommend that islamic dawah is the only way forward to curtail such unethical behaviors among muslims in northern nigeria the study also recommended that there was an urgent need for muslim scholars in northern nigeria and beyond to intensify efforts through preaches in masjid schools and other public gatherings on the menace of tiktok on muslim ummah most importantly the youth

introduction how do national models of solidarity shape public support for policy responses to social and economic crises the covid19 pandemic has laid bare the limitations of models of economic governance across the advanced industrial world including gaps in national systems of social protection overreliance on social benefits derived from labormarket relationships and the effects of decades of underinvestment in educational and vocationaltraining systems in the process it has highlighted trends that long predate it discrediting the longheld neoliberal nostrum that limited states and an expansive scope for market forces lead inexorably to generalized economic prosperity it has also shown the need to revisit the question of social solidarities and norms of community and mutual support that inform prevailing conceptions of economic citizenship as well as expectations of the scope and character of state involvement in the economy in the process it has brought renewed attention to the origins and effects of nationally distinctive socialprotection institutions which now more than ever seem essential to the capacity of capitalist economies and their citizenries to adjust to shifting social and economic challenges using covid19 pandemic as a signal case we investigate how the acute uncertainties occasioned by such shocks reshape citizens capacity for empathy and mutual support their willingness to sacrifice for the sake of societal welfare and their support for particular kinds of collective responses that enjoy broad legitimacy and reflect a shared sense of public purpose in so doing we draw analogies with other kinds of national trauma such as wars which have historically transformed both patterns of social solidarity and support for an expansion of governments role as with the creation of a comprehensive british welfare state in the aftermath of world war ii we present systematic publicopinion data and tie public views to policy initiatives undertaken by advanced industrial states in order to show how and the extent to which public policies have garnered support and how patterns of policy interventions have varied crossnationally in the process we also generate broader insights about how historical episodes that generate massive increases in economic insecurity inform distinctive collective understandings and support particular patterns of economic governance in so doing we move beyond prevailing institutionalist and rationalist approaches to investigate the sources of existing institutional and policy frameworks in public opinion and prevailing public discourses related to work fairness the economic role of the state and the meaning of economic citizenship and solidarity this means treating existing institutional frameworks not as analytical points of departure but rather as expressions of underlying public norms and models of solidarity of which both they and the character of policy responses to economic shocks are expressions we focus on germany and the united states countries with widely divergent modes of integration of capitalist markets differential levels of state capacity distinctive systems of social protection and starkly different institutionalized relationships between capital and labor attention to these differences allows us to explain how interactions between socialprotection arrangements and related labormarket institutions inform public expectations of government and support for a range of policy responses to covid19 such distinctions between the american and german models and by extension liberal and mixed economies more generally have been analyzed in decades of research from the comparativewelfarestate literature to the wellknown distinction between liberal and coordinated market economies advanced by the varietiesofcapitalism literature however we go beyond them in analyzing broad patterns of social solidarity and attendant models of economic governance focusing on the state as a key variable with particular emphasis on how prevailing conceptions of social obligation shared by both elites and mass publics support distinctive patterns of state intervention we trace american and german policy responses between march 2020 and july 2021 the period during which the key policy responses to the pandemic were crafted across a number of policy domains including social protection financial assistance to firms tax breaks for individuals and families and fiscalstimulus initiatives we then undertake systematic analysis of public opinion in germany and the us about such initiatives and broader questions of trust inequality and solidarity this comparative casestudy approach furthers our understanding of causal mechanisms at work in these two country contexts moving beyond the mere observation of models to key social and discursive mechanisms that sustain them over time we argue that differing conceptions of public purpose and models of solidarity have led to distinctive patterns of public support for both state action in general and policy responses in both countries the emotional trauma wrought by the pandemic led to a marked increase in public trust of government and public officials at the same time the policies supported by the public varied significantly with levels of economic embeddedness and the degree of institutionalization of economic relationships in the us where such relationships are much more disembedded and atomized public discourse reflects a more individualized conception of social organization and social trust and cohesion have been undermined by partisan and ideological battles public and elite support has coalesced behind particularistic and palliative benefits aimed at individuals and affected firms in germany by contrast both the public and elites have favored policy instruments that support strategically important groups such as skilled labor and firms in exportintensive industries supported by a more robust conception of social purpose and mutual reliance and aiming proactively to prevent or minimize social and economic dislocation these patterns of public opinion and institutional configurations both reflect and reinforce distinctive models of social solidarity in germany this model tends to reflect a greater sense of shared public purpose and collective welfare focused upon the economic fortunes of key groups in the economy within which a sense of shared identity tends to cohere in the us by contrast a much more individualistic conception of deservingness effort and responsibility undermines such collective identities and with it support for government initiatives in the service of a sense of shared public purpose these differential responses and the models of solidarity that underpin them carry with them distinctive sets of life chances for workers for whom structural economic and power inequalities are both symptoms and reinforcing causes of nationally distinctive social contracts in the next section we develop our theoretical framework which synthesizes sociological and historical conceptions of capitalism with moraleconomy understandings of fairness and associated patterns of public opinion we then present an overview of german and american policy responses to the pandemic highlighting characteristic differences then we present a second set of empirical data connecting patterns of public opinion in the two countries to levels of social trust and support for particular policy interventions we end by exploring the theoretical significance of our findings and speculating about their implications for other episodes of national trauma from embeddedness to public purpose and solidarity theoretical underpinnings of responses to economic crisis the epidemiological and economic shock of the covid19 pandemic was equally a social and political one unsettling conventional wisdoms about the relationship between the state and the market as such it presents an opportunity to analyze the relationship between public support for social and economic policies designed to buffer workers and norms relating to social solidarity and mutual support among citizens our theoretical point of departure is that the degree of social cohesion involving horizontal bonds among citizens shapes citizens attitudes toward and trust in the state in investigating patterns of change in both of these contexts we shed light on how periods of heightened economic uncertainty and trauma shape the structure and cohesiveness of social bonds and public support for evolving models of economic governance thus we work to connect theoretically and empirically patterns of social cohesion and embeddedness to the possibilities for a congruent conception of public purpose between the public and governing elites theoretical approaches to systemic reactions to crises in developing our macrolevel theoretical framework we build upon two distinctive scholarly traditions the first entails work on the comparative historical sociology of capitalism exemplified in the work of polanyi polanyi provides a sociological conception of the emergence of capitalism demonstrating that a market society was a deliberate construction of the state constrained by limitations to the commodification of labor prior to the beginning of the process of market construction in the 18th century economic life was informed by the older norms of reciprocity and redistribution informing such practices as sharing among kinship groups in contrast to the transactional norms that emerged subsequently the implication is that the norms that govern patterns of adjustment to economic disruption are informed by deep structures of human solidarity that legitimate particular patterns of state economic engagement and attendant policy expectations this idea suggests in turn that differently constituted political economies with varying historical patterns of economic relationships among groups and between groups and the state will generate different public expectations and support for policy responses polanyis emphasis upon the socially embedded character of capitalist economic relations provided a touchstone for critiques of the neoliberal marketbased orthodoxies since the 1970s granovetter for example brought similar insights to bear on contemporary economic debates over the appropriate and feasible scope of market arrangements in advanced industrial economies he argues that even highly modern forms of economic life the level of economic embeddedness has always been and continues to be more substantial than allowed by economists and formalists economic sociologists locate the foundations of capitalist economies in the social relationships on which market transactions ultimately rely a view at odds with the transactional and atomized conception of human beings central to classical models while polanyis account is more developmentalist than granovetters they share a key conviction that is central to our approach that economic and social relations are coconstitutive and that individuals capacity to support collective economic endeavors is tied to the extent and character of social embeddedness in this way economic activity is understood not merely as a matter of individual initiative but also as part of a broader pattern of engagement in which citizens derive support from one another and the state the second related body of scholarship that informs our analytical framework seeks to historicize and identify mechanisms that govern workers individual and collective responses to disruptive economic change the moraleconomy literature exemplified in the work of thompson grew out of the new left including scholars such as stuart hall and ralph milliband who contended that culture and ideology had become as important as class thompson argues that a moral economy suppose s definite and passionately held notions of the common weal a consistent traditional view of social norms and obligations of the proper economic functions of several parties within the community such scholarship provides powerful tools for understanding contemporary public and élite reactions to the devastation of the covid19 pandemic in like fashion we seek to understand how differing degrees of social embeddedness and the horizontal tiesboth actual and notionalthat constitute them inform public trust in government and support for particular kinds of policy responses this leads to our first of five theoretical expectations which establishes a broad theoretical framework for the microlevel propositions described subsequently proposition 1 individuals are connected to the market in nationally distinctive ways and differing patterns of social embeddedness generate divergent expectations of the state taken together these literatures generate different expectations regarding citizens responses to exogenous shocks such as the covid19 pandemic in contrast to economistic models of atomized individuals they posit a deeply socially embedded frame within which individuals act within social contexts and are willing to constrain their individual prerogatives for the sake of collective welfare relatedly they lead one to expect that societies with different constellations of political and social arrangements will respond differently to such shocks in terms of both citizens willingness to acknowledge the importance of societal benefit and their expectations of the character and extent of state support microlevel approaches to the nexus between politics and public opinion we now consider the mechanisms that inform individuals reactions to collective shocks the sudden onset of covid19 and the resulting epistemological and narrative instability across both mass publics and elites provides potentially fertile ground on which to assess the effects of such shocks on social cohesion trust and support for social and economic policies whereas our knowledge about political and social institutions guides our expectations about what governments might be expected to do we must turn to publicopinion research to understand how the public reacted in these two countries and how such reactions shaped state responses in theory it is possible to differentiate between the publics reactions to the pandemic itself and to policy responses to deal with it by asking questions about both the pandemic itself and government measures in practice however this proves to be more difficult as there is a significant time lag between sudden events and their effects on public polling a rich scholarly literature about crises and their effects on public opinion provides guidance about how to understand crises that cannot be easily attributed to broader problems with society government or the economy with much longer gestational periods and time horizons whereas in such instances citizens attitudes about crises are shaped by their assessment of the perceived underlying problems we focus instead on publicopinion reactions to pandemics and other similar catastrophes such as wars and natural disasters there is robust evidence for a unifying effect of external shocks in support of the executive and incumbent governments and administrations such rally effects can be seen after military conflicts assuming the presence of some media attention the microlevel mechanism is that those who are ambivalent about the executive tend to increase support for government elite criticism of government immediately after the onset of a crisis is often less prevalent in the media and citizens perceive a stronger elite consensus in such contexts and adjust their attitudes accordingly the individual reactions that lead to such effects are driven by powerful emotions threats trigger anxiety and the desire for security which citizens often seek from public officials and institutions some psychological theories emphasize humans yearning for a world that is predictable and secure although military conflicts are the moststudied trigger of a rallyaroundtheflag effect similar effects can be observed in the affirmation of ingroup memberships in response to perceptions of threats from outgroups in other words perceptions of threats and insecurity tend to generate expectations of both the state and fellow citizens and the effects of such dynamics extend beyond policies to social behavior more generally altruism with respect to ones ingroup seems closely tied to conflict and catastrophe that said one should expect different kinds of public reactions and different levels of support for policies that reflect and reinforce distinctive conceptions of social solidarity proposition 2 the onset of pandemics will increase support for incumbents and political trust in government in the short run wars have been shown to create prosocial behavior at the individual level and to encourage burdensharing and institutionbuilding at the collective level the collective experience of hardship during war seems to lead to a logic of we share the burden we share resources covid19 was not a war but it had some characteristics that remind us of wartime experiences for example covid19 was potentially deadly for millions with as a result we are constrained by the timing of polling e orts and their relationship to government actions such as executive orders introducing physical distancing measures unknown consequences for citizens longterm health increases in prosocial behavior was a plausible expectation as the economic devastation wrought by the pandemic far exceeded the coping capacity of individuals or even significant social groups the traumatic experience of covid19 might also lead to altered preferences and thus a higher level of prosociality reflected in social trust proposition 3 social trust will increase in both countries in the short run as with wars in this scenario citizens might support major government interventions related to health policy as in the case of economic policy it would thus be plausible to expect citizens to grow accustomed to a more active role for government and for this effect to be more visible in the us where baseline state capacity is weaker than in germany however it remains unclear whether this shift in attitudes would be related primarily to the scope of government or rather to the intensity of its activities proposition 4 with respect to social and economic policy pathdependent crossnational policy divergence will develop with increased support for highly individualized provisions in the us in contrast to support for more collectivelyor grouporiented policies in germany given the magnitude of the pandemics shock to the two societies it is reasonable to expect significant change in the policy priorities within their populations however the two countries differ significantly in the organization of their healthcare systems a fact that would be consistent with different sets of expectations in germany coverage of health insurance is quasiuniversal with funding burdens and managerial tasks shared between worker and employer representatives the publichospital system is robust and the publichealth infrastructure is well developed in the united states by contrast despite the expansion of coverage resulting from the affordable care act coverage is spotty and incomplete and benefit terms are much less generous public hospitals are also fragmented and uneven in coverage and publichealth infrastructure is underdeveloped and underfunded with widely varying capacities across states the pandemic should increase public concerns about unemployment though the character of the concern and respective points of emphasis are unclear a priori in germany normal unemployment insurance pays up to 67 of a workers previous wage with benefit duration scaled by age and time of employment but typically lasting at least a year thereafter the lessgenerous hartz iv benefit kicks in vail in the united states by contrast unemployment insurance is limited to a few hundred dollars per week varying significantly by state in generosity and terms of eligibility whereas german workers and employers view unemployment insurance as a benefit paid for through contributions over time in the us the benefit is heavily stigmatized and is contingent upon oftenonerous jobsearch reporting and monitoring requirements these policy and institutional differences are both possible drivers of distinct patterns of state intervention and historical artifacts of deeply rooted differences in public conceptions of politics and social organization the economic dislocation resulting from the pandemic leads one to expect social inequality to become more prominent in peoples minds though in ways shaped by these policy and institutional differences the pandemic was much more difficult for people with fewer assets who could not work remotely and who were responsible for caring for children or dependent adults under such circumstances it is reasonable to expect an increase in the salience of economic inequality but it is less clear a priori how citizens socialized in these two systems would interpret and respond to it traditionally the american public is much more tolerant of social inequality bénabou and tirole relate this discrepancy to the prevalence of the belief that individuals and their children can succeed economically it is thus reasonable to expect that the salience of social inequality would rise in both countries but that the demand for government action will be limited in the us as fewer citizens view government as a legitimate remedy to social problems this reasoning leads us to our fifth and final proposition proposition 5 support for policy measures to reduce inequality will increase in germany but not in the us research design and data we look at two countrycrisis episodes the united states in 20192021 and germany in 20192021 we concentrate on policy responses at the national level as a first set of reactions and on public opinion as a second we also consider variation within that period over time in each country the challenges related to health the labor market and the economy were similar but the reactions were quite different we are thus echoing other comparative approaches to moral economies in which the two countries are often selected as representative of different welfare regimes we explore the extent to which similar challenges were channeled differently in the two countries causally we employ the logic of withincase designs assuming that germany in february 2020 is similar to germany in january 2020 with the obvious difference that the first local infections of covid19 were discovered in february the exogenous origin of the pandemic leads to the plausible assumption that a temporal change between january 2020 and subsequent periods can be attributed to covid19 however we must be careful not to discount the difference between reactions to the pandemic and reactions to behavior by political actors thus for instance a rise in political trust after the onset of the pandemic might be a function of fears being more prevalent in the population or instead of an appreciation of adopted policy measures public opinion data bear out this contention in a recent pew survey fewer than four in ten americans surveyed believed that addressing inequality should be a top priority of government in contrast in an oecd poll more than half of germans surveyed strongly believed that inequality was too great well above the oecd average and in increasing shares over time since see mitchell and oecd we have collected extensive data building on various efforts by other scholars and on secondary usage of existing analyses we also make use of ten commercial and scientific public opinion data sources some of them with different surveys all data are accessible to the public scientists or through available commercial databases the publicopinion data differ slightly in their sampling procedure and their survey mode we use different indicators of public opinion to assess the relationship between citizens and the state and among citizens we examine confidence in national government trust in national government support for the incumbent social trust and attitudes toward specific policies all of these variables capture slightly different aspects of citizens connections to the state or to other individuals the objective of this triangulating kaleidoscope of publicopinion pieces is to paint a broad picture about changes attributable to the pandemic and attitudes toward policies adopted to fight it we can trace changes over time of some measures of public opinion and static snapshots of others given the observational nature of our data we cannot distinguish whether changes over time were already anticipated by policymakers when implementing these public policies empirical analysis publicpolicy responses to covidin germany and the united states like many advanced industrial countries germany and the united states rapidly deployed vast fiscal and administrative resources following the advent of covid19 in march 2020 and continued economic support into the summer of 2021 these measures included loan guarantees and payroll subsidies to businesses investments in public infrastructure and direct assistance in germany the scale of policy responses echoed that following reunification in 1990 when more than e2 trillion was spent over three decades in the us the response involved a major deployment of state power and resources unmatched since the great depression shifting the prevailing policymaking paradigm away from the smallgovernment and neoliberal orthodoxies that even the post2008 great recession had been unable to displace both countries fiscaland economicpolicy responses were breathtakingly ambitious including all discretionary spending until march 2021 the us spent more than any other country while germanys at 203 of gdp was seventh largest in the world figure major events in the covidpandemic and policy responses preempting dislocation in germany subsidizing business supporting core workers and families and bolstering public investment germanys economicpolicy strategy in the wake of covid19 involved a combination of generous support for publichealth initiatives and an extension of both direct and indirect support to core constituencies of the social market economy including industrial firms small businesses workers in key industries and families in late march 2020 merkels government announced two major initiatives to support economic activity and buffer disproportionately affected groups the first the socalled coronaschutzschild für deutschland allocated e3533 billion including e35 billion for personal protective equipment for hospitals and investments in vaccine development e55 billion to remedy hospitals and doctors deteriorating finances and to provide support to families including subsidies for lost earnings and extended access to family allowances and e50 billion in socalled soforthilfe for small businesses freelancers and the selfemployed the second initiative the wirtschaftsstabilisierungsfonds earmarked e8917 billion for larger firms particularly those with strategic economic importance this measure included e400 billion in loan guarantees e100 million for an assistance program for firms within the kreditanstalt für wiederaufbau and tax breaks and abatements to help firms clean up their balance sheets the government also provided extensive support for workers particularly those in manufacturing and key export sectors the signal initiative in this category involved the socalled kurzarbeitergeld or shorttime work program originally created in the aftermath of german reunification and resuscitated in the wake of the great recession these schemes allow atrisk workers to work reduced hours while receiving up to 90 of their previous pay so as to avoid disruptive and costly layoffs between march and december 2020 alone an additional e235 billion was spent on related programs in a supplementary budget of e1225 billion adopted in the same month the government extended other forms of support to german workers including an additional e77 billion for the secondtier assistance program for the unemployed in june 2020 the government adopted a second major stimulus package worth e130 billion that focused on tax relief to german firms and consumers and additional resources for families with children long a core constituency of the postwar social market economy the two vat rates were cut from 19 to 16 for the standard rate and 7 to 5 for necessities such as groceries the initiative also provided an additional e300perchild bonus payment to families and more than doubled the incometax exemption for single parents to e4000 the package also extended a number of tax breaks including subsidies for municipalities suffering from declining tax revenue and a 40 cap on socialsecurity contributions for firms it increased depreciation allowances and created more generous provisions for declaring losses from previous tax years finally the measure made significant investments in renewable energy and infrastructure including investments in electric vehicles batterytechnology development and the modernization of germanys aging fleets of buses and commercial vehicles in october an additional e15 billion was provided for grants to companies and in march 2021 an additional e150 per child was paid to families although the eu invested significant funds in vaccine development and distribution both publichealth regulations and investments in economicadjustment funding was undertaken largely on the national level although some of the funding eg the recovery and resilience facility derived from eu sources the allocation of the spending was largely an affair of the member states taken together these nationallevel initiatives provided urgently needed support for both investment and consumption and represented remarkably openended commitments for a country normally associated with fiscal probity at the same time they reflected significant continuity of policy orientation with a focus on key social and economic groups and a more socialized conception of welfare preemptively intervening to avoid social and economic damage rather than mitigating it after the fact though germanys more robust network of automatic stabilizers such as unemployment insurance might help to explain the fact that officials favored a more targeted approach with the general population benefitting from preexisting more general benefits the reduction in generosity of such benefits with the socalled hartz iv reforms in the early 2000s has constrained such support accordingly the disproportionate support afforded to economically important groups during the pandemic suggests the durability of established insideroutsider cleavages that have long characterized the german exportled growth model to the extent that such automatic stabilizers are operative they provide support that is different in scope and scale from the robust targeted measures that constituted the core of the german response repairing damage in the united states investing in public health and a targeted shortterm expansion of the safety net in early 2020 congress in rare bipartisan fashion responded aggressively to the pandemic passing three distinct but related measures the first the coronavirus preparedness and response supplemental appropriations act devoted a modest 83 billion to support public health dedicated funds to vaccine research funded broad publichealth initiatives on the federal state and local levels and purchased personal protective equipment for medical professionals the second package the socalled families first coronavirus response act focused on the pandemics economic effects on individuals it devoted a total of 192 billion to paid sick and medical leave for certain categories of businesses and significant subsidies to the supplemental nutrition assistance program temporarily increased the generosity of medicaid and medicare and subsidized existing unemploymentinsurance benefits the third and much more extensive measure dubbed the coronavirus aid relief and economic security act represented the most extensive crisisrelated package since the new deal costing 22 trillion the measure involved four distinctive areas of assistance the first entailed an increase in the generosity of unemployment insurance providing an additional 600 per week and extending the length of eligibility a second measure offered onetime relief payments of up to 1200 per adult and 500 per child the third extended support to businesses directly affected by the collapse in demand including 350 billion for forgivable loans to small and mediumsized enterprises and 58 billion for airlines which had seen air traffic decline by about 60 the fourth measure included funds for overwhelmed hospitals additional funds for vaccine development veterans health and the centers for disease control and prevention and money for medical equipment and community health centers in april congress passed an additional program the paycheck protection program which provided loans forgivable under certain circumstances to firms in exchange for their commitment to keep workers on their payroll in addition the law created a new type of unemployment assistance as opposed to insurance which extended eligibility to previously ineligible people including those who had exhausted their statelevel benefits those who quit their jobs to care for ill family members and the selfemployed whose incomes were affected by the pandemic following president bidens electoral victory in november 2020 congress adopted an 900 billion package that focused on extending existing programs to support affected households and businesses the measure provided additional incomecontingent stimulus payments of 600 per person additional unemployment payments of 300 per week childcare and nutrition assistance for the poorest americans and emergency assistance to renters on the business side it provided an additional 248 billion for the paycheck protection program and funding for colleges and universities and the entertainment industry it also devoted modest resources to infrastructure initiatives including money to expand broadband internet access for families whose children were being educated at home and 45 billion for airlines highway repairs and public transportation following two surprising democratic victories in the georgia senate runoffs which gave democrats unified political control congress enacted the 19 trillion american rescue plan in march 2021 with no republican support this package was unprecedented in scope with large extensions of previous measures as well as an array of new initiatives including onetime incomecontingent payments of 1400 for each adult and child and an extension of additional federal payments for unemployment insurance breaking with historical patterns of federal support for children which had traditionally been provided through nonrefundable tax credits the measure introduced 6 months of direct family allowances scaled by family income and refundable beyond a familys tax liability this paradigmshifting initiative which like most of the package was fiercely opposed by republicans represented an unprecedented assumption of federal responsibility for supporting children the package also extended 350 billion to state and local government and money for educational the contrast between the targeted timedelimited nature of this program and its reliance on loans and the much more generous and openended kurzarbeitergeld program in germany is typical the recent excision of this measure from the inflation reduction act passed in august shows how precarious this shift was institutions restaurants earlychildhood development programs vaccine distribution public transportation and infrastructure as well as more than a half billion dollars for the federal emergency management associations emergency food and shelter program focusing overwhelmingly on directly affected individuals and business and lowincome families the measure was much more targeted than its german counterpart and reflected a more individualistic and fragmented model of solidarity this difference is consistent with broader policy patterns in the two countries welfare states germanys neocorporatist logic and administration yield contributory policies jointly managed by workers and employers across a wide range of policy areas from unemployment insurance to pensions to health care in the us with the sole exceptions of social security and medicare by contrast policies tend to focus on individual behaviors and often impose onerous work and jobsearch requirements for eligibility though this varies significantly by state salient examples include temporary assistance for needy families and many stateadministered unemploymentinsurance schemes empirical analysis public opinion reactions in view of these divergent policy responses we now turn to the mechanisms located in individuals views and priorities that lie behind such patterns we start by examining potential rallytotheflag effects gallup runs a longestablished global series asking for confidence in ones government both countries reveal a clear jump in aggregate confidence in government between 2019 and 2020 the german publics confidence rose by 8 points from 57 to 65 the american publics confidence rose by 10 points from 36 to 46 what is more the high levels of confidence in both countries are exceptional in the long run dating back to 2006 in this series the secondhighest confidence level in germany was 63 in 2015 in the us only 2006 and 2009 witnessed higher levels at 56 and 50 the change from 2020 to 2021 is downward again in both countries with 56 points this is what we would expect if an emotionally driven rally to the flag effect were in place this outcome is consistent with proposition 2 above relating to expectations of increased trust in government though it also provides reason to expect distinctive patterns of support crossnationally for a comparable indicator we see a similar picture a sizeable jump in trust in government by 19 points in germany and nine points in the us between 2019 and 2020 followed by a decline in 2021 that we have already seen for confidence in national government this increase in political trust after the onset of the pandemic has been demonstrated for other contexts in western europe in both countries there was an increase in approval of the leadership of the respective country which was much smaller in the united states than in germany these trends reflected the different levels of general support or approval of national governments the relative changes were upward in both countries between 2019 and 2020 after 2020 the united states experienced a change in leadership from trump to biden german approval rates decreased by nine points whereas the us public had a small increase in approval by two points despite the many institutional differences as expected in proposition 2 we see similar indications of deeply human emotional reactions human nature and the associated need for assurance and safety dominates over institutionally embedded learning experiences we also find some evidence of an increase in social trust in 2020 the levels of social trust were indistinguishable in the two countries at 58 59 in 2014 however the levels were much lower at 42 and 38 respectively in 20172018 the german estimates were unchanged whereas in the us they had declined to 32 thus available evidence shows higher levels of social trust in 2020 than in earlier years but with similar levels at the height of the crisis this outcome supports our proposition that countries with higher degrees of another indicator by gallup world poll reveals a similar picture with of germany in and in trusting their national government some or a lot compared to and in the usa social embeddedness will experience greater social trust in the presence of social and economic dislocation with respect to attitudes toward specific economic and social policies in germany there is strong evidence for support for statusmaintaining policies and investments in preserving and protecting key groups in the labor market according to our estimates from mayjune 2020 in table 6 four measures that directly protect jobs had approval rates of 50 and more perhead payments for the public by contrast were only supported by 21 of the populace in another survey conducted at the same time oneoff payments for families with children also found a majority of 57 the absence of any questions about healthcare reflects the fact that the nearuniversal socialized healthcare system is uncontroversial in germany with respect to american publicopinion data regarding specific policies health policy was the most salient policy area before the crisis and remained so afterwards various surveys reveal that this was the most important issue for the american public 89 in february 2020 just before the pandemic 85 in may 87 in september and 91 in october 2020 in other words the electoral salience of health policy was not really affected by the pandemic in the us because it had been so salient before it thus comes as no surprise that healthpolicy changes suggested to fight the pandemic found broad majorities as well finally we consider public views on inequality in germany there is evidence for increased support for a wealth tax for people with at least e500000 in assets to combat the economic consequences of the pandemic in may 2020 51 supported such a measure compared to 56 in november 2020 and 58 in february 2021 this increase in support however is not mirrored in support for an increase in the solidarity contribution levied since the 1990s in order to promote socioeconomic equality between east and west among americans 67 supported a universal basic income for the course of the pandemic in july 2020 but there is no evidence for robust support for sustained measures to combat inequality both countries show high levels of concern about division though this is not the same as concern about inequality after the covid crisis 67 of germans and 89 of americans were worried about greater division in society although statelevel implementational differences in publichealth measures such as mask mandates varied in the united states there is no evidence that such differences exerted any systemic effects on nationallevel support for publicspending initiatives designed to buffer citizens from the economic effects of the pandemic in germany such regional differences were more muted with variations stemming largely from regional and timedelimited differences in the severity of the outbreak and to a lesser extent ideological differences among länder governments in general terms länder governments sought to achieve consensus and to limit crossregional variations in the implementation of federallevel mandates we therefore conclude that both states federal structures exerted limited and nonsystemic effects upon public policy and patterns of public support although some recent policy initiatives by the biden administration might lead one to conclude that the american public has become more broadly supportive of government intervention we believe that caution is warranted on this score to be sure the passage of the 2022 inflation reduction act which embarks on a set of serious industrialpolicy initiatives related mostly to combatting climate change might lead one to conclude that support for robust government intervention had durably increased however given widespread public unfamiliarity with the acts provisions broad public support for the legislation should be taken with a grain of salt even broad support for some of the acts main provisions such as tax credits for investments in clean energy infrastructure public support for the act must be set against americans historical preference for tax credits which are easier to sell politically than direct fiscal outlays which they distrust these factors suggest that this departure from past trends is fragile and unlikely to be reproduced across other contexts indeed the recent abandonment of the refundable and more generous child tax credit promulgated as part of postcovid stimulus measures would seem to justify such skepticism in sum we find support for positive reactions associated with a rallytotheflag effect in both countries indicated in increases in confidence and trust in government and approval of the national leaders for prosociality social trust shows an increase in both countries for 2020 compared to earlier years the policyspecific reactions are surprisingly predictable given the intensity and breadth of the pandemic in its consequences citizens seem to remain relatively consistent in how they want governments to react the german public seems to be supportive as we would expect of aggressive policies to combat inequality whereas in the us we only see evidence for timedelimited measures that would last only for the duration of the crisis in addition postcovid patterns of policy making in both countries with the partial exception of the ira in the us have continued to hew to established paradigms the german reliance on the kurzarbeitergeld program and the american abandonment of the refundable child tax credit serve as illustrative examples to be sure with these surveys we cannot be sure how citizens would have responded to other survey questions with that caveat we argue that these outcomes are consistent with our propositions relating to both common effects across countries and crossnational variation in public support for particular sets of policy responses conclusion social embeddedness public opinion and public policy the lessons of covid we have traced german and american policy responses to covid19 and explained them as the products of differing patterns of embeddedness and associated models of solidarity using a systematic investigation of shifts in public opinion in the two countries with particular emphasis upon levels of public trust in government and support for varying policy initiatives the it is worth noting that the act also contained a widely popular provision enabling medicare to negotiate drug prices with pharmaceutical companies which no doubt bolstered support for the law overall frontiers in political science frontiersinorg trauma of the pandemic led to highly emotionally charged public responses with significant increases in public trust in and reliance upon government in both countries this development reflects a significant rallyaroundtheflag effect a reaction that was perhaps surprising in the united states given the deep currents of public distrust of government that have prevailed there since the 1980s that said the character of shifts in public opinion differed markedly in the two countries in the united states where economic relationships are much more disembedded and the moral economy more fragmented and individualistic the public disproportionately supported individualized benefits and assistance to individuals and firms directly affected by the pandemic in germany by contrast where economic and labormarkets are more deeply embedded and where workers and employers have traditionally shared a common if sometimes contested sense of public purpose surveys reflected support for investments in existing collectivized labormarket institutions rather than merely to repair economic damage after the fact these distinctive arrangements and patterns of social embeddedness we argue help to explain the fact that the measures supported by german citizens tended to be more solidaristic and institutionalized with the kurzarbeitergeld and state support for new hires serving as a key example if the american response reflected a logic of posthoc palliative care then its german counterpart reflected one of preventative medicine combined with systemic investment in established social and economic relationships although the full scale of the effects of the pandemic will take several years to reveal themselves our research suggests several important implications relating to the effects of cataclysmic shocks such as pandemics natural disasters and wars first despite widely varying baseline levels of support for government crossnationally such events tend to bolster public support for the collective responses that only states can provide second the kinds of policy interventions supported by citizens may well parallel and perhaps even reinforce preexisting levels of social embeddedness in the economy with patterns of groupbased solidarities acting as both outgrowths and reinforcements of existing institutions and established political and social practices in this context distinctive national moral economies and social and economic institutions are tightly linked with exogenous shocks revealing underlying shared moral and conceptual frameworks that are not reducible to simple institutional dynamics but rather reflect deeply embedded understandings of the imperatives of remedying structural inequalities and differential access to economic resources these findings are consistent with those presented in other recent work including finally in a more speculative vein we suggest that the ways in which such underlying normative structures mediate between catastrophes and both public attitudes and social and economic arrangements may take years to unfold much as the black death in the 14th century began to erode feudalism in ways that were far from obvious at the time such longterm this article cited is one contribution to a special issue of social policy and administration several of the articles of which deal with crossnational and crossregional variation in policy responses to covid consequences could also be highly regionalized and pan out differently across large polities especially when they are federal states in future research we hope to exploit the increasing availability of longitudinal publicopinion data related to covid19 to arrive at more systematic conclusions about the relationship between catastrophes and public attitudes in an era in which such catastrophesranging from pandemics to natural disasters whose severity and frequency are increasing in the wake of humanengendered climate changeare becoming both more common and more severe their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding author funding the author declare financial support was received for the research authorship andor publication of this article the libraries of tulane university wake forest university and the university of duisburg essen provided research support and the latter generously funded the access to the roper archive and gallup analytics ag would like to thank the european research council for funding this paper including publication costs through the consolidator grant project politsolid political solidarities accessible at politsolid publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of supplementary material the supplementary material for this article can be found online at 1273824full supplementarymaterial

how national models of solidarity shaped public support for policy responses to the covidcrisis in

introduction biases in automated decisionmaking have negative implications for different stakeholders individuals and groups who are at risk of discrimination and systematically inferior outcomes organizations which may receive bad publicity andor may suffer from legal consequences given that systematic discrimination is often penalized by law and societies which risk inflexible social stratification and political riots by those who have been discriminated against thus it is critical to ensure fair decisions especially those taken or supported by algorithms an unfair decision is often hard to detect and repair this is particularly challenging when the decision is based on machine learning ml cannot provide meaningful explanations of how a decision was made thus in case of errors easy corrections are not possible static and rulesbased algorithms can also generate biases which remain obscured unless outcomes are systematically reviewed since algorithms are chosen based on their performance on the task at hand rather than on fairness undesired effects often go unnoticed recent advances in algorithmic fairness claim to provide a remedy algorithmic fairness is used to refer to technological solutions that prevent systematic harm to different subgroups in automated decisionmaking from a technical perspective af seeks to mathematically quantify bias and based on this metric to mitigate discrimination in ml against subgroups in recent years several operationalizations and applications of af have emerged in the information systems research these publications have often viewed unfairness in decisionmaking systems as a technical issue and have sought technical remedies thus they have followed most other studies which view af as a technical discipline however unfairness in algorithmic decisionmaking is not solely a technical phenomenon it has societal organizational and technical sources is reinforced by both social and technical structures and as we argue should be approached from a sociotechnical perspective 1 the sociotechnical perspective acknowledges that a systems outcomes depend on mutual influences between technical and social structures as well as between instrumental and humanist values decisionmaking does not happen in a purely technical context persons are subjects and objects of decisions or experience higherlevel consequences thereof however a purely social framing may also be inappropriate if it does not consider how the proposed social solutions fit the multiple algorithms in decisionmaking processes algorithms not only support persons in taking a decision but may also delude them may trick them into a decision or may simply be used as an excuse when a decision becomes unpopular thus the social and technical components of decisionmaking become intertwined in many ways demanding a broader ecosystembased perspective the sociotechnical perspective bears the potential to yield holistic solutions to the unfairness that emerges in the stateoftheart decisionmaking configurations an effective approach to af requires coordination and balance among technical innovation politicallegal actions and social awareness however we do not yet have a unifying perspective that integrates technological and social efforts in the context of af researchers across disciplines have proposed various solutions focusing on specific aspects of af but have lacked a comprehensive overarching framework to ensure coherence among the approaches for instance the political decision that forbids the collection of sensitive attributes does not align well with the 1 we develop afs meaning from a purely technological notion as has been dominant to date to a sociotechnical notion positioning af as a phenomenon according to the former af comprises technological means that prevent systematic bias in an algorithms output in our proposed sociotechnical notion af describes the use of algorithmic as well as organizational or processual ways to assure that the application and output of whole decision processes that involve algorithms does not produce systematic discrimination and injustice we use fairness to refer to the notion or construct being used to assess the quality of a decision or a state algorithmic solutions that use exactly these attributes to assure that no group is systematically discriminated against thus organizations have rarely considered af to be relevant because the proposed technological solutions are considered incomplete and thus not practically applicable motivated by this void we explore the potential of adopting a sociotechnical perspective to understand the origins of algorithmic unfairness and to study its impacts in is practice specifically we contribute by interrogating the premises that underlie purely technical and social perspectives discussing how a sociotechnical perspective yields new insights about afs complex nature and showing how is research can take a leading role in creating and implementing holistic af solutions our research objective is to embed af in the sociotechnical view of is we address it according to the steps proposed by alvesson and sandberg first we review the technical literature on af identifying underlying assumptions of current af practice we then investigate the premises behind positions that criticize current af approaches as groundless or inadequate nonetheless we acknowledge that fairness has emerged as an important social construct that may be compromised by a purely technical perspective simultaneously we accept that technology will be involved in highstakes decisions and fairness considerations we regard af as an inherently sociotechnical construct and elaborate on its roles in sociotechnical systems further we map the existing body of af literature onto a sociotechnical perspective identifying the points at which algorithmic fairness can arise in sociotechnical systems and then formulate research directions for is they show how a sociotechnical perspective can help address challenges of af overall we interrogate the fundamental assumptions that underlie current af research and propose future research directions the remainder of this paper is structured as follows in section 2 we provide a background on the technical notion of af and contrast it to the notions of fairness in other disciplines in section 3 we describe our overall methodology in section 4 we explore the premises of the literature on af as a technical or a social construct in section 5 we argue that af should be understood as a sociotechnical phenomenon in section 6 we employ this view to classify the origins of biases and propose directions for the is discipline to mitigate bias background on fairness and algorithmic fairness af seeks to detect quantify and subsequently mitigate disparate harm across subgroups affected by automated decisionmaking in this section we review how fairness has been defined in af and summarize the current discussion of how fairness has been conceptualized in other disciplines this allows us to discuss the relationships between af and other notions of fairness fairness as a mathematical construct a technical approach to af uses mathematical formalizations of fairness the question what is fair is reduced to a single mathematical expression the mathematical notion of fairness is integrated into algorithms as a mathematical constraint or directly into the objective function for illustration we use a recidivism risk assessment example in which an ml system assesses the risk that a prematurely released prisoner will commit another crime such systems are widely used in the us with compas as a typical example however these systems were found to show systemic discrimination against people of color making clear that it is necessary to study af key to af is that there are different mathematical notions of fairness these are loosely grouped into various concepts of fairness across groups or individuals notions of fairness at the group level build on a predefined sensitive attribute that describes membership in a protected group against which discrimination must be prevented in practice the sensitive attribute is declared a priori systems for recidivism risk assessment use race as a sensitive attribute to ensure fairness across people with different skin colors based on this sensitive attribute grouplevel notions of fairness interpret discrimination by how the prediction models outcomes are distributed across groups inside and outside the protected group an exemplary notion of fairness statistical parity requires the likelihood of events to be equal across all groups in our example it requires the recidivism system to predict white individuals and people of color as posing a risk in the same ratio figure 1 algorithmic fairness at the group level defines mathematical notions using the above confusion matrix other grouplevel notions of fairness rely on prediction errors whereby the confusion matrix from figure 1 is considered for instance one notion equality of accuracy requires ml to attain equal prediction accuracies across both groups specifically it requires the system to keep both the ratio of individuals who do not pose a risk and those who pose a risk the same across white prisoners and those of color as can be seen in the different notions there is no universal operationalization of fairness further it is mathematically impossible to fulfill all the different notions of fairness at once thus the is designer must choose an appropriate mathematical notion for assuring an unbiased outcome yet one for which little guidance is available explainable or interpretable ml can offer support by allowing practitioners to observe both the outputs of their models and the reasoning that support them however explainable ml often delivers insights that are not perceived as useful by persons further all notions of fairness share the same key requirement within the data the sensitive attribute must be available to algorithms so that potential discrimination can be mitigated even though collecting such data may be illegal owing to the sensitive nature of the attributes notions of fairness at the individual level are based on the assumption that similarly situated individuals should be treated similarly this approach strives to ensure fairness independent of group membership this requires a definition of similarity that is suitable in the given use case and provides the basis on which to perform pairwise comparisons in recidivism risk assessment this requires two individuals whose relevant attributes are equal to be subject to the same decision as in grouplevel fairness individuallevel fairness requires access to sensitive attributes it also leaves open how to specify which attributes are relevant or how to formalize relevant yet nonquantitative attributes fairness as a social construct philosophical debates about fairness were originally driven by the question of the distribution of goods and rights and the utopian ideal of a fair ruler todays understanding of fairness suggests that all persons with equal gifts should have equal opportunities for advancement regardless of their initial position in society in short equal distribution of chances for selfadvancement to achieve equity in goods distribution dominates the current philosophical debate thus it is unfair to prevent individuals from improving their situation by limiting chances intentionally or otherwise based on race origin or gender law criminology sociology and the political sciences often take a modern philosophical approach to addressing fairness this leads to the emergence of restorative transitional or retributive justice concepts in which society establishes a fair distribution by repair rebalancing of power or punishment in which fairness is neither given nor predefined instead it is continually constructed this line of reasoning stresses actionable notions of social fairness constantly trying to balance several forces and preserve fairness af has emerged as a defining and affirming force however its mathematical limitations are new compared to the social construct anthropology focuses on the historical origins of fairness as an innate human value also observed in other primates for instance persons and primates who contribute the same amount of work as others but receive a lesser payoff are likely to stop working they tend to punish those engaged in the unequal distribution of goods this suggests that the sense of fairness emerges from evolution toward collaborative societies since collaborative behaviors are relevant for survival fairness propagates over generations thus primates may have a builtin fairness calculation mechanism af may look like an attempt to discover this mechanism which is likely to include as yet unknown aspects that are hard to quantify neuroscience looks for the origins of fairness in the human brain rather than in history brain processes concerning fairness occur in an evolutionarily old brain area this supports claims from anthropology and suggests that fairness is emotional and can be experienced as an intrinsic need a neurological rewards system is activated when goods distribution reaches a fair state however this process is moderated by external factors including similarity among affected individuals situational identity or salient personal goals this may explain why people often disagree about what is fair thus achieving fairness remains an ongoing process rather than a onetime challenge finally psychology sees fairness as a perception of an individual comparing themselves to other individuals whom they consider to be relational partners this view was adopted by organization science with three aspects differentiated distributive reciprocal and procedural these aspects led to the formulation of organizational justice theory reciprocal fairness demonstrates that persons expect truthful and respectful treatment if they act accordingly procedural fairness requires that individuals affected by a decision be given provided with justification and be allowed to contribute to the decision and voice concerns organizational justice was adopted in the is research and is often used to study fairness perceptions inside organizations and their relationships to technologydriven organizational change while all aspects of organizational justice may be affected by algorithmic bias the distributive aspects receive the most attention methodology we engage in problematization so as to establish an informative research agenda for is and the sociotechnical notion of af problematization is an approach for developing research questions from a body of literature we explicate the underlying assumptions in existing studies and question them this frames research as an ongoing dialogue that relies on challenging the status quo rather than gapfilling problematization is a way to facilitate more influential management and organizational literature theories it has been promoted in the recent is literature and was adopted in earlier is studies since the research into af in is is still emerging and relies on perspectives on af from reference disciplines we chose to interrogate assumptions that characterize the af discourse via a multidisciplinary review alvesson and sandberg differentiated between various categories of assumptions that differ in depth and scope inhouse root metaphor paradigm ideology and field assumptions for more detailed descriptions of each category we refer the reader to alvesson and sandberg we use this classification to assess the identified assumptions impacts this provides a solid base for theorizing af in sociotechnical perspectives of is the literature we analyzed was collected from different sources and was then classified on the one hand we screened articles from four key af conferences this led to 166 candidate articles for analysis on the other hand we conducted a querybased search across the top 25 of outlets from a multidisciplinary background and conducted a criteriabased selection within them this led to the selection of 114 more articles in a subsequent step we classified all articles by their approaches to af focus scope and methodological paradigm further we listed and analyzed the implicit and explicit assumptions according to the identified approaches the appendix contains complete descriptions of the steps involved in the data collection and analysis problematizing algorithmic fairness in this section we problematize af we explicate the premises of the papers that were classified as following the technical approach and studies that tracked a more social perspective we infer assumptions that underlie af based on a systematic literature review specifically we identified common assumptions in the literature classified as having either a technical or a social orientation and identified articles that can be used to exemplify the assumptions we found when describing the assumptions we refer to articles from the literature review the analysis revealed that the articles lacked a shared coherent agenda further at first sight the assumptions they make may even contradict one another not all the assumptions we list in the following sections coexist in each paper we considered the papers differed concerning the assumptions they rely on while the literature independent of its core approach provided valuable inputs it has not conceptualized af as a sociotechnical construct despite the overall goal of preventing technologybased societal discrimination shared across fields perspectives or attention foci we dont intend to invalidate the research in the reviewed studies or to suggest the existence of irreconcilable camps we argue that af should be seen as a sociotechnical construct this perspective can reconcile the approaches to af the premises of the technical perspective identification of the assumptions that underlie the perspectives is the first step toward a unified sociotechnical understanding of af and an agenda for advancing the research in a more coherent holistic direction the literature on af has been dominated by the technical perspective accordingly af has been defined as efforts to translate regulations mathematically into nondiscriminatory constraints and develop predictive modeling algorithms that take into account those constraints while at the same time be as accurate as possible or as the aim of assessing and managing various disparities that arise among various demographic groups in connection with the deployment of mlsupported decision systems in various settings while there is nothing wrong with the aim of obeying nondiscrimination constraints or managing disparities this perspective is restricted by the underlying notion of fairness the technical literature relies on a range of paradigmatic assumptions ie shared beliefs definitions and methodological approaches we will now review these assumptions along with appropriate examples from the reviewed studies first the proposed solutions often assume a comprehensive a priori understanding of where and why biases occur the studies frame specific biases as problems in search of a solution in a good engineering way the studies focus on selecting a notion of fairness that is appropriate to this bias then develop a mathematical construct to represent it and use it in the algorithms they posit that there is a mathematical or formal way to adequately resolve biases without generating new previously unknown biases the studies follow the engineering assumption each problem has a humanmade technical solution a solution is good when it solves the problem second technical af posits a conceptual equivalence of various notions of fairness there are concurrent fairness ideals each with varying social connotations still most technical researchers treat them synonymously and select among them as if they were interchangeable there is no consistency concerning what should be considered when selecting a fairness ideal how the selection should be conducted or what the longterm social consequences are of employing any of the measures for instance some studies have simply referred to court cases or have repeated arguments from ethics or political philosophy others have advocated including the selection process for an adequate notion of fairness in a participatory design process or a survey these approaches have moved the decision on an adequate notion of fairness away from the designer or the researcher to the broader public who is presented with various notions of fairness and is asked to choose among them yet even in these cases the implications of the choice have barely been considered depending on the population sampling method this method can even exhibit bias further the thought experiments and hypothetical situations used in these approaches were shown to often fail overall each selection approach makes an equivalence assumption assuming that fairness ideals are to some extent equivalent and that choosing between them takes place in a closed environment as opposed to openended reality third having chosen a fairness ideal the technical literature has posited a mathematical operationalization of it owing to their general and abstract formulation many ideals that rely on equity or equality dont directly fit mathematical disparity measures because the ambiguity of ethical and legal rules allow human judges to deliberate about a concrete situation balancing the distribution of goods or rights developing a strict metric involves value assessments without a specific context or situation often presented as a translation this induces the illusion of mathematically expressing abstract notions without either losses or unexpected consequences we refer to this as the translation assumption fourth the need to quantify a notion of fairness pushes researchers and practitioners to primarily focus on distributive justice yet fairness may go beyond the distribution of goods to address interactional or procedural justice if a system cannot be used by some people of color because facial recognition does not work properly for them this impacts on their dignity and belongs to the interactional justice dimension many technical studies implicitly reformulate this as a distributive justice concern further the studies have focused on betweensubject justice across groups or individuals and not on withinsubject justice this can generate perceptions of unfairness an individual could be treated differently at two different points in time despite behaving in exactly the same way because others changed their behaviors and the system adopted the altered distribution these examples highlight the consequences of a distributiveness assumption which posits that all fairness issues can be presented as a statistical distribution while a statistical engineering approach to af has dominated the current debate there are alternative approaches to assuring fairness through technical interventions however they suffer from further assumptions and often commit to one or more of the flawed assumptions the counterfactual fairness discourse has pursued a view of af that uses directed acyclic graphs to model social biases that may occur in data this line of research assumes that social bias is a global causal structure element and needs to be explicitly modeled in algorithmic decisionmaking alternatively some researchers see the origins of bias in data and treat the problem as a database repair process they work to achieve the desired balance and train the models using a sort of ideal biasfree dataset rather than real data while some biases or protected groups may be easier to identify and explicate others are more implicit limited to a local community or simply rely on urban myths and fake news some members of society may feel stigmatized if social biases need to be explicated and presented in a model or data positing that the biases can be comprehensively explicated many approaches fall victim to an explicitness assumption finally almost all engineering approaches to unfairness share independence assumptions we identified three assumptions concerning independence contextindependence timeindependence and componentindependence as follows contextdependence refers to whether a onesizefitsall approach is replaced by developing tailored problemspecific solutions for af here most technical studies use multiple synthetic or publicly available datasets that represent various independent decision problems these studies developed and evaluated solutions with these datasets and claim applicability across situations this contradicts the evidence that proved that fairness assessments are highly contextdependent timedependence refers to whether af solutions consider dynamics of the environment here technical studies on af often rely on data from the past to prove their systems fairness but prescribe future use they see data and the decision context as static committing to a timeindependence assumption componentdependence denotes that individual components of an af system interact with the environment previous studies that followed a technical perspective on af focused on improving and testing a single classifier ignoring other technical components that will interact with it the classifier will be like a small gearwheel in a larger technological system involving classifiers data preprocessors and interfaces to other systems in a broader sense it will become part of a complex sociotechnical system whose characteristics emerge not only from its parts but also from interactions between the parts and the context because a system is more than the sum of its parts there is no guarantee that a system composed of fair parts will in fact be fair thus these studies commit to a componentindependence assumption the three abovementioned independence assumptions prevail explicitly or implicitly despite singular studies that paid attention to context accepted temporal dynamics of fairness issues or addressed technical systems in a holistic way they represent notable exceptions rather than the norm equivalence assumption operationalizations and notions of fairness are equivalent and can be exchanged based on their performance in legal scholarships the notion of fairness is evolving and multifaceted we set an overarching goal to develop a unified machine learning framework that can handle any definition of fairness the combinations and also new definitions that might be stipulated in the future while the problem of selecting an appropriate fairness metric has gained prominence in recent years is perhaps best understood as a special case of the task of choosing evaluation metrics in machine learning translation assumption complex ambiguous notions of fairness or legal rules can be although the di doctrine is a law in the united states violating the di doctrine is by itself not illegal it is illegal only if the violation cannot be justified by the decisiontranslated into mathematical or statistical terms without loss maker in the clustering setting this translates to the following algorithmic question what is the loss in quality of the clustering when all protected classes are required to have approximately equal representation in the clusters returned distributiveness assumption representing problems of interactional or procedural justice in terms of distributive justice so as to facilitate statistical processing though helpful in seeing a systematic error gender and skin type analysis by themselves do not present the whole story is misclassification distributed evenly amongst all females are there other factors at play likewise is the misclassification of darker skin uniform across gender explicitness assumption existing prejudices social biases and protected groups can be known upfront and can be made explicit in the model we advocate that for fairness society should not be satisfied in pursuing only counterfactuallyfree guarantees we experimentally contrasted our approach with previous fairness approaches and show that our explicit causal models capture these social biases and make clear the implicit tradeoff between prediction accuracy and fairness in an unfair world we propose that fairness should be regulated by explicitly modeling the causal structure of the world independence assumptions we adopt surrogate functions to smooth the loss function and constraints and theoretically show that the excess risk of the proposed loss function can be bounded in a form that is the same as that for traditional surrogated loss functions experiments using both synthetic and realworld datasets show the effectiveness of our approach • context the premises of the social perspective the social perspective on algorithmic fairness is becoming increasingly important positions with a social perspective on af are appearing at computer science conferences and in journals as well as in outlets from other disciplines including the social sciences philosophy and criminology and law this makes clear that researchers across disciplinary boundaries are engaging in the social aspects of af and are trying to understand it as a problem that cannot be completely solved through technology for instance they indicate that sources of algorithmic unfairness go beyond the issue of unbalanced data and derive from a lack of political power balance or the lack of political discourse about what fairness is other studies have described the status quo from the perspectives of social science or organizational science the multidisciplinary debate aims to identify and overcome the limitations of the technical approach most studies refer to a commonsense image of ml and in the context of problematizing suggest the presence of different assumptions that fall under the concept of root metaphors the assumptions relate to a general understanding of the subject matter shared beyond a single discipline in this case it is the shared notion of ml and algorithms engineering as being solely about data and their processing we will now review these assumptions listing them in table 2 along with examples from the reviewed studies the studies that follow a social perspective have addressed differences between the mathematical notions or even methods used to represent fairness in algorithms while the technical community has developed a wide variety of methods for reducing discrimination in ml they were rarely considered in social discourses as a separate way of operationalizing fairness however as discussed these methods may have crucial implications for both the technologys design and for the sociotechnical context some methods require explications of potential social biases while others rely on the availability of sensitive data and yet others manipulate the data to reduce risks of bias this explicates that social discourse of af treats technical approaches to af as a black box without decoding the notions of fairness encoded by the engineers and their social political or organizational implications although the social perspective acknowledges afrelated progress of the technical perspective the engagement with the subject matter has remained superficial it often seemed that technical af was reduced to a generic algorithmic approach given that the variety of technical af and the interplays between specific social and technical measures remain unpacked we refer to a black box assumption some studies have engaged in a bad actor debate they try to identify who is to blame for unfairness in automated decisionmaking there are two general lines of argumentation some argue that the application of ml in highstakes decisionmaking is the problem while others argue against developers designers and organizations who provide these solutions we call the first tendency the technology agency assumption and the second the human agency only assumption others propose a shared responsibility humans and algorithms coconspire in upholding discrimination we agree that understanding liability for discrimination is important to countering it with regulation it is necessary to understand who or what the source of discrimination is nonetheless some aspects of this debate may benefit from acknowledging recent developments in the technical approach to af for instance that decisions concerning fairness measures are often taken through participation of a broader public while we understand that it is important to identify the origins of biases the discourse often does not reveal how exactly the bad actor in question impacts on the algorithmic decisionmaking and which technical components are affected yet such deliberation could support the technical af community in approaching the key points finally several authors especially in legal science have idealized the status quo in law enforcement and have declined algorithmic support while others have proposed replacing the current system with a codebased sentencing each side has committed to a purity assumption claiming that only it yields unbiased decisions however there is cumulated evidence that unfair decisions have been made in the past independent of whether or not they relied on human reasoning or algorithms biases in law enforcement may emerge from existing training incentive systems or archetypes in the organizations and these biases may be present in both persons and in algorithms instead of claiming that one or the other is better or fairer one must acknowledge that accountability mechanisms and legal standards that govern decision processes have not kept pace with technology we claim that coordinating algorithm development with overall justice system development may lead to law enforcement with fewer systematic biases research in algorithmic fairness has recognized that efforts to generate a fair classifier can still lead to discriminatory or unethical outcomes for marginalized groups depending on the underlying dynamics of power because a true definition of fairness is often a function of political and social factors quijano again speaks to us posing questions of who is protected by mainstream notions of fairness and to understand the exclusion of certain groups as continuities and legacies of colonialism embedded in modern structures of power control and hegemony bad actor assumption • technology agency unfairness emerges as the result of applying technology to the taking of decisions • human agency only unfairness always emerges because of humans technology just perpetuates human biases or a power imbalance of course not all work in this area reduces discrimination entirely to some set of blameworthy humans behind the machine many discussions make clear that algorithmic discrimination can happen in ways that are unintentional or difficult to account for for example when upstream social biases are reflected in training data in ways that may be difficult to predict in these cases biases are said to sneak in whether on purpose or by accident or in ways that only emerge over time purity assumption seeing either the justice system or algorithmic decisionmaking as superior and as the reference point for fairness second it shows why automated predictive decisionmaking tools are often at variance with fundamental liberties and also with the established legal doctrines and concepts of criminal procedure law the need for a sociotechnical perspective overall the current af discourse suffers from assumptions that render exchanges between various approaches difficult especially the relationships between social and technical aspects of af have largely been overlooked the social and the technical perspectives both provide valid points and remedies although some articles have addressed the relationship between the social and the technical they have rarely moved beyond identifying problems in each area thus the efforts have not added up to a holistic and comprehensive solution in our view this results from a selective perception of what algorithmic fairness is some researchers see it as a technical phenomenon and seek solutions in technology others see it as a symptom of discrimination in society and seek a remedy in changing the social structures that enable discrimination both approaches make valid points they also dont directly contradict each other at first glance enhancing algorithms or manipulating data does not interfere much with political or social agendas however this development may confuse practitioners decisionmakers and society apart from clearly misguided decisions such as when the lack of sensitive attributes in the data disables the use of most effective af solutions other problems may also emerge thus we address why a sociotechnical perspective is needed it discusses practical consequences of a potential sociotechnical framing of af and therefore supports the overall statement that we urgently need a sociotechnical perspective without a coherent perspective that acknowledges the interdependencies between the social and the technical aspects of af organizations may be reluctant to effectively tackle this problem if they treat algorithmic fairness as a purely technical problem they may assume that adding a social element will sufficiently solve unfairness they may believe that positioning an employee as a control instance who needs to sign off decisions made by the algorithm will sufficiently mitigate discrimination this aligns with the humanintheloop claim according to which introducing human control into algorithmic decisionmaking will prevent or limit unintended consequences of purely algorithmic decision processes following the sociotechnical perspective we argue that this reasoning is problematic it assumes that the human and the algorithm are distinct moral agents capable of making an independent decision and it implies a picture of a righteous and critical person who is able to question algorithmic output or assess the focal situation we argue that the algorithm and the person are not as independent as it may seem algorithms empower and constrain persons they may direct human attention to only some aspects to be considered they may require a specific decision output format and they may require the person to take decisions in a decontextualized environment likewise persons may inappropriately interpret the algorithms output or take random uninformed decisions following the illusion that their opinion is just one out of several votes for instance it is known that employees rely on decisions taken by the algorithms and rationalize or explain them rather than controlling their quality and bias thus rather than calling for a human in the loop we need to gain an understanding of humanalgorithm ensembles as collective moral agents and thus respect the complex mutual influences between the ensembles subparts in our view the sociotechnical perspective on af is the first step in this direction the evaluation of complex decision processes involving persons and algorithms as parts of an ensemble requires an overall approach to assess whether the ultimate outcomes produced by the sociotechnical system are fair and to identify reasons for potential unfairness if one focuses on the technical and the human components separately they ignore unexpected interferences between the components risking an unfair final decision finally without holistic guidance companies risk choosing a combination of incompatible technical and organizational fairness measures especially if such decisions are made by different units accordingly we argue that it is crucial to view af as a sociotechnical construct is has a long tradition of systemic sociotechnical approaches to solving urgent and important problems for instance is encapsulated the social and psychological effects of organizational implementation of new technologies in the sociotechnical concept of technostress is is also concerned with supporting collaboration that uses a mix of technical and social componentscollaboration engineering finally is offers a holistic understanding of trust as a phenomenon not limited to persons but also emerging in relation to technology we see great potential for approaching fairness as a sociotechnical phenomenon while decisions in all domains will increasingly rely on algorithmic processing of data and will involve ml predictions they will also involve a person as a decisionmaker target of the decision or evaluator it is essential to understand interactions between technical and social components to embrace the complexity of fairness while existing research makes valuable contributions to either technical or social aspects the is discipline owing to its sociotechnical anchoring can better understand how these efforts complement depend on and mutually influence one another nonetheless the studies of af in is have resorted to the technical perspective and have focused on ways to improve algorithms through for instance more adequate scoring methods better assessment of tradeoffs or better understanding of current applications this has led to some very recent suggestions or calls to extend the notion of af to embrace the behavioral procedural and contextual aspects of algorithmic decisionmaking although those extensions and calls are a step in the right direction they have neither explicitly problematized the assumptions that underlie existing formulations of af nor addressed the dynamics of interaction and balance between the social and the technical aspects of af in our view is needs a reorientation toward the sociotechnical perspective if it is to provide a holistic understanding of af as a phenomenon a sociotechnical perspective on algorithmic fairness clearly neither a technical nor a social view alone is sufficient we will now position af as a sociotechnical phenomenon the sociotechnical perspective has formed the foundation of is research for decades it builds on the key insight that work involves interactions between persons and technology persons including individuals and collectives as well as the relationships among them or attributes thereof including structures cultures economic systems rituals best practices organizations or social capital form the social component the technology including humanmade hardware software data sources and techniques that describe ways of using them to achieve human goals or serve human purposes form the technical component of a sociotechnical system the sociotechnical view stresses the mutual interdependency between the components so much so that connections between them are reciprocal and iterative but neither incidental nor nominal the social and technical components engage in joint optimization to create a productive sociotechnical system the is tradition has also acknowledged that components should be treated equivalently regarding importance and impact a sociotechnical account of af requires careful consideration of how machines and persons can and should coengage or collaborate to achieve fairness we will now first examine the characteristics of af that suggest the sociotechnical lens is most appropriate to attend to it providing arguments for why it is a sociotechnical rather than a social or a technical phenomenon we will then show how the sociotechnical view addresses the limitations of existing af research we will refer to the rolling example of a recidivism prediction system and will use this example at various points to ease the understanding of an abstract matter why is algorithmic fairness a sociotechnical phenomenon multiple characteristics of af position it as a sociotechnical phenomenon first the algorithm creation process is a social practice developing algorithms is to some extent a research activity driven by epistemic values including consistency accuracy or generalizability similarly contextual values that replicate the developers personal or humanist concerns are equally important the developers background may impact on their perception of what is fair and for whom since definitions of fairness relate to the stakeholders interests developers could tend to prefer some fairness measures over others second algorithms inevitably impact on the lives of individuals groups and societies based on where they are used and what they are used for a widely used algorithm for selecting healthcare system entry was found to discriminate against racial minorities thereby affecting thousands of people finally algorithms have and are becoming the object of public debate around af algorithms have long been an object of sociotechnical practice at the same time algorithms are involved in fairness assessments decades ago the justice system moved from narrativebased consideration of cases to prosecution that relies on ml techniques for instance algorithms are used to predict areas in need of policing so as to automatically identify potentially criminal individuals online or for analysis of biological or computer data acquired during prosecution all these applications bear risks of discriminating these systems accuracy may be higher for some types of crimes or for some ethnic groups similarly digital technology was shown to restrict freedom of public administration the mythical computer rather than every officer or the organization was taking decisions about what a fair welfare subsidy is although the publicity identified humans as decisionmakers accountable for fairness in fact the work was and continues to be distributed between social and technical components as presented here there is not only a need to consider af as a sociotechnical phenomenon but there are good reasons to do so developing a sociotechnical perspective for algorithmic fairness we will now develop a sociotechnical perspective for af and start by discussing basic constructs relevant to the sociotechnical view of af we will also provide examples from the case of recidivism risk assessment the sociotechnical perspective focuses on interactions between the technical and social components of an is for instance the recidivism prediction case involves judges penitentiary workers inmates and their attorneys as well as institutions and law enforcement rules all these individuals and collectives form the social component of the prison release decision system they take decisions or are directly affected by them when individuals take decisions in companies or organizations they widely rely on decision support systems such systems like any technological system have various components in the af case the component for ml is particularly relevant through reciprocal interactions the components achieve coherence which results in an effective is all the individuals involved in penitentiary processes and the tools they use are engaged in continual adaptation they establish new work practices that allow them to take better decisions while the algorithms are retrained based on decisions taken or are simply changed to reflect new rules or routines based on this we propose that a sociotechnical view of af assumes complex relationships between social and technical components such that the working of the overall system cannot be derived from structure or internal processes of its components this specifically implies that we cannot predict that an overall is will become fairer by only improving the technical components fairness an effective is should lead to better instrumental and humanistic outputs decision systems are typically employed to improve the decision accuracy while reducing the decision costs for instance a recidivism risk analysis system should relieve the overcrowded justice system reduce processing time for jail release applications provide prison inmates with earlier decisions and lead to more frequent application processing cycles at the same time it must obey ethical norms including fairness thus a sociotechnical view of af assumes multiple interrelated or even contradictory outcomes beyond fairness this implies that fairness cannot be seen as a unique goal instead the overall system should be evaluated against multiple goals including fairness where fairness is a necessary condition but is not sufficient to ensure that the system is useful an is is embedded in an environment a larger social economic regulatory or material context which offers structures for the iss operation compas the aforementioned recidivism prediction system was improved based on societal pressure from ngos based on this we propose a sociotechnical view of af to assume a dynamic and mutual interaction with the context this implies that the is needs mechanisms to interpret and process inputs or feedback apart from the classical elements of a sociotechnical perspective of an is we followed chatterjee et al by also considering information as a core element within a sociotechnical system given that datas role for achieving af becomes inevitable in our view it complements the overall sociotechnical perspective we are pursuing here the recidivism prediction system relies on data about past inmates and their offenses it also mines data about the inmate under consideration as well as statistical and ml models that link the data we propose a sociotechnical view of af to assume information as a key to steer the interaction between the social and the technical components since data are neither neutral nor independent they require a critical approach in sum the proposed perspective on af positions the decisionmaking as involving humans and algorithms at the very core of the system the reciprocal interactions between these individuals or collectives and the technology are what enable the system to yield a decision information provided to the individuals and to the algorithms is what underlies and structures the decisionmaking the system is embedded in the environment which is affected by the decisions taken by the system and reacts to them the proposed sociotechnical view provides tools to explore relevant aspects of af how does a sociotechnical perspective surpass existing premises the sociotechnical framing of af not only establishes a tool set to precisely understand and describe the nature and mechanisms of algorithmic discrimination it also helps to overcome the limitations of previous approaches as discussed in sections 41 and 42 and as presented below this follows the strategy suggested by alvesson and sandberg who suggest reconsidering the problematized assumptions in light of a new theoretical perspective we will now revisit premises identified in the literature and compare them to the sociotechnical view first a sociotechnical perspective suggests that solutions to algorithmic unfairness problems may not function properly if they dont factor in social components and dynamics of adaptation among the components this wholly contradicts the engineering assumption presenting a classifier that produces a less biased output is not yet a solution we can claim that a solution is successful only if the entire sociotechnical system achieves a state of coherence in which it generates fewer biases the proposed sociotechnical lens approaches equivalence assumptions by acknowledging that notions of fairness and their operationalizations could be adequate depending on the overall systems state the technical literature often sets out to identify the best notion among many this attempt is destined to fail in complex and dynamic environments where the operationalizations fits may vary the proposed perspective makes it clear that it is not possible to explicate biases to be addressed upfront algorithmic unfairness emerges as an undesired system output measuring performance against biases that were known a priori is also not sufficient an audit against all possible biases would be necessary for the output finally the sociotechnical perspective overthrows all the independence assumptions and the bad actor assumption because all components are involved in creating unfairness or assuring fairness through ongoing mutual adaptation the process is highly dynamic the process of analyzing and assigning responsibility for insufficient fairness cannot be reduced to a single component translation and distributiveness assumptions relate to mathematics as the primary tool for representing fairness while this may be true and necessary for the technical component humans have dealt poorly with mathematical formalizations especially in the context of distributions since perceptions of fairness are at the heart of being human humans are highly unlikely to engage in mathematical calculations while making fairness assessments however when technical components speak mathematics and humans do not mutual adaptation can be hindered and can prevent the system from being jointly optimized while the proposed framework does not directly relax this assumption it makes clear that this point requires attention sociotechnical systems require understanding all the processes involving data technology and humans these components will differ in every application of ml and af human practices and behaviors are situated which makes a great difference in the fairness of a recidivism prediction system or other systems for instance for assessing creditworthiness because the environments differ the components differ thus the outcomes also differ this makes clear that reducing af to a single approach following black box assumptions is inadequate because it omits numerous technical approaches and because suggests that these situations are comparable finally our proposed perspective interrogates the purity assumption the technical and societal contexts provide inputs that prescribe the workings of a system and observe system outcomes however in many cases the reactions of the society or the justice system to the occurrence of algorithmic unfairness was sluggish unfair systems are in constant use thus it is misleading to idealize technological solutions or parts of society as being under the influence of a purity assumption the assumptions we identified negatively influence the variety and applicability of measures against unfairness the sociotechnical perspective reveals that social and technical components are equally involved in discriminating and in assuring fairness only when one attends to how these components interact ie how decisions emerge from the mutual adaptation and optimization between humans and algorithms and how these interactions relate to the instrumental and humanist outcomes the system should produce will we be able to effectively address af to overcome the current lack of a sociotechnical perspective on af we will now propose research directions for creating a sociotechnical knowledge base on fairness directions for sociotechnical research into algorithmic fairness the sociotechnical perspective on af overcomes assumptions present in the literature and offers a framework for identifying sources of algorithmic bias to date sources of bias were either related to the ml workflow or ascribed to social biases we will now address sources of bias identified in the literature and classify them according to the components of a sociotechnical system or the interrelationships between them as presented below the origins of algorithmic unfairness are distributed across the entire sociotechnical system we identify directions for is research to eliminate various algorithmic discrimination types at their source however these research directions are rarely limited to one component of the sociotechnical system but instead call for a holistic approach to af for instance to eradicate biases that emerge through lowquality information one must address the social and organizational processes related to data generation and management similarly to overcome technological limitations one may need to ascertain the perspectives of various stakeholders accordingly we will now address the identified sources of algorithmic unfairness discussing how a holistic sociotechnical perspective helps to resolve them specifically technology may be responsible for specific algorithmic discrimination types but as opposed to the technical perspective we claim that potential solutions relate to social and organizational practices or procedures we claim that algorithmic unfairness can only be effectively addressed from a sociotechnical perspective and propose lines of research to substantiate this standpoint what sorts of core theories should be employed to inform the design and evaluation of technological artifacts that then need to obey fairness and potentially other ethical values which measures should be used to ensure that the system does no harm how can we standardize evaluations and make them applicable to both practitioners and researchers how do we conduct those evaluations in realistic contexts without risking real harm to test subjects the evaluation and auditing of technical solutions requires both appropriate metrics and procedures as well as insights into the algorithms and their decision routines based on these insights the designers could identify risks of bias even before testing the system endusers could easily review system decisions based on the applied procedures and the considered data the explainability or interpretability of ml is a subdiscipline of its own and despite many efforts from several scientific communities and practitioners its progress and practical uptake remain limited while the discourse on explainable ai has reached is it remains nascent the fairness example makes it clear that we need technological systems that reflect and explain themselves and their actions research outside is has focused on two stakeholder groups that particularly benefit from ml explainability developers who based on insights can improve their model without costly experimentation and endusers who should become able to enter a dialogue with the machine here the existing studies have identified additional stakeholders who depend on a deep understanding of what algorithms do highstakes decisionmakers who rely on predictions such as governments who try to adapt plans to worldwide developments such as pandemics or global warming and refer to mlbased predictions but also need to explain their decisions to the public auditors of medical application tools who decide whether or not an application is a medical product judges and others in the justice system is can contribute to this discourse by identifying and specifying domaindependent and contextdependent requirements for explainable ml who are the stakeholders that rely on a deep understanding of ml technologies what explanation type is needed for each of them how can a system reflect on its predictions concerning fairness or other fundamental values how do we combine the autonomy of a technological system with the requirement to make everything explicable information as a source of algorithmic unfairness the information that embrace data and models is another technical source of algorithmic unfairness data not only perpetuate social biases encoded in the data generation process but may also introduce new biases many studies have proposed solutions such as reweighting or filtering and balancing the datasets or adapting algorithms including specific preprocessing and postprocessing steps they attempt to mitigate unfairness in the information subsystem by adaptation in the informationtechnology subsystem in recidivism prediction unbalanced data introduced more racial bias than biased data however balanced and complete data are not easily available ml solutions require vast amounts of data and often rely on datasets that were neither developed for use in ml nor with a specific focus on fairness but that were collected for other documentation purposes while organizations globally possess collect and process large volumes of data only a fraction of the data is accessible to ml researchers and practitioners this creates obstacles to the development and evaluation of fair models and algorithms while data governance and management have a long tradition in is the proposed framework and practices pertain mostly to issues of investment and value generation in the organization they rarely thematize how to lever the value of data via ml and how to ensure that outcomes are fair af discourse calls for putting these issues on the agenda so as to extend the data governance and management literature in is which data management practices are adequate to generate fair data or make existing data fair how do we incentivize organizations to follow those practices how do we ensure fairness in combination with other desired features such as consistency integrity or security how can existing data be made available to researchers engaging in the study of ai for humanist goals interactions between social and technical components as a source of algorithmic unfairness algorithmic unfairness emerges owing to mutual adaptation between social and technical components humans often buy into the myth of infallible or objective algorithms and data in other cases we deliberately move the responsibility for decisions to the computer and rarely question it in doing so they cocreate unfairness however adaptation in the opposite direction can also generate discrimination data models algorithms and preprocessing and postprocessing routines are created and curated by humans and can perpetuate their individual social biases compass model was trained using historical data from a law enforcement system dominated by white officers who may have made decisions using an implicit or explicit racial pattern the model adapted to this pattern and reproduced it more broadly without systematic human audits given the human tendency to outsource tough decisions the system discriminated against prison inmates based on their race interactions between social and technical components yield appealing fields for is research the is community is interested in studying the division of work between humans and ai using terms such as machines as teammates or the future of work while this research often presents ai as a way to empower human workers af requires both empowerment by machines and empowerment against machines while we dont see machines as evil there are situations in which humans require a sense of selfefficacy and sovereignty to disagree with and push back against a machine this can be achieved through adequate control mechanisms in machines through assigning the last word to humans or through partnership and dialogue between the two what is the appropriate division of work between humans and machines in highstakes decisionmaking how do we establish a partnership decisionmaking process between humans and machines how do we incentivize workers and organizations to critically question machine predictions how do we prevent groupthink in humanmachine teams answering these questions can contribute to a more differentiated discourse on machines as teammates it can also establish a more dynamic adaptation relationship in the ml domain similarly is has addressed technology development as a sociotechnical endeavor further is has for decades dealt with dynamics and agency in complex systems with a special focus on ai autonomous technologies as parts of sociotechnical systems introduce a new agency type beyond humans many other frameworks and theories for analyzing behaviors social practices or changes in an organization ascribe agency solely to humans the af discourse supports the need to review and update frameworks and provide robust definitions of a nonhuman agency so as to facilitate the discourse within is and adjacent disciplines this can help to turn af discourse away from bad actor arguments toward a shared solutionoriented effort how do the agencies of human and nonhuman entities impact on the generation of values in sociotechnical systems how do the agencies interfere with each other what are the intended and unintended consequences of nonhuman agency how should fairness be guaranteed despite agency being distributed across multiple human and nonhuman actors finally is intends to develop stable systems ie ones that reach the optimal fit between the technical and the social components borrowing the notion of entropy from thermodynamics chatterjee et al framed the level of discrepancy or nonalignment between the components in an is as entropy in the case of af entropy grows when the technical component does not yield fair results as expected by the social component this mismatch leads to an unstable incoherent overall system following the thermodynamics metaphor one could say that the system heats up this relationship points to a larger discourse relating to the application of ai value alignment whenever the values that underlie the technical and the social components differ the performance of the overall sociotechnical system declines chatterjee et al claimed that information acts as a moderator in this situation coherent and useful information can cool down the system while incoherent or contradictory information may make the entropy rise even further in short the quality of information introduced in the system is crucial for reaching a stable and coherent state the literature suggests that af requires highquality data rather than adding more training data it is more important to provide information with specific characteristics on the one hand this information may embrace carefully selected fairness constraints that fit the social components expectations on the other hand it may mean selecting or manipulating the training data accordingly by filling blind spots improving the variety of the dataset or ensuring that the training data fit the application environment other information types can likely help to achieve a fair state of the overall system which offers potential for is research which information types reduce entropy in sociotechnical systems how does one identify the entropy level in algorithmic decisionmaking systems how does entropy change over time in such systems how can information transfer the desired notion of fairness apart from mathematical formulas the environment as a source of algorithmic unfairness finally interactions with the environment may introduce or perpetuate algorithmic unfairness this can emerge as a result of governance issues social order or public discourse around ai for instance kuhlman et al identified the lack of cultural diversity among ml researchers as the reason for algorithmic bias he recommended exchange and feedback between ml researchers and members of underrepresented or protected groups as a remedy they address the broader societal contexts impacts on the sociotechnical system here influence in the opposite direction is also likely given that the notion of fairness is not static and is constantly being formed and disputed decisions taken by technological artifacts can change what society considers fair over the long term this exchange needs careful analysis it is common knowledge in is that the environment of an is affects how technology is utilized and such utilizations outcomes notions of fairness are ingrained in these structures and are subject to change when structures change is has studied how work practices organizational hierarchies and economic structures change owing to technological innovation it is now necessary to understand how fundamental values change through the introduction of new technologies understanding the forces involved in this evolution are necessary to be able to predict how technologies will impact on society while computer science researchers and practitioners are often confronted with accusations of developing and rolling out technologies without considering their negative effects they often lack tools to predict and analyze undesired consequences the origins of af are the best showcase for this thus the is discourse on the implications of technology use needs to be updated and needs to focus more on predicting rather than reacting to undesired developments having acknowledged the complexity of changes through technological progress the is community needs to step in as a moderator of these changes how do technology and sociotechnical systems impact on the fundamental values in organizations and societies how can we govern technologies impacts on society how do sociotechnical systems interact with one anther to establish shared values how do notions of fairness change through these interactions feedback loops can introduce another source of unfairness after deployment an iss output can influence the environment which impacts on future inputs to the system it may introduce bias into the system or may have unintended longterm consequences for the environment in our previous example the system for assessing recidivism risk may draw on socioeconomic variables such as the previous income so as to predict a defendants risk of committing another crime such a system may introduce a feedback loop when identifying a high recidivism risk the system may prolong an offenders sentence and this longer sentence could negatively affect this individuals socioeconomic status in this case one can expect a lower income and thus an increased likelihood of a new crime when the individual then commits a new crime the system for assessing recidivism risk may then rely on the lower income and may again recommend a prolonged sentence thereby diminishing the chances of the individuals early release as seen in this example the feedback loop is reinforced by the underlying ml system similar examples of feedback loops have been documented in online advertising with female candidates being shown fewer ads for highpaid jobs a system for recidivism risk assessment is shown here the system grants an early prison release by using ml with a higher salary predicting a lower recidivism risk leading to an early release an early prison release also increases chances for social advancement and thus a higher salary this leads to a reinforcing behavior in sum algorithmic unfairness does not emerge solely from algorithms or data used for decisionmaking it can arise out of ineffective or lazy adaptations between technological and social components or interactions within a larger context yet the research has focused on technical solutions and the solving of issues that emerge from interactions between components via technical solutions rather than addressing the entire sociotechnical system or its context as noted a sociotechnical approach requires that one acknowledge the interactive and equal roles of social and technical components implications positioning af as a holistic sociotechnical phenomenon has implications for is practice and research we see the following implications as particularly relevant and impactful first af should be seen as a multidisciplinary endeavor in which researchers transcend the boundaries of individual disciplines combining strengths from different disciplines to advance the interface of social and technical systems at risk of algorithmic fairness second af is complex singular and punctual interventions work only for a short time until data algorithms or human perceptions change it is crucial that legislative bodies and legal practitioners understand this otherwise they risk multiplying specific rules on which data can be stored and how or which measure to apply in the evaluation this may not lead to de facto humanist goals and values such as fairness measuring outcomes of sociotechnical systems is more appropriate than intervening in lowlevel processes within a sociotechnical system third af is a valuable objective and has real impacts on organizations if the sociotechnical systems reach a coherent state without discrepancies between the social and the technical the overall systems productivity will increase this is only possible if notions of fairness align across the is if employees struggle with notions of fairness in the software they use they could refuse it or employ workarounds organizations should implement fairnessoriented solutions carefully not just for society but also for themselves af themes have implications for is engineering education should both equip students with the necessary technological understanding and should cover humanistic social and behavioral dimensions practitioners should judge their artifacts critically for academia it is important to provide detailed descriptions of all datasets this helps to assess the risk of biases introduced during data collection that can adversely affect decisions fairness the insights we have presented have limitations that are typical of any literature review field portrayal is limited by the databases and keywords used along with the filtering used in selection processes further the summary of the articles we presented is limited a complete list of references appears in the appendix and we encourage the reader to consider them in detail conclusion we claim that af is just a precursor to a larger debate on value alignment relating to autonomous or semiautonomous technologies while an abstract value alignment discourse is emerging outside is the af example shows that problems can become complex and fuzzy once confronted with reality in particular the reciprocal interactions between the social and the technical components as well as their embedding in a larger environment disrupt theoretically valid ideas this is exemplified by the purely technical approach to fairness in automated decisionmaking here stateoftheart technical approaches cannot guarantee a fair outcome at scale similar effects may be expected when algorithms begin to directly affect other humanist values thus it is crucial to formulate the problems of value alignment in a sociotechnical way from the outset this means considering how social and technical components will change depending on the desired humanist outcomes how the interdependencies between them can be employed to prevent undesired outcomes how they can complement one another and which moderators can effectively help them achieve a coherent state of low entropy and how the broader environment is affected by the outcomes the system produces to date the debate on value alignment has focused more on creating rules to assure that algorithms dont overrule humans and obey human values whatever they may be this formulation forgets that social values and specifications thereof will change through interactions with technology and will evolve and undergo adaptation such that the social and the technical components will experience states of low and high entropy the af case makes clear that the system is dynamic and complex and human values have not yet been articulated in a way to make algorithms simply obey them af could not be achieved with a simple constraint with a range of constraints or with supervised and unsupervised approaches the debate on value alignment requires that one acknowledge that values are shaped and negotiated in sociotechnical processes is is predestined to contribute to this discussion its practical orientation technical understanding and sensitivity to societal progress is should pursue further research into sociotechnical af before algorithmic fairness turns into another dark side of it titles and abstracts yielded 166 relevant articles these articles were included in the subsequent analysis to create the multidisciplinary set we employed the following procedure inspired by the systematic approaches to literature studies in is we composed a broad search query to accept all potentially relevant articles the query we used looks as follows or pre1 this query accepts various phrases including fair ai fairnessconstrained ml algorithmic fairness or ai bias is it an article with an individual contribution does it use the words used in the query with the intended meaning does it refer to fairness justice or discrimination does it refer to machine learning artificial intelligence or algorithmic decision making as a source a remedy or an aspect of discrimination does it make contribution towards af or discusses it as a core aspect overall the selection criteria were formulated and applied with caution to guarantee that the selected literature represents the broad discourse about algorithmic fairness overall 280 articles from various disciplines and including diverse viewpoints form the basis of this critical review 166 in the conference set and 114 in the multidisciplinary set the articles were subsequently analyzed as presented in the next subsection literature classification each article was classified according to four dimensions fairness perspective the fairness perspective describes the approach towards or framing of fairness that dominates in the given article here we differentiate between social and technical perspectives some articles treat fairness as a social phenomenon and acknowledge the human origin of fairness others see it as a technical phenomenon that is as something that originates in the data or can be expressed in statistical or mathematical terms we did not encounter a paper that commits to the sociotechnical perspective as presented in section 5 and characterized by mutual interdependency joint optimization and equivalency between the technical and social components several articles nominally refer to a sociotechnical perspective but they discuss af in relation to the whole society position it on a political level and refer to frameworks provided by gender studies colonialism feminism democracy or human rights frequently these papers use the term sociotechnical to highlight the contrast of their perspective with the technical discourse but they focus on the social aspect of af by framing fairness as an aspect of human society upon careful consideration we thus decided to count such articles towards the social perspective overall the technical perspective dominates with 210 items while 70 items characterized as following a social perspective for two reasons first it foresees the connection of inputs and outputs through processing within the system and a feedback loop with the environment given the importance of the broad societal impact of the decision algorithms and claims that through interaction with the social environment those algorithms might reinforce disparity differentiating between humans who are directly affected by the system and the general society might be useful for better characterizing the existing contributions second the role of data for af becomes inevitable such that chatterjee et als attempt to include information as a component seemed beneficial for our purposes we claim the agency of data becomes obvious in af where data frequently and without a clear provenance or an explicit creator decides upon an individual or a groups treatment cf open corpora such as imagenet the methodological paradigm describes the overall scientific approach of an article the most frequent approach is subsumed under engineering which involves formulation of a problem conceptual or formal development of a solution and evaluation of this solution against the identified problem and comparison with other possible solutions overall 151 studies follow this approach 37 studies focus on exploring bias in a specific application domain a data set or a case these studies contribute understanding concerning the sources of bias or characterize it quantitatively and qualitatively in addition 30 articles rely on literature review as their main evidence promotesinhibits entropy overall the studies use a wide range of available methods but more than 50 percent focus on engineering new approaches to address algorithmic bias finally the scope describes whether the research was done in a particular application domain ie is domain specific or whether the paper claims generic insights going beyond a particular domain overall we identified 77 domainspecific articles the domains include among others health criminal justice and loan allocation the remaining 203 articles all make generic claims for instance they propose a new technique or metric to prevent algorithmic bias test it on multiple datasets and offer it as a contextindependent solution to algorithmic discrimination literature analysis having classified the literature according to the above categories we then reviewed the papers to identify assumptions they rely on we focused on the clusters emerging from the classification starting with the largest ones moving to medium ones and on down to individual cases we identified typical assumptions for the clusters and concluded that the assumptions map to the perspective on fairness that dominates in the papers this mapping is reflected in the structure of the paper which differentiates between the assumptions of the technical perspective and the assumptions of the social perspective we grouped similar or overlapping assumptions to offer a comprehensive presentation to the reader analyzed articles conference set appendix the appendix details the procedure used in our systematic literature review the overall objective was to characterize the discourse on af and to identify potential limitations and assumptions typical for the discourse we conducted the following steps literature search and selection classification and analysis at the end of the appendix we provide the list of all considered articles literature search and selection we selected literature from two sources key machine learning conferences which explicitly address the topic of algorithmic fairness to capture the most recent developments in af and querybased search in a multidisciplinary scientific database to capture the discourse on af beyond computer science we refer to literature from and as the conference set and the multidisciplinary set respectively they were merged before analysis we only considered peerreviewed articles and restricted our time span to january 2017 through december 2020 to create the conference set we proceeded as follows we selected outlets with key importance to the af community in ml by consulting nonis colleagues and the most recent peerreviewed overviews of af we settled on the following four conferences acm conference on 2 we reviewed all proceedings of these conferences between january 2017 and december 2020 including overall 9392 articles for this we screened the titles of all articles published in these conferences for the occurrences of words suggesting relevance to af discourse such as fair justice bias or discriminate leading to a preselection of 187 articles based on the review of the abstracts we selected articles that contribute to af discourse we also dismissed articles submitted as tutorials the manual screening of article fairness perspective is component methodological paradigm scope jabbari s joseph m kearns m morgenstern j roth a fairness in reinforcement learning in proceedings of the 34th international conference on machine learning 701617

algorithmic fairness af has been framed as a newly emerging technology that mitigates systemic discrimination in automated decisionmaking providing opportunities to improve fairness in information systems is however based on a stateoftheart literature review we argue that fairness is an inherently social concept and that technologies for af should therefore be approached through a sociotechnical lens we advance the discourse on af as a sociotechnical phenomenon our research objective is to embed af in the sociotechnical view of is specifically we elaborate on why outcomes of a system that uses algorithmic means to assure fairness depend on mutual influences between technical and social structures this perspective can generate new insights that integrate knowledge from both technical fields and social studies further it spurs new directions for is debates we contribute as follows first we problematize fundamental assumptions in the current discourse on af based on a systematic analysis of 310 articles second we respond to these assumptions by theorizing af as a sociotechnical construct third we propose directions for is researchers to enhance their impacts by pursuing a unique understanding of sociotechnical af we call for and undertake a holistic approach to af a sociotechnical perspective on af can yield holistic solutions to systemic biases and discrimination

background borderline personality disorder is a serious mental health challenge worldwide globally the incidence of bpd has been estimated to be about 13 of the general population 1 but little data is available on the number of patients with bpd in south africa the most prominent characteristics of people with bpd are pervasive disturbances of interpersonal relationships selfimage and affect these characteristics are illustrated by marked efforts to avoid rejection which can lead to identity disturbance impulsivity and unstable and intense relationships 2 individuals with bpd make frequent use of health services and are di cult to manage without team supervision and support family members of people living with bpd experience a considerable objective and subjective burden 3 fossati and somma 4 agree that bpd places a heavy burden on people suffering from the disorder and those living with them moreover nouvini 5 con rms bpd often leads to tumultuous interpersonal relationships where those suffering from the disorder feel invalidated and misunderstood by loved ones who believe them to be manipulative and immoral people with bpd are prone to feeling angry and alienated from members of their families while family members may feel helpless and angry at the way their siblings with bpd relate to them 6 therefore living with a person with bpd may cause widespread disruptions in family members routines 7 it has also been determined that family members of relatives diagnosed with bpd have ineffective coping strategies related to a lack of communication skills and knowledge and at times they nd themselves having to manage situations for which they are not prepared 8 family caregivers of people diagnosed with bpds experiences have been studied by hoffman fruzzetti and buteau 9 buteau dawkins and hoffman 10 lawn and mcmahon 11 and kay et al 8 various challenges such as negative feelings towards their relatives social humiliation nancial strain marital discord caregiver and nancial burden grief and isolation were some of the similarities in these studies 8 9 10 11 barr et al 12 also examined family members or carers experiences supporting someone with a personality disorder the authors 12 reported that carers described the importance of early assessment and intervention for personality disorders in support greer and cohens 13 research focused on the partners of individuals with bpd who experienced emotional challenges dual roles as both a romantic partner and parentaltherapeutic gure and a lack of control individuals with bpd pose a challenge to their siblings as bpd affects not only the person with the disorder but also those around them 7 this notion is supported by kovacs et al 14 who claim the mental health problems of one family member in uence the whole family system including sibling relationships furthermore siblings may not identify themselves as carers and therefore feel unable to access health services themselves even though they play a signi cant part in providing support for their brother or sister 15 the oxford learners dictionaries 16 de nes a sibling as one of two or more individuals sharing one or both parents in common in most societies throughout the world siblings often grow up together thereby facilitating the development of strong emotional bonds in this article a sibling refers to a sister a brother or an adopted brother or sister of a family member who has bpd there seems to be a gap in the literature as previous studies have not clari ed siblings caring relationships and experiences in the south african context the aim of this article is thus to report on a study that explored family members lived experiences of a sibling with bpd in south africa insight into these lived experiences could provide recommendations for mental health nurses to promote the mental health of family members affected by this phenomenon methods procedure data were collected using indepth phenomenological individual interviews supported by observations of participants and eld notes kept by the researcher the main question posed to the participants was how is it for you to have a sibling with bpd the researcher conducted interviews on a day and time suitable for the participants in 2019 the interview venue was an o ce at the mental health hospital free from interruptions appropriate followup questions were asked during the interviews as required using communication skills such as probing re ecting clarifying and summarising the interviews ranged from 379 minutes to 55 minutes were audiorecorded and transcribed verbatim any information that was personally identifying was removed from the transcripts data analysis data were analysed to understand participants lived experiences using teschs thematic coding 17 method the researcher also adhered to husserls descriptive phenomenological approach 18 which meant she bracketed or put aside her own preconceived opinions for data analysis all transcripts were read carefully while making notes as they came to the researchers mind similar ideas were clustered and then organised as major topics unique topics and leftovers the data were coded units of meaning were identi ed and linked together to form themes with supporting categories direct quotations from the participants were included to support the identi ed themes an independent coder experienced in qualitative data analysis also analysed the data and consensus was reached between the researcher and independent coder after discussion themes were then presented to participants for validation to ensure that accurate meaning was captured results three themes emerged from the data analysis these are discussed in the sections that follow theme 1 multiple challenges in understanding gaining control and struggling to cope with their own lives participants reported that having a sibling with bpd put a strain on families as it affected not only the person with the illness but also those around them their reported experience was that their sibling with bpd was emotionally draining participants felt sad frustrated lost powerless and angry due to the highs and lows of not knowing what to expect from their siblings the participants expressed how their families were affected it was affecting everybody in the family my grandparents it was taking a large toll on all of us it affected everybody as everyone felt disrespected seeing your sister like that is not fun its not nice and it affects you because half the time you ask yourself why why participants were cautious in their interactions with their siblings as they did not want to trigger their illness they also reported their frustration at their siblings poor cooperation others blamed their parents for not taking more urgent control over their sibling with bpd some participants felt resentful because they observed their siblings with bpd always got their way and did not realise their impact on others lives participants were angry because their siblings with bpd did not think about how their behaviour affected those around them when they attempted suicide the following direct quotation supported this view i was angry with her for trying to kill herself leaving us behind … i felt disappointed and was also sad that i was going to lose my sister over something that i dont even know some participants wanted to act in a vengeful manner so that their sibling with bpd could get an idea of how their behaviour and actions affected others i actually feel like its on purpose to choose a dress that she would not look good in just to … show her a little bit of … but that is not me my graduation is coming … but i have decided not to invite her some participants experienced joy and were relieved after their siblings nal diagnosis when a name was given to all the chaos these experiences of joy were reported as now that i understand living with her is easier because i have an idea of what the condition is about i read more about it and it did make sense now theme 2 impact of a lack of communication and education participants loved their siblings but wished for twoway communication channels where both parties could be heard and validated patients with bpd often present with a number of behaviours that are considered disruptive such as causing selfharm expressing violent behaviour impulsivity or suicidal ideation these behavioural tendencies put the patient at signi cant risk to themselves and others if left unmanaged participants appeared to need attention and encouragement from their parents in how they responded to their sibling with bpd a lack of support from parents had an impact on participants reactions to their siblings illness when they felt unsupported they were more likely to respond negatively and develop resentment towards their sibling however if participants felt supported they tended to contribute positively to their siblings care parents lack of support is expressed in the following direct quotations its not really her doing … but my parents … she gets a different treatment to us to a point there is a ne line between treating her differently for her condition and favouring her i feel very bad because she is the fragile one i can say umatebe so even if our parents ght i try to pull myself together so that i can comfort her and my younger sister and be there for them family members experienced that their relationships with the individual who had bpd were con icting participants were aware of their siblings lack of awareness of the impact of their behaviour on their family still they yearned for calm discussion and respectful communication if it was not going her way we would have ghts and it was really not pleasant at all she makes it obvious around the house please keep your distance and puts that face that says stay there we therefore need to have a strategy around how we approach her according to the participants healthcare professionals did not communicate with or educate families regarding individuals bpd diagnosis and the management thereof participants reported having di culties understanding what was going on as they were not informed about their siblings illness this caused great confusion amongst the family members sometimes family members act as caregivers for the individual with bpd and are case managers during a crisis yet they are rarelyif at all included in the treatment plan when their siblings are diagnosed therefore they may struggle knowing how to respond effectively to these individuals problematic behaviours like angry outbursts selfharming acts and expressions of a fear of abandonment little support and education are offered to family members and most have limited knowledge of the bpd treatment programmes that their siblings receive when admitted to the hospital participants reported they still do not know how to manage or support their siblings after being discharged the family members were left to search for information themselves and resorted to using the internet to obtain information about the disorder the following direct quotations are illustrative of this nding we had to nd out on the internet what borderline personality disorder after the doctors told us her diagnosis i still think it would help us as a family if they explained this illness in more details psychiatrists and everyone had their own ideas they said it is bipolar and all the medicines they gave her never did anything for her it actually made it worse and i think that is why she became so aggressive i dont know we didnt know what was wrong until we took her to hospital to see a doctor that is when they told us about the disorder that she has and how we should go about dealing with her theme 3 individual coping mechanisms participants reported that having a sibling with bpd put a strain on families and they tried coping with the situation using different strategies some coping strategies included defence mechanisms such as suppression avoidance rationalising blaming and projection family members often experienced subjective burdens or emotional consequences because of their siblings illness participants used suppression to cope and explained they postponed dealing with their own thoughts or feelings and put it all aside participants use of suppression as a coping mechanism was explained as follows we just have to bear with her and assist her as much as we can im enraged at her still today but i will never say it to her but i do feel like that one participant used avoidance family members rejected and avoided contact with the affected individual and some cut off the relationship andor stopped talking about that person a participant said i dont want her in my life and its not a nice thing to say because she is my sister re ecting her use of avoidance as a coping mechanism some participants also used rationalising as a coping mechanism participants justi ed their siblings acts and moods by reminding themselves they were vulnerable or ill he was diagnosed with hiv which i later then thought that could have been the reason why he was behaving the way he was we didnt know what was wrong but we felt that the illness began when she was at school because there she had all the freedom … we did not realise that she was using dagga a few participants blamed their parents for not controlling and disciplining the sibling with bpd the use of blame is illustrated in these comments now that you live on your own its nice but its not the way i planned my life so she basically ruined my life she didnt think about us or her family who need her she didnt even think about her children participants also used projection as a coping mechanism they found it hard to understand the cause of their siblings behaviour changes some family members experienced mixed emotions of loving yet hating their siblings due to how they relate to them i mean this is my sister im not supposed to want her dead at home … i also think things that triggers her illness is that she is not happy with the environment that we are living in but there is nothing that we can do because we live in a tavern our parents dont have money to buy a house so they rented a place somewhere and left us at home i think that is one thing that triggers her she also mentioned our parents issue our parents ght a lot that also affects her my family is not a conducive family discussion this study explored individuals experiences of having a sibling with bpd multiple challenges were experienced by the participants including a lack of understanding gaining control and struggling to cope with their own lives families and friends of an individual with bpd experience high levels of psychological symptoms including anxiety and depression objective and subjective burdens and grief 19 moreover family members experience negative feelings despair sadness and regret humiliation guilt and shame towards their relatives diagnosed with bpd 8 family roles and relationships become strained due to the emotional challenges of having a sibling with bpd gi n 7 agrees and states that people appear less tolerant of their siblings selfharming behaviour and are quick to express their expectations that they should take responsibility for their lives and behaviours uys and middleton 20 further concur with the ndings of this study that patients and their families still receive very little information about mental illness often they are not even told what the diagnosis is and sometimes vague terms like breakdown are used also in a focus group run by dunne and rogers 21 family members reported they had to research the diagnosis for themselves using books and websites they expressed a wish to be informed about how to effectively manage situations that arose with their loved ones the ndings of the study on which this article is based indicated that families struggle in their own daily lives and in dealing with their relatives with bpd these experiences signal the need for mental health communities to become more knowledgeable about bpd and its treatments the establishment of support groups for family members and ways to communicate this information to those who need it as proposed by buteau et al 10 this suggests mental health nurses would bene t from understanding individuals experiences of having a sibling diagnosed with bpd the mental health nurses could then develop material to educate and train families on how to manage their interactions with their siblings living with bpd more effectively a lack of communication and education was empasised by participants in this study interpersonal relationships suffer due to a lack of constructive communication and education on the disorder resulting in family members understandably being tormented by the threat or perpetration of aggressive acts as noted by gunderson 22 participants reactions varied from wanting to protect their sibling to anger at the perceived attentiondemanding aspects of their behaviour mental health nurses should therefore assist family members by providing support and referral information for mental health education 22 gunderson 22 further states family members should not assume the primary burden to ensure patients safety instead family members should contact professionals for help if there is a perceived threat of harm or the patient has already engaged in selfharming behaviour according to choi 23 when families contribute to a collaborative treatment plan and are empowered to participate in the therapy or treatment process all participants in the family system potentially contributing to the problem may be assisted and effectively challenged bailey and grenyer 24 emphasise that the family environment has an important implication for the clinical outcome of patients with a mental illness it has also been found that where parents focused their energy on actively caring for a child with bpd their relationships with their other children became more distant 7 therefore it is important when mental health nurses engage with families of people with bpd to emphasise the dynamics within the family and remain aware of how it impacts the whole family as stated according to uys and middleton 20 patients and their families receive very little information on the affected individuals diagnosis and treatment plan this view is supported by gi n 7 who claim family members experienced meetings with health professionals and the treatment team were for the bene t of the clinicians and often just factnding sessions for health professionals in light of the challenges family members experience fossati and somma 4 highlight that relatives of individuals with bpd should have the opportunity to receive stateoftheart evidencebased information on bpd and its available treatments to destigmatise the diagnosis and support the familys role in bpd development therefore adequate family interventions in bpd treatment programmes should be accessible and inexpensive moreover family members of siblings with bpd are likely to be involved in stormy rollercoaster relationships and as a result may feel overwhelmed by the extreme unpredictable feelings and situations even when they do not suffer from any mental disorder themselves 4 as illustrated in this study family members may blame themselves for their relatives illness or for not being able to do more to help this can result in emotional consequences including anxiety guilt anger frustration despair and hopelessness 25 ultimately ineffective coping skills are attributed to a lack of knowledge among family members preventing them from making appropriate choices in assisting their relatives diagnosed with bpd 8 similar ndings were reported in this study and the inadequate coping mechanisms mentioned by the participants were related to their lack of knowledge of the disorder based on this discussion family intervention programmes are likely to create awareness of the different problems family members who have siblings with bpd encounter lawn and mcmahon 11 determined that family carers of people diagnosed with bpd experience signi cant exclusion and discrimination when interacting with mental health services therefore education for all health professionals is indicated especially those who are likely to encounter bpd carers to improve their skills and attitudes in working with people diagnosed with bpd limitations and future research although data saturation occurred in the analysis of qualitative interviews the studys small sample size may be a limitation as other views may not have been represented further research focusing on the provision of collaborative care for people with bpd and their families could be conducted conclusion bpd affects the person diagnosed with it and everyone around them individuals face signi cant challenges when their sibling is diagnosed with bpd they often have di culty coping with their siblings demands while trying to live their own lives they also experience a range of emotions in their quest to get control over the situation at hand while battling to live their own lives often interpersonal relationships suffer due to a lack of knowledge and education about the disorder family members yearn for constructive communication and support to help them balance their lives and cope with the demands of having a sibling with bpd recommendations are proposed for mental health nurses who spend time with patients and families of patients with bpd mental health nurses could play an advocating role in the multidisciplinary team caring for the individual with bpd this advocacy role would ensure healthcare professionals communicate and provide education to families about the diagnosis and management of bpd mental health nurses could establish support groups for families and patients with bpd the mental health nurses could establish family intervention programmes such as family therapy which would focus on con ict resolution couples therapy for the parents of individuals with bpd could be conducted to ensure they are able to manage the challenges brought into the family when one child has bpd these recommendations provide a basis for mental health nurses to promote family members mental health competing interests the authors have no competing interests to declare authors contributions nn supervision writing review editing wc participant recruitment data collection data analysis and writingoriginal draft mp supervision cphm supervision all authors read and approved the nal version of the manuscript

background family members of people living with borderline personality disorder bpd experience a considerable objective and subjective burden this article aims to report on a study that explored family members lived experiences of having a sibling with bpd in south africa method this qualitative study used indepth phenomenological individual interviews supported by participant observations and eld notes for data collection data were analysed using teschs thematic coding results seven participants were interviewed and three themes emerged from the collected data the study revealed that participants experienced multiple challenges in understanding gaining control and struggling to cope with their own lives participants also experienced the impact of a lack of communication and education lastly the study revealed that the participants used individual coping mechanisms to cope with having a sibling with bpd conclusions this research illuminated the challenges experienced by family members of a sibling with bpd these ndings provide a basis for recommendations for mental health nurses to promote the mental health of affected family members

background the un convention on the rights of persons with disabilities article 1 defines disability as the result of longterm physical mental intellectual or sensory impairment which in interaction with various barriers restricts the individuals ability to participate in society on an equal basis with others disability is not the impairment itself but rather the product of attitudinal and environmental barriers 1 who estimates that 15 of the global population has a disability a higher prevalence of disability is reported among women in poor families in lowincome countries 1 the uncrpd guarantees the sexual and reproductive rights of people with disabilities including their right to marry and have a family 2 however women with disabilities are too often prevented from enjoying these rights in many countries including nepal 3 4 5 the literature suggests that society continues to undervalue women with disabilities restricting their fundamental rights including their sexual and reproductive rights and contributing to exclusionary practices by national governments policymakers and civil society while women with disabilities have the same desire and legitimate right to become mothers as all other women their childbearing and parenting ability is often brought into question 67 nepal ratified the un crpd in 2010 8 in addition there is a range of national laws and policies addressing the needs and rights of persons with disabilities 9 however many people with disabilities still experience discrimination denial of their rights and unequal access to basic services 510 compounding this patriarchal societies such as that found in nepal have a strong gender bias favouring men it is much harder for women with disabilities than their disabled male counterparts to engage in activities such as education marriage employment and political participation 1112 marriage is an expected cultural practice in nepalese society however studies reveal that it is challenging for women with disabilities to find a marriage partner due to societal misconceptions and assumptions that incorrectly see such women are burdens rather than contributors to families and society 6111314 stigma stereotype and prejudice the terms stigma and associated social responses such as prejudice and discrimination are often used interchangeably in the literature goffman 15 identified stigma as a feature that discredits and makes the person experiencing it different from others this phenomenon is often accompanied by negative stereotyping rejection loss of status and discrimination 16 a number of factors such as lack of knowledge superstition belief systems and fear contribute to stigmatization leading to exclusion of people with disabilities in nepal as in many cultures disability has a long history of being perceived negatively as a misfortune caused by the curse of god or associated with sins in a past life 17 18 19 the negative social attitudes and behaviours towards disability are expressed in a number of ways including the exclusion of persons with disabilities from social roles and activities 20 thus people with disabilities are less likely to have access to education employment marriage or to be allowed to participate in political and social events feeling uncomfortable with people with disabilities avoidance and maltreatment are reported as are other forms of the negative attitudes and behaviours 20 21 22 evidence also shows that attitudes towards disability may change over time and differ from person to person and culture to culture 2021 attitudes also differ by type of disability with those with more visible disabilities often facing greater discrimination and exclusion 142023 in this paper we share findings from a study that focused on public beliefs and attitudes towards disability in rural nepal with particular reference to the experiences of women with disabilities around sexual and reproductive health specifically during their pregnancy childbirth and motherhood methods the study was conducted in rupandehi a southern district of nepal with a population of 880196 of which 5089 are female 24 out of 125 recorded ethnic and indigenous groups in nepal the study district population is comprised of upwards of 95 different groups and indigenous inhabitants including 28 subgroups of dalits who are grouped together as a socially and economically disadvantaged caste group and considered untouchables the majority of people live in rural villages though the urban population is growing fast in terms of caste breakdown by the 2011 census the study district population was comprised of 25 janajati 21 brahmin and chhetries and 12 dalit 112 of the district population are reported to have a disability 24 the nepal human development report 2014 reported life expectancy at birth for nepalese people at 70 years the national human development indicator value is 0541 while the hdi value for the study district is 0498 25 the data reported in this paper is extracted from a larger original study that the authors conducted to investigate maternal healthcare access for disabled and dalit women in nepal the larger study followed the mixedmethods approach by which quantitative and qualitative data were collected simultaneously the study collected quantitative data using a survey questionnaire while qualitative indepth interviews and focus group discussions were conducted to understand the experience of disabled study participants nondisabled women with a range of social and educational backgrounds from the same communities and the views towards disability of women who serve as community health volunteers this paper reports the findings from a subsample of the qualitative component of this larger study women with disabilities dalit and nondalit women without disabilities and female community health volunteers participated in this study faceto face semistructured interviews with 17 women with physical and sensory disabilities and six focus group discussions with women without disabilities in the study district were conducted to ascertain community attitudes towards women with disabilities four of the six focus groups were comprised of nondisabled women from the surrounding community selected to represent a range of different ethnic backgrounds and educational levels the total number of this group was 42with groups ranging in size from 10 to 12 an additional two groups of female community health volunteers comprising 6 and 8 participants respectively were chosen with the help of local health facilities all participants were purposively selected and the interviews and discussions were conducted in a natural setting with the help of local nongovernment organizations and disabled peoples organizations we sampled 19 women with physical visual intellectual speech and hearing disabilities who had experienced pregnancy and childbirth two women one with an intellectual disability and one with a hearing and speech disability were excluded from the interview because of the complexities involved in communication and in assessing mental disability due to the limited knowledge of the study team an adapted screening tool from the un washington group on disability statistics was used for disability assessment 2627 interviews with women with disabilities were conducted individually in their homes the focus group discussions were conducted in four different villages with diverse groups to capture the views from multiple perspectives to reflect the key social divisions within the area both dalit and nondalit women were included in the discussions dalit are considered untouchables and are at the bottom of the caste hierarchy constituting about 12 of the district population 28 two additional focus group discussions were conducted with the female community health volunteers to understand their service experience and views towards pregnancy and childbirth in women with disabilities this was important as they play a key role in delivering basic maternalchild healthcare serve as the first contact at the community level the number of interviews and focus group discussions were determined by data saturation interview checklists and topic guides were used in conducting indepth interviews and focus group discussions the checklists and topic guide for focus group discussions covered participants beliefs and values concerning disability views on sexual and reproductive needs and marriage of women with disabilities and their feelings and levels of comfort around women with disabilities the interview guide for women with disabilities included questions on their own views and experiences in the family society and workplace in regards to their disability marriage pregnancy and childbirth the checklist and topic guides were fieldtested and the first author a native nepali speaker with the help of two local trained female research assistants conducted the discussions and interviews the role of the research assistant was to obtain consent of participants and to take notes during interviews and discussions developing a sustained contact we fostered a relationship with study participants and encouraged their contribution considerable effort was put into maintaining neutrality and balancing the power relationship between the researcher and the participants at all stages of the research process all interviews and discussions were audiorecorded with the participants written approval after completion of field data collection we followed a series of steps before the analysis proceeded to the interpretive phase the first step involved transcribing verbatim all the audiorecordings in nepali and translation into english which was done by the first author and three other language specialist then the first author reviewed all transcripts and the interview notes reading rereading and reviewing for overall understanding following the framework method developed by ritchie and spenser we then analysed data in five stages familiarization identifying a thematic framework indexing chartingmapping and interpretation 29 to ensure accuracy for interrater reliability a second person the senior project coordinator of the larger study assisted in conducting the interviews crosschecked the transcriptions translations and data coding at this stage where no new concepts emerged from the further review and coding of data we developed subthemes and grouped together the concepts identified in the text based on their similarities and relationships to develop themes and subthemes the themes and subthemes were then analyzed in relation to the research questions and are described in the following section results characteristics of study participants the sampled study participants consisted of 12 women with physical disability four with visual disability and one with a hearing and speech disability the majority 12 of the participants were nondalit while five were dalits the ages of these women ranged between 23 and 35 years all women were married and had personal experience of pregnancy and childbirth less than half reported that they found partners themselves over onethird of women had no formal education while four women had some college education misconception and misunderstanding about disability participants who had disabilities reported that their disabilities were regularly regarded by others as a misfortune and they frequently encountered inappropriate behaviour from neighbours and society women with disabilities reported being regularly humiliated stigmatized and negatively stereotyped a woman with a physical disability expressed her frustration about how the community treats her due to their misconceptions about disability if somebody is going out and meets a person with disabilities they sayit is bad luck i saw the face of a disabled… we are blamed if they are unsuccessful in work this is the kind of discrimination we are facing if we participate in any ceremonies and weddings they say why did she come here everybody will see her and some bad things may happen a dalit woman with physical disabilities another woman with a visual disability stated there was an incident during my first baby it was during teej festival when i had gone to a fair my baby was three and half months old a woman there said that it was pathetic to see a blind person having children i did not recognize the woman but i got very angry why did i have to be a character of sympathy when everything was normal had the baby been in pain or had it been crying such comment would be meaningful i returned home without going around a nondalit woman with visual disabilities participants from disabled and nondisabled focus groups reported that folk beliefs about the sexual desires and reproductive capability of women with disabilities persist and that their sexual wellbeing is often neglected in nepali culture women do not openly talk about sex and sexuality however as nondisabled focus groups were femaleonly discussions about these topics was more open the participants in focus group discussions none of whom had disabilities stated that due to cultural and social mores their families and neighbours regularly spoke negatively about sexual desire and ability to conceive for women with disabilities only one nondisabled focus group participant raised the issues of rights and argued that people with disabilities have the right to have children many focus group participants agreed that people with disabilities have the same desires as people without disabilities however not everyone agreed as one educated participant with a physical disability in her indepth interview recalled her own grandmotherinlaw was suspicious about her ability to conceive we had a grandmother here but its been about 2 years since she died she used to keep on asking if i would have the baby so i guess she might have had that feeling after 6 months of her dying i became pregnant a nondalit woman with physical disabilities when asked about adult relationships and intimacy almost all the focus group discussion participants without disabilities stated that women with disabilities can have relationships become pregnant and give birth but that they would not be capable of caring for and rearing a baby some of the women with disabilities reported that their parents did not understand their emotional and sexual needs and never talked to them about marriage many of the focus group discussion participants believed that emotions and desires about sexuality and pregnancy for women with disabilities are the same as for women without disabilities as two of the focus group discussants noted i think that the desire for sexuality is the same for people with disabilities and people without disabilities but there are differences in problems and difficulties fgdnondalit women …of course they want to have a baby every woman wants to have a baby people think that after having a baby it will grow up and support he will earn and feed the family later fgddalit women other focus group participants reported that people in the community have both positive and negative views towards pregnancy childbirth and motherhood for women with disabilities all people will not have the similar thoughts some views in a negative sense and disgust some say that she needs help for herself and how she rears the baby and some others show their sympathy fgdnondalit women in a focus group discussion of female community health volunteers one woman added an additional cultural interpretation the meaning of giving birth she said for a mother is to be satisfied with all senses if a mother cannot see the baby hear the baby cry or play with them then what would be the point of having a baby if they are blind then it will be difficult if they give birth there will be a problem who will take care of the child if they cannot hear the babys cry then what is the meaning of giving birth it will be really difficult… fgdfemale community health volunteers one participant with visual disabilities expressed her disappointment that even after demonstrating her ability doing all household chores some family and neighbours doubted her ability to care for a baby i did hear such comments and doubt on how i would take care of a baby when i myself could not see but they had seen me doing all the household chores so people had mixed opinion some said i would take proper care whereas the others said i would not a nondalit woman with visual disabilities another widely held belief is that a mothers disability will usually be passed on to her baby this was found to be a primary reason for negative attitudes among people without disabilities towards marriage and pregnancy in women with disabilities women with disabilities were often counselled not to marry or were not considered acceptable marriage partners because of this misconception some fgd participants firmly believed that the baby and subsequent generations would inherit any disability present in the mother others disagreed few participants however demonstrated any knowledge of the fact that some types of disabilities were congenital and many others were not as one participant noted they should not give birth the baby might also have a disability due to the disability of mother so it is risky fgddalit women one participant with visual disabilities expressed her frustration that this belief often discourages her from becoming pregnant people say disability is often hereditary since both of us were blind everyone thought our life would be complicated with a baby some of the neighbours said we should not have planned for a baby and most suggested it would have been better if we had used family planning devices i used to say to my neighbours that not all disability is hereditary some could be and some not whatever happens we will see… a nondalit woman with visual disabilities the study participants reported that disability is the concern of the whole family with society stigmatizing nondisabled family members as well and that this often complicates their own marriages and relationships as one participant with visual disabilities stated when there is a person with disability at home everything gets connected to himher for example i am a blind person in my home so when my elder brother was getting married the issue of looking after me was raised by many also people tend to think the baby to be born in the house will also be blind people think it is heredity… people often looked at the eyes of my brothers children so it is obvious that they would talk about our baby a nondalit woman with visual disabilities societal and cultural beliefs exert a strong influence upon individuals creating doubts and fears even if the individual is educated for example a welleducated participant with physical disabilities who did not initially believe her disability would be inherited later developed doubts after talking to her neighbours i had a fear that my baby would have the same disabilities as me when i heard things from the society because of the belief that we have in society i had doubts in my mind a nondalit woman with physical disabilities some dalit women without disabilities in the focus group discussion argued that all babies born to parents with disabilities do not acquire disability … they may have normal children there are examples that the deaf have very clever children both the mother and father are deaf but their children are talent in some cases there could be heredity fgdnondalit women negative attitudes were also expressed in relation to identity many of the women with disabilities reported that on many occasions as a child they were not given a name at all but just referred to as their disability in the eyes of others their identity was their disability many reported that they found this humiliating and an assault on their individual identity neglected or ignored sexual and reproductive needs and the rights of women with disabilities marriage between people with and without disabilities was often not easy the study participantsboth nondisabled and disabled reported that marriage of a woman with disabilities is a complex issue factors include benevolent protection from parents who fear that another family would not treat their daughter properly fear from the paternal family that the woman with disabilities would not be good enough for their son and would prompt malicious gossip fear about conception childcare and domestic responsibilities some fgd participants expressed the view that people with disabilities should be paired off with other people with disabilities interestingly the majority of the women with disabilities interviewed were married to male partners with disabilities in addition most of them had chosen their partner as opposed to having an arranged marriage this was in stark contrast to the social practices in the study area where arranged marriages remain the norm these participants reported that their families had not considered arranging a marriage for them therefore they had sought a partner of their own and lived separately from the extended family a smaller number of the participants with disabilities reported that their family members were positive and helpful about their marriage and pregnancy a woman with visual disabilities reported that her motherinlaw and other family members regularly reassured her saying that her husband with visual disabilities would be able to create a happy life for them even my motherinlaw used to say that my husband would keep me happy no matter what so she often told me not to worry even my greatmotherinlaw was supportive and so were other family members a nondalit woman with visual disabilities a few of the study participants with disabilities were women who had married a man without disabilities they reported that their partners had married them expecting to acquire their parents property as part of the dowry which was an incentive for the marriage however they reported that these arrangements had not often succeeded with further disputes concerning terms of the inheritance between the families and subsequent breakdown of the relationship in many cases one of the participants with disabilities whose parents had bequeathed their property to her and who had married a man without disabilities described her experience my husband had been asking for this property to convert to his name but i didnt agree then he started torturing me i could not live together with him and i was separated it has been around 2 to 3 years now since we separated a nondalit woman with physical disabilities the study found that many families and neighbours perceived pregnancy and childbirth in a woman with disabilities as an additional burden it would be difficult if a woman with mobility problem gives birth in such cases it is better not to give birth if the woman cannot take care of the baby it would be difficult to those for giving birth as well they will also have difficulty to care and rear the child if she is blind or only the mobility disabled she should give birth even for her own future support it would be better to give birth as per the individuals physical ability fgdnondalit women it would be as per the situation some love them and care more but if they have given birth even with their severe type of disability then the family or neighbours may perhaps look negatively and may feel disgust fgdnondalit women it was found that women with disabilities faced enormous pressure from societys negative attitudes about their pregnancy and childbirth on many occasions women with disabilities being interviewed for this project stated that they themselves felt guilty and a burden and faced discouragement in all aspects of life many respondents with disabilities reported that their family particularly their motherinlaw was not helpful during their pregnancies however after the baby was born mothers reported that most mothersinlaws welcomed their new grandchild relatives and society view us as a burden to them and they think they have to look after us throughout their life this opinion is prevalent in every person of the society they think a blind person is incapable of doing every kind of thing maybe some people with visual disabilities do not get married because they do not want to nevertheless people think they did not get married because of their blindness nobody understands that even blind people have choices in life such things make us feel really bad a nondalit woman with visual disabilities another dalit participant with physical disabilities stated that she often came across negative reactions from her neighbours she would not be invited to neighbours functions as they considered her disability a burden saying …why invite people with disabilities to the ceremony instead of getting help from them we have to care for them…they cannot do anything…they come sit and only talk ……they are not helpful… a dalit woman with physical disabilities the same participant recalled that she faced more trouble from her family than from the neighbours during her pregnancy and childbirth she reported that her motherinlaw was negative and totally unhelpful when she was pregnant so much so that her husband brought her back to her own parents home for the delivery other family members said we should feed her and take care of her child too let her stay there my motherinlaw said if i had given birth to you i would care for you so i stayed 56 months with my mother nobody came from my husbands family to bring me back from my maternal home when my baby started to crawl my husband came to bring me back without the permission of his mother my mother said i will not send my daughter if you cannot take care of her i will care for her whatever i can she further described the fact that her sister and mother were supportive cared for and counselled her keeping her with them during her pregnancy and childbirth while she was being badly treated by her motherinlaw my mother…she tried to convince me that many people do not get married but you are lucky so you got married… who could have known that your new family members would not care for you after marriage…… sometimes i thought to commit suicide by taking poison even after conceiving a dalit woman with physical disabilities in nepal mothersinlaw have a powerful influence over their sons attitudes as the woman above continued i felt bad…i had given birth to a child that had added more trouble…i was tolerating the rudeness and bad behaviour while i was alone…but after having the baby i had the additional responsibility to care for the baby nobody would marry me as well…i had pain and became restless by thinking all this somebody had talked to my husband so he came to take me back with him a dalit woman with physical disabilities some participants said that having a child was part of a strategy to ensure future support for people with disabilities as a parent rejection and exclusion by the family and society as noted above the study found that families of women with disabilities in the study population commonly denied the rights of women with disabilities to marry or have children in the first place the reasons included family prestige overprotection by the parents lack of understanding about disability and the reproductive needs of people with disabilities and misconceptions created by stereotyping and prejudice including around the fear of inheritance of the disability as noted earlier a dalit woman with physical disabilities stated that her husband was blamed for marrying her and excluded for several years by his parents and relatives they did not talk to me and my husband for a year they had scolded so much saying he should have searched a nondisabled woman why did he marry me… they said i cannot plant paddy cannot do other works why he married with such a woman they did not speak for a year with him too later they said to him that it was your fate you did not follow what i said but married such but earlier they used to scorn us saying he would not have a child by marrying a woman with disabilities a dalit woman with physical disabilities another participant with visual disabilities had a similar story she chose her partner with visual disabilities herself and their marriage was initially rejected by the husbands family until it was clear the child had not inherited their blindness with the first child the problem was that we had not been accepted by our home family as we got married ourselves moreover people thought that our babies would also be blind only when they realized that the baby could see then only was i taken home along with the baby they bought a separate home in bhairahawa and kept us there now it is different we have very good relation with other family members earlier it was very difficult a nondalit woman with visual disabilities women with disabilities were asked about their involvement in major family decisions and attendance at neighbours functions to understand their inclusion within as well as beyond the family few participants reported involvement in their family decisionmaking the majority of respondents with disabilities also reported that they were not involved in the womens groups some who had been part of womens groups reported that they felt discriminated against disdained or considered inferior prompting many to leave such groups one participant reported that the group specifically doubted her ability to make monthly savings contributions and did not invite her to become a member what should i say why they dont call when the neighbours go there that is why i dont feel like going there and i will not go there…they might have the thought how will i get money to be in the group a nondalit woman with physical disabilities it was also apparent that many communities excluded women with disabilities from participating in ceremonies and rituals considering their presence bad luck one of the participants reported some people say it is unfortunate if they see us some do not like us to be present in ceremonies and rituals considering us as a symbol of bad luck if i go somewhere and anyone comments negatively i do not go again i have heard somebody saying she came herself in spite of sending other family members a dalit woman with physical disabilities facing challenges due to powerlessness some of the fgd participants without disabilities and many of the participants with disabilities in their indepth interviews reported that women with disabilities are discriminated against in every sphere of life some participants with disabilities reported that female community health volunteers do not visit them while women without disabilities are visited and counselled during their pregnancy a few participants reported that whilst initially invited to attend womens group meetings they subsequently felt ignored and their opinions disrespected prompting them to leave the group importantly women with disabilities further stated that the discrimination is not only outside but is also within their homes one participant with a disability described the discrimination she faced from her own family members during her pregnancy and childbirth there was so much…i am afraid to talk with anyone about those times and the discrimination and troubles that i faced i have to reassure myself and i like to take satisfaction because of my children both of us me and my sisterinlaw delivered at home nobody helped me but the entire family cared throughout the 24 h while my sisterinlaw gave birth i was at my maternal home when i gave birth to my son and had good food but with my daughter they gave me cheap food a dalit woman with physical disabilities another dalit woman with physical disabilities reported that she was discriminated against at work by the neighbours due to her disability she stated that her mother also frequently abused and discriminated against her before her marriage her mother continues to do so as she lives close by there are two younger sisters they love me but mother hates me they are far away so mother loves them i am disabled and she does not love me my leg became weak and my mother used to verbally abuse me she said that it would be better if i had died a dalit woman with physical disabilities an fgd participant described discrimination and exploitation within her own family to a niece with hearing disabilities i have a niece who cannot speak well she got married but people at her home didnt care for her they thought deaf people should be given leftover food as she cannot speak for herself such is the perspective of people fgdfemale community health volunteers the study found that people in the society think that women with disabilities are weak and have no power such an environment creates feelings of helplessness and fear in the minds of women with disabilities the participants reported many examples of violence abuse and exploitation by the family members as one of the study participants noted sometimes i had such feeling i felt as weak not able to do anything even when people said something good i felt they were saying it to humiliate a nondalit woman with visual disabilities both dalit and nondalit women with disabilities reported facing challenges in the family and society due to their disability however dalit women with disabilities stated their experience of disparities exclusion and bad treatments in the society was due more to their disability rather than their lower caste status a dalit participant with disabilities expressed her dissatisfaction at being stigmatized and mistreated being disabled is more painful…if i did not have a disability nobody would speak bad or painful words to me…i would not seek support or help from anybody…society would not consider me a symbol of bad luck and i would not be excluded a dalit woman with physical disabilities some of the respondents reported that their husband or other family members abused them one participant reported that her mother frequently abused her verbally and physically due to her disability ……helped by my brotherinlaw he has known all about me and my trouble how i was suffering being scolded and beaten i could do work and was also doing but she used to beat me saying that i was sitting idly and eating doing nothing a dalit woman with physical disabilities emotional support not all respondents reported negative attitudes to women with disabilities despite the negative social environment a number of participants both in focus group discussions and individual interviews reported that their families and neighbours were supportive and positive toward disabled people some disabled women specifically reported that their neighbours were kind sympathetic and supportive during their pregnancy and encouraged them to go for services some also reported that female community health volunteers visited them at home during their pregnancy as one of the fgd participants stated all people will not have the similar thoughts some views in a negative sense and disgust some say that she needs help for herself and how she rears the baby and some others show their sympathy fgdnondalit women discussion findings from this study provide a range of insights from both women with disabilities themselves and from members of the families and communities in which they live it is interesting to note that the culture and social attitudes towards women with disabilities was often reported as unfavorable with misconceptions about disability in general indicating that negative social attitude towards disability prevailed in the study district findings revealed that many women with disabilities are stigmatized and discriminated against in various forms by society and even within their own families however importantly while exclusion and negative attitudes were commonly reported by and about women with disabilities the findings were mixed with some women with disabilities as well as some people without disabilities expressing attitudes that are more inclusive in relation to the negative attitudes and social behaviours towards women with disabilities several key issues were identified and despite many peoples openly prejudiced views some degree of benevolent prejudice towards pregnant women with disabilities was also common issues regularly raised in fgd and interviews included the marriage of women with disabilities their ability to conceive give birth and safely raise a baby moreover many respondents with and without disabilities reported anxieties and fears that their impairment would be transmitted to their babies and that pregnancy and childbirth of women with disabilities would be an additional burden for their family the study found little exposure to and insufficient knowledge about disability among participants without disabilities leading to blanket assertions which resulted in discrimination rejection and exclusion of people with disabilities many women with disabilities reported that they faced discrimination and humiliation as well as violence from their family members particularly from their mothersinlaw and husbands the study reflected more broadly already established findings that women with disabilities live under various forms of oppression which includes being denied opportunities and facing rejection showing that women with disabilities are often not valued in nepalese society and sometimes have no individual identity beyond that of their disability as in other societies around the world myths folklore and misconceptions about disability such as disabled people are tragic figures that society should pity 30 31 32 33 were found commonly among the individuals without disabilities and community health worker groups interviewed consistent with this finding the literature also shows that the negative attitudes more commonly exist among poor and educationpoor communities 33 34 35 36 beliefs about disability expressed by the nondisabled participants in this study are also commonly found in the religious and folk beliefs in many traditions including hinduism buddhism and islam for example in india and nepal many people believe that disability is a punishment or curse from god moreover people with disabilities are traditionally perceived as inauspicious and are often discouraged from attending religious and wedding functions 193334 while hinduism has as a central tenet the concept of equality the strong belief in reincarnation is sometimes interpreted to mean that people disabled in this life may have done something wrong in a previous life 193337 exclusion was often expressed through patronising attitudes these were often manifested through people in the community questioning the ability of women with disabilities to exercise their right to make key life decisions around marriage pregnancy and childbirth a number of factors such as inadequate knowledge about disability and the needs of people with disabilities misconceptions and incorrect beliefs as well as fear of contagion the inheritance of disability and uncertainty about how to interact with people with disabilities contributed to this negative attitude the focus of this particular paper is the question of pregnancy childbirth and motherhood among women with disabilities who already have one or more children a linked but important additional question addressed elsewhere 5 is the access of women with disabilities to contraception and the availability of this access compared to that of their nondisabled peers positive perceptions about the ability of women with disabilities to give birth and rear their children were minority views however they did exist and there was strong variation regarding these perceptions by disability type for example women with intellectual or mental disabilities were often presumed to pose a greater risk to the child than were women with other types of disability the families routinely although not universally perceived the women with a disability as a burden since they assume this woman would contribute less to family chores and income such negative attitudes led to discrimination within families with little or no priority given to the needs of women with disabilities including their treatment rehabilitation or other essential care required issues related to the ability of women with disabilities to marry and doubts about their ability to give birth and rear children are consistently highlighted by studies conducted in countries such as india and korea 3334 38 39 40 however not all research is consistently negative on this in contrast to our findings another nepali study by simkhada et al 19 found positive attitudes towards the rights of women with disabilities to marry and have children such contradiction in peoples views is not surprising in a multicultural society like in nepal moreover this study looked at different groups with lower educational and awareness levels in a different part of the country than did simkahada et al significantly women with disabilities themselves often shared reservations about their ability to successfully marry become pregnant and raise children while some had come to understand and appreciate their own ability and had some knowledge of new and changing attitudes regarding the rights and potential of women with disabilities a number had not been reached by progressive ideas and attitudes regarding people with disabilities evidence shows that negative attitudes towards disability are changing gradually 21 this study reflected some of this changing attitude with respondents reporting some positive attitudes towards people with disabilities and respondents with disabilities reporting numerous examples of kindness and acceptance some of this is also based on individual attitudes and on familiarity with the disability from personal or family experiences whilst in this study disabled participants perceived these as positive experiences it could be argued that these actions were more closely linked to paternalistic caring rather than reflecting notions of equality and mutuality however increased education and levels of awareness among the public changing sociocultural contexts and policy changes including nepals ratification of the crpd and the development and passage of a number of related laws and policies in line with the crpd might also be influencing changing public views about women with disabilities it is important to note that women with disabilities showed not only vulnerability but a number of strengths for example many who felt that their families were unwilling or unable to find them marriage partners had identified and arranged their own marriages often in the face of considerable opposition this selfstarting approach to marriage which flies in the face of established custom is worth a more indepth discussion than can be provided here but it is of note many disabled women reported wanting a child deciding to become pregnant and seeking antenatal health care as well as support for childbirth even though they knew or feared that they would meet with resistance and lack of support by some family health care providers and members of the surrounding community there was also an understanding expressed by some women with disabilities and as well as members of the broader community that in a very practical sense having a child represents long term planning as it guarantees that the disabled womanas is true for many other women in the communitysome security and support in older age at the outset of this study we hypothesized that women who were both disabled and dalit would be doubly discriminated against this was based on studies that state women with multiple vulnerabilities may face compounded discriminations 41 significantly however this study found disability far outweighed class as a daily concern disabled women both dalit and nondalit faced similar challenges dalit women with disabilities consistently reported that they experienced discrimination due to their disability rather than their lower caste status nondalit women reported facing barriers in education social inclusion and family life very similar to those reported by dalit women further studies are needed to explore this intersectional issue in greater depth finally it is important to note that there was a mix of attitudes throughout the community based on a range of factors including membership in different ethnic minority groups personal familiarity with disability education and individual beliefs and temperament this mix of attitudes in the public arena even in a remote area is an interesting finding and one that generates recommendations for policy and practice there is certainly a need to encourage social policy and information efforts to raise public awareness and improved education and advocacy campaigns to mitigate against misconceptions about disability and promote the sexual and reproductive rights of women with disabilities but the range of attitudes and beliefs found also offers an important starting point for such effortsit may be possible to build on the best and most progressive attitudes towards women with disabilities already existing in the community and such interventions must not only target the general community our findings show that many women with disabilities themselves need more information and support as they move forward through pregnancy childbirth and motherhood we acknowledge several limitations associated with this study the study was a part of a safe motherhood project in nepal therefore the study population was limited to one project district additionally like all qualitative studies our findings may not be generalizable to other areas with different social and cultural contexts furthermore the views expressed by the participants reflect the attitudes towards disability in general rather than specific types of disability conclusion although negative attitudes are prevalent among the public in the study district towards women with disabilities their marriage pregnancy and motherhood we found a range of attitudes related to pregnancy childhood and motherhood among women in the general public in this area of nepal without doubt women with disabilities face significant challenges from family and society in every sphere of life due to negative attitudes which reflects inadequate public knowledge and misconceptions about disability stereotyping and prejudice yet there were also a range of positive attitudes expressed by focus group members that warrants further exploration and that could provide a starting point for positive changes in policy and programmes to better support women with disabilities who become pregnant in this region and finally it is important to emphasize that disabled women themselves faced a number of significant social and economic challenges but also showed a range of strengths that must be supported and encouraged consent for publication not applicable competing interests the authors declare that they have no competing interests

background this study reviews the attitudes and behaviours in rural nepalese society towards women with disabilities their pregnancy childbirth and motherhood society often perceives people with disabilities as different from the norm and women with disabilities are frequently considered to be doubly discriminated against studies show that negative perceptions held in many societies undervalue women with disabilities and that there is discomfort with questions of their control over pregnancy childbirth and motherhood thus limiting their sexual and reproductive rights public attitudes towards women with disabilities have a significant impact on their life experiences opportunities and helpseeking behaviours numerous studies in the global literature concentrate on attitudes towards persons with disabilities however there have been few studies in nepal and fewer still specifically on women methods a qualitative approach with six focus group discussions among dalit and nondalit women without disabilities and female community health volunteers on their views and understandings about sexual and reproductive health among women with disabilities and 17 facetoface semistructured interviews with women with physical and sensory disabilities who have had the experience of pregnancy and childbirth was conducted in rupandehi district in 2015 interviews were audiorecorded transcribed and translated into english before being analysed thematically results the study found negative societal attitudes with misconceptions about disability based on negative stereotyping and a prejudiced social environment issues around the marriage of women with disabilities their ability to conceive give birth and safely raise a child were prime concerns identified by the nondisabled study participants moreover many participants with and without disabilities reported anxieties and fears that a disabled womans impairment no matter what type of impairment would be transmitted to her baby participantsboth disabled and nondisabled reported that pregnancy and childbirth of women with disabilities were often viewed as an additional burden for the family and society insufficient public knowledge about disability leading to inaccurate blanket assumptions resulted in discrimination rejection exclusion and violence against women with disabilities inside and outside their homes stigma stereotyping and prejudice among nondisabled people resulted to exclusion discrimination and rejection of women with disabilities myths folklore and misconceptions in culture tradition and religion about disability were found to be deeply rooted and often cited as the basis for individual beliefs and attitudes conclusion women with disabilities face significant challenges from family and society in every sphere of their reproductive lives including pregnancy childbirth and motherhood there is a need for social policy to raise public awareness and for improved advocacy to mitigate misconception about disability and promote disabled womens sexual and reproductive rights

introduction salivary bioscience has found increased utilization within pediatric research given the noninvasive nature of selfcollecting saliva for measuring biological markers with this growth in pediatric utility more understanding is needed of how socialcontextual factors such as socioeconomic factors or status influence salivary bioscience in large multisite studies socioeconomic factors have been shown to influence nonsalivary analyte levels across childhood and adolescent development however less is understood about relationships between these socioeconomic factors and salivary collection methodological variables variability in salivary methodological variables between participants may impact the levels of analytes measured in a salivary sample thus serving as a potential mechanism for nonrandom systematic biases in analytes methods our objective is to examine relationships between socioeconomic factors and salivary bioscience methodological variables within the adolescent brain cognitive development study© cohort of children aged 910 years old introduction socioeconomic factors or status that drive health inequities are well established however a thorough understanding of sesdriven health inequities is needed within pediatric populations to elucidate earlylife biological antecedents of adult health inequities previous studies among pediatric populations demonstrate multiple salivary biomarkers implicated in associations between the broader social environment and physiology including neuroendocrine markers metabolic markers and immune markers however a number of these biomarkers rely on invasive sampling techniques particularly blood draws risking harm to participantresearcher rapport and overall willingness of communities to participate in biomedical research particularly among pediatric populations one approach to address this research gap in biological measures among pediatric studies is the use of salivary biosciences salivary biospecimen technologies have grown in popularity over the last decade within research studies and clinical testing to noninvasively measure levels of analytes within diverse human populations this utility is primarily due to its contextual practicality allowing for sample collection outside of laboratory or clinical settings as well as the noninvasiveness and feasibility of saliva sampling relative to more invasive techniques such as phlebotomy the many advantages of collecting salivary samples over other types of biospecimens in research include being a lowcost option particularly for studies requiring multiple samples the ability for a participant to selfsample and adaptability to various field settings this method offers increased feasibility to measure physiological correlates of ses and related factors given the noninvasive nature ease of collection of salivary samples and reduced cost of sampling these costsaving benefits afford strengthening of study design such as sampling from more participants increased number of collections within participants or increased number of biomarkers assayed from each saliva sample further salivary bioscience demonstrates great potential for diagnostic capability including pediatric endocrine dysfunction cardiometabolic disease monitoring lithium levels for psychiatric disorders and diagnosing covid19 at home additional methodological strengths of salivary sampling allow for the inclusion of communities that have been traditionally underrepresented in research and eases the burden of participation for families improving adherence certainly a history of scientific injustices exists disproportionately affecting low socioeconomic status and raciallyethnically minoritized communities and driving historical and currentday underrepresentation in biomedical research that has often resulted in varying degrees of distrust of researchers these historical and current injustices often occur when the cultural appropriateness of biological sample collection is not adequately considered salivary collection is a tool that can minimize cultural insensitivities inherent in the collection of biological data given its acceptance among diverse adolescent communities however it is important to note that any biological collection can be precarious and warrants culturally and equity guided investigations some potential examples include some cultures or communities may feel averse to producing a saliva sample particularly when observed by an experimenter and may prefer other biological methods over saliva age of study sample matters with children generally exhibiting aversion to blood sampling but willingness to produce saliva and certain cultures may perceive discarding unused saliva into waste as disrespectful it is our recommendation that the community preferences for or against saliva collection be well understood before leveraging salivary biosciences given these advantages feasibility and promising diagnostic future of salivary biosciences it is essential to first understand how the experimental design and saliva collection methodology should be standardized to ensure precision of measured analyte levels particularly for the investigation of health inequities and for increased application within pediatric research or clinical utility without this deeper methodological understanding spurious differences in experimental design and methodological implementation of salivary biosciences may undermine the interpretability accuracy and utility of salivary analytes several decisions in the experimental design can directly influence the methodology of salivary sample collections for example a design that rigorously standardizes collection of salivary samples can reduce or eliminate unintentional biases due to variations in collection methodological variables these methodological decisions include how much time should be allowed between a participants waking time to their saliva collection time the time of day the saliva sample is collected the amount of physical activity allowed prior to sampling if caffeine is consumed prior to sampling or other oral considerations that can impact measured analyte levels standardized collection practices help eliminate unintended experimental noise where nonbiological factors may influence the composition or volume of whole unstimulated saliva without stringent standardized collection practices of how and when saliva samples are collected leveraging salivary biosciences on a large scale may result in unintended methodological variations which can impact the analyte levels measured in the collected saliva sample and thus take a detour from true biological levels warranting caution many adrenal steroid analytes demonstrate diurnalcircadian or seasonal rhythms marked by patterns of varying levels over an extended period of time for example cortisol a marker of psychological stress fluctuates throughout the day peaking approximately 3045 min after waking followed by tapering levels in the evening in addition the amount of sunlight at various points of the day drives circadian rhythms waking later in the day when sunlight is different than morning light may shift circadian phases and thus alter typical patterns of analytes not only is the time since waking important the time of day when the sample is collected is also a source of experimental variation for example salivary dehydroepiandrosterone and testosterone levels are typically highest in morning samples and drop continuously throughout the day to produce lower levels in evening samples in addition dhea is implicated in physiological responses to acute stress thus saliva sampled later in the day may represent different hormonal profiles compared to morning collections given fluctuating levels with circadian patterns or greater opportunity to experience acute stressors as the day goes on given these considerations minimizing variations in collection practices or precollection exposures are important for making accurate conclusions about the source of differences in analyte levels variations in methodological factors may become increasingly problematic for obtaining precise measured analyte levels in maturing adolescent populations especially where pubertal maturation is underlying the biological systems producing the analytes of interest further methodological variables related to lifestyle such as rigorous physical activity and caffeine intake prior to salivary sample collection may introduce bias in analyte levels by altering physiological states or the integrity of the saliva sample rigorous physical activity can alter levels of dhea or testosterone particularly in saliva samples taken during early stages of pubertal maturation when hormone levels are very low salivary dhea levels among adolescent males have been documented to increase postexercise yet with varying slopes according to pubertal development caffeine intake prior to saliva sampling can impact analyte levels through a few different mechanisms including shifting the salivary ph increasing sample acidity and therefore impacting the performance of certain phsensitive assays or promote bacterial growth thereby compromising the integrity of salivary fluid in addition caffeine intake may risk dehydration in the participant that would reduce salivary flow rate andor activation of physiological pathways that overlap with origins of the analyte of interest such as caffeine activating the adrenergic pathway and increasing urine concentrations of metanephrine although these observations are in serum or urine samples unclear evidence on correlations of serumurine metanephrine with salivary levels as a function of caffeine intake warrants consideration of caffeine exposure in salivary collections standardized collection practices can minimize differences between and within participants in these methodological variables by regulating time of day when the saliva sample is collected prohibiting participants from consuming caffeine or performing rigorous exercise beforehand and standardizing the duration of saliva sampling between and within participant sampling analytes closely connected to circadian patterns may be particularly sensitive to variability in sampling times or alterations in ph levels due to caffeine consumption the present analysis examined relationships with several salivary methodological collection variables in a large usbased representative pediatric cohort participating in the adolescent brain cognitive development study© in the abcd study detailed data was collected on methodological variables mentioned above but was not standardized in the collection protocol allowing for our evaluation of potential nonrandom methodological variation relating to saliva collection and key socioeconomic factors socioeconomic factors have been of central focus for understanding health inequities socioeconomic factors reflect access to economic or social resources and are often represented by individual or composite measures of household income level poverty status parental education attainment or occupation these factors have been described in the literature to influence child developmental outcomes low ses has been associated with poor school readiness and academic achievement more frequent adverse experiences structural brain differences and altered executive functioning studies investigating the relationship with ses using salivary samples among children from low ses households have noted higher baseline neuroendocrine profiles and steeper neuroendocrine trajectories over time relative to children from high ses households ses has been purported to operate as a function of resource availability for a study participant if collected at the home participants may have limited access to freezers to store salivary samples mailing resources to mail collected saliva technology such as text messages or phone that would facilitate reminders to collect samples at consistent timings or more accurate collection time records without the aid of digital tools possible limited availability and access to social and economic resources may influence salivary sample collection variables when participants selfschedule throughout the day when to come into the laboratory for sampling thus collections performed at a laboratory or at a study site issue the question whether collection methods differ as a function of participant resource availability relationships between ses and other variables important in salivary collection namely physical activity and caffeine consumption have been demonstrated positive relationships between ses and the amount of physical activity performed among adolescents have been reported such that low ses tends to be associated with less physical activity compared to those with a high ses however variations in the measurement of both ses and amount of physical activity may contribute to some null findings despite overall reductions in the amount of caffeine consumption among children and adolescents since 2000 those living at 099 and 100199 of the federal poverty level have consistently consumed caffeine at higher rates compared to those living at greater than 200 of the federal poverty level particularly among children ages 611 years old rates of caffeine consumption in households with low or very low food security and incometopoverty ratios below 20 are significantly higher compared to households with incometopoverty ratios above 20 thus childadolescent physical activity and caffeine consumption are a possible source of methodological variation in saliva collection when not standardized in the collection design given that many analyte levels fluctuate on a circadian rhythm patterns of saliva collections earlier or later in the day among one socioeconomic context relative to others in the study sample would suggest potential nonrandom systematic errors in salivary analyte values due to broader social determinants similarly socioeconomicrelated differences in physical activity or caffeine consumption prior to salivary sampling may serve as another mechanism for nonrandom systematic errors in salivary analyte levels without disentangling these contributors the inclusion of these salivary analyte values in analyses would bias conclusions regarding differences in biological outcomes thus it remains important to capture a greater understanding of socioeconomic influences on salivary bioscience methodology before leveraging salivary data for accurate investigation of health inequities the present analyses will inform how special considerations need to be made when leveraging salivary analyte levels from large multisite studies in childhood a critical period of development when inequities during early life developmental periods get under the skin investigations of the relationship between salivary collection methodological variables and socioeconomic factors among child populations are limited however with the emergence of salivary technology we are observing widespread utilization of salivary biosciences in large cohort studies the objective of this study was to examine the association between key socioeconomic factors and materials and methods background on study sample and sample characteristics this analysis was performed using a sample of children aged 910 years at enrollment participating in a 21site study in the united states from the adolescent brain cognitive development study© release 30 this dataset was selected given that it is a largescale longitudinal pediatric collection of whole saliva via passive drool for analysis of several hormonal analytes although there have been three collection timepoints todate in this dataset this current analysis focuses on baseline measures collected in 20162018 only longitudinal change was not the focus of the a priori aims and any existing methodological variation observed at baseline are most likely repeated and similar in future waves of saliva collection in this cohort participants reported to the study site for salivary sample collection where one salivary sample was collected via passive drool from each participant at each annual timepoint participants and their guardianparent did not receive prior instruction to prepare for the saliva collection during the study visit upon arrival at the study site a minimum of 30 min time passed between participants arrival and starting the saliva collection during this time participants were instructed to not eat or drink anything other than water then asked to rinse their mouth out with water 10 min prior to providing the saliva sample if participants were given a lunch break or arrived immediately after lunch the protocol allowed for minimum of 60 min before sampling thus the majority of saliva samples occurred 60 min after a large meal participants and their guardianparent arrived at the study site for collection based on when the study site and participant schedules aligned current guidelines for optimal utilization of salivary bioscience recommend the notation of time of recent meal oral health or injuries braces or recent loss of deciduous teeth however many of these variables were not controlled or collected in the abcd study given considerations for reducing participant burden and experimentally prioritize the central aims of the abcd study including multimodal mri comprehensive profiles of adolescent substance use and mental health assessments when present at the study site a research assistant documented the arrival time of the participant presence of parent or guardian and the time the participant reported waking after the ra instructed the participant to passively drool into a sample collection tube the ra then documented the timing of the salivary sample duration of sample collection discoloration or visible imperfections as well as duration from collection to placement into a 20°c to 80°c freezer guardiansparents were compensated for their participation in the abcd study with the level of compensation being varied between study sites to account for differences in cost of living salivary samples were then shipped from study sites on dry ice confirmed for frozen state upon arrival and assayed by an external laboratory to reduce statistical noise within the analytic sample unrelated to sampling methodological variables we removed participants whose biological sex at birth was not collected reported unable to complete and refused from analyses we further crossreferenced each participants biological sex at birth with the biological sex reported at the time of salivary sample collection and removed those with mismatched sex we adopted this decision to crossreference reported sex at birth with biological sex reported at baseline collections because early abcd protocol indicated that a participants sex at birth would determine which hormone panel would be analyzed at the study visit only 2 participants were marked as male at birth but had missing entries at salivary sample collection those 2 participants were reclassified as male for analyses we also reclassified the 4 participants reported as intersex at birth with the sex reported at salivary sample collection in addition participants with a gestational age less than 28 weeks and a reported birthweight less than 1200 grams were removed from the analytic sample these participants were erroneously included in the study given that the exclusion criteria required gestational age to be 28 weeks or greater the final analytic sample consisted of n 10567 of which 5534 were male and 5033 were female at baseline measures demographic and socioeconomic variables the inclusion of child age in statistical analyses was informed by evidence of differential sleep habits caffeine intake and physical activity habits between children ages 7 to 10 years old sleep habits including sleep duration which may inform waking time before salivary collection is significantly associated with child age around 9and 10yearolds further documented significant declines in physical activity with increases in child age between ages 9 and 15 years demonstrates a need to control for child age as a precision variable due to independent relationships with the outcome in these analyses regarding caffeine intake inconsistent relationships in the literature warrant investigation in our analyses while previous evidence demonstrates general increases in caffeine intake with increases in age several studies observed lower caffeine intake between 9and 10yearolds while other studies observed similar caffeine intake among 910yearolds given these existing associations bivariate relationships were examined between child age and salivary methodological variables after observing significant bivariate relationships multivariate models were adjusted for child age as a precision variable to isolate effects due to independent relationships between each predictor and the outcomes to examine relationships between salivary collection methods with socioeconomic factors we constructed the following measures poverty status represents the households socioeconomic position relative to the federal poverty level this was indexed according therefore deep poverty is an important unique construct of experienced poverty the participants guardianparent selfreported their level of education and if partnered also reported the partners level of education household education in our analyses represents the highest level of education in the household reported by the parent if the parent reported having a partner then the highest level of education thus to leverage a single operationalization of household education and to reflect inclusivity in genderneutral terminology we used the highest level of education in the household reported by the parent household marital status was categorized as yes if the parent reported being married otherwise marital status was categorized as no if the parent reported being widowed divorced separated never married or living with partner p b 20 20 p c yes no p c n n n n area deprivation index was calculated as the scaled weighted sum of 17 neighborhoodlevel characteristics within the participants reported census block group a detailed list of census variables has been summarized in kind et al and adapted for use in abcd this includes proportion of population aged ≥25 years with 9 years of education proportion of population aged ≥25 years with less than high school diploma proportion of employed persons age 16 in a white collar occupation median household income income disparity median home value median gross rent median monthly mortgage percent owneroccupied housing percent of population age 16 unemployed percent of families below poverty line percent of population below 138 of poverty line percent of singleparent households with children 18 years percent occupied housing units without vehicle percent occupied units without telephone percent occupied units without complete plumbing percent occupied units with more than 1 person per room higher adi scores and thus upper quartile categorization refer to higher levels of area deprivation while lower quartile categorization refers to lower levels of area deprivation similar assessments of adi have been widely applied in pediatric developmental research and support the validity of adi for predicting child and family wellbeing specifically within the abcd cohort many childhood outcomes such as brain structure and function as well as body mass index are associated with the adi measure used in this analysis methodological variables for salivary collection the following salivary collection variables were analyzed time since waking reflects the duration of time from the participants selfreported time of waking to the start of the salivary sample collection documented by the ra if a participants time since waking was calculated to be less than 30 min greater than 15 h or was missing values were assumed to be erroneous data and therefore were excluded from the analyses samples with time since waking less than 30 min were removed because due to abcd protocol it is highly unlikely that saliva sampling occurred within this time frame specifically after participants arrived at the study site the research assistant preformed a series of precollection assessments including obtaining consentassent explanation of saliva sampling and conducting demographic and pubertal questionnaires before soliciting a saliva sample given that the estimated time to complete these steps was at least 30 min samples documented to be collected within 30 min of waking are likely erroneous collection time of day refers to the time of day the salivary sample collection took place at the local study site laboratory collections that were reported before 0600 am and after 900 pm were assumed to be erroneous data and therefore excluded from the analyses physical activity was categorized dichotomously reflecting whether the participant was vigorously physically active for at least 20 min within the 12 h prior to sampling participants were classified into less than 20 min of physical activity or greater than 20 min of physical activity caffeine intake was categorized dichotomously as a yes or no response referring to whether the participant reported consuming caffeine from drink within the 12 h prior to sampling we categorized affirmative responses coinciding with reports of nonzero milligrams of caffeine as yes and denial responses coinciding with reports of zero milligrams of caffeine as no for these analyses statistical analyses associations between socioeconomic variables and salivary collection variables were examined through a series of bivariate tests a spearman test of correlation was performed to examine correlations between ordinally coded socioeconomic variables given that neither the participants age in months nor the continuous salivary collection variables were normally distributed a spearman test of correlation was performed to examine the strength and direction of their relationship a kruskalwallis nonparametric test of equality was performed to identify differences in continuous salivary collection variables between levels of categorical socioeconomic variables a chisquare test of independence was performed to identify associations between categorical salivary collection variables and categorical socioeconomic variables a series of univariate and multivariate multilevel linear or logistic mixed effects models were performed to examine potential confounding effects among socioeconomic factors determining salivary collection outcomes to account for clustering effects by study piecewisesem lubridate hmisc results descriptive statistics within the entire sample the mean number of hours between participant waking and time of collection was 579 h and the average time of collection was approximately 12 h and 53 min after midnight local time time since waking and collection time of day were significantly strongly positively correlated no significant associations were observed between physical activity and caffeine intake a descriptive summary of salivary collection methods for the entire analytical sample according to income group is presented in figure 2 correlations between socioeconomic variables for the entire analytic sample are reflected in table 2 all socioeconomic variables were significantly correlated with each other albeit with ranging direction and strengths household poverty status was strongly positively correlated with household education yet moderately positively correlated with household marital status household education was also moderately positively correlated with household marital status adi was negatively correlated with household poverty status education and marital status child age was significantly negatively correlated with time since waking and collection time of day albeit weakly no significant bivariate associations were observed between child age in months and physical activity nor caffeine intake significant bivariate associations were observed between household poverty status and all salivary collection measures but varying relationships between other ses factors and salivary collection measures mean time since waking was significantly different between levels of household poverty status yet it was not significantly associated with household education household marital status was also not significantly associated with time since waking regarding bivariate associations at the neighborhoodlevel with adi mean time since waking was significantly different between quartiles of neighborhood deprivation additionally while mean collection time of day was significantly different between levels of household poverty status and household education it was not significantly associated with household marital status nor adi lastly categories of physical activity and caffeine intake were not significantly independent of household poverty status household education marital status nor adi whether or not a participant engaged in physical activity prior to sampling appeared to be significantly associated with household poverty status household education marital status and adi in addition caffeine consumption prior to sampling was significantly associated with household poverty status household education marital status and adi child age in univariate models no significant independent relationships were observed between child age in months and time since waking and collection time of day however because of significant bivariate associations between child age and these salivary collection methods child age was adjusted for in multivariate models predicting the outcomes described below time since waking time since waking refers to the timeframe between the participants waking time and subsequent start of saliva collection univariate analyses demonstrated a significant 534 longer time since waking among deep poverty households compared to high income households adi was not significantly associated with time since waking multivariate when adjusting for child age or adi in multivariate analyses significant relationships were observed between household poverty status and a longer time since waking deep poverty households demonstrated a significant 206 longer time since waking compared to high income households adjusting for only child age moreover when adjusting for both child age and adi time since waking was significantly 588 longer among deep poverty households compared to high income households collection time of day collection time of day refers to the local time of day of the salivary sample collection in univariate analyses deep poverty households significantly demonstrated collection start times 243 later in the day compared to high income households no significant differences were observed between marital status levels multivariate in multivariate analyses adjusting for child age marital status and household education significant relationships between household poverty status and collection time of day were maintained collection start times among deep poverty households were 241 significantly later in the day compared to high income households when including adi in multivariate analyses marginal significant relationships between household poverty status and collection time of day were still maintained physical activity physical activity refers to any rigorous physical activity for 20 or more minutes in the 12 h prior to providing a saliva sample in univariate analyses significant increases were observed in the odds of physical activity with decreasing levels of poverty deep poverty households demonstrated 42 lower odds of physical activity within 12 h of salivary sampling compared to high income households despite a stepwise increase in odds of physical activity with lesser impoverished households these households were still less likely to engage in physical activity relative to high income households albeit not significantly in univariate analyses lower levels of household education demonstrated a significantly lower odds of physical activity compared to households with graduateprofessional educations to note univariate relationships between household education and physical activity were not significant after bonferroni correction there was a pattern of increasing odds of physical activity with higher education levels households with a less than hs education demonstrated a 43 reduced odds of physical activity 12 h prior to salivary sampling compared to graduateprofessional households households with a hs graduate some collegeassociate or college education demonstrated a respective 26 27 and 16 reduced odds of physical activity compared to the reference group adi was not significantly associated with physical activity in univariate analyses multivariate in multivariate analyses adjusting for household socioeconomic factors and adi relationships between household poverty status and odds of physical activity became fully attenuated relationships between household education and odds of physical activity became partially attenuated only households with some collegeassociate education demonstrated 21 lower odds of physical activity within 12 h of salivary sampling compared to households with graduateprofessional educations this result however is not significant after bonferroni correction despite univariate nonsignificance between adi and physical activity a marginally significant relationship between adi and physical activity emerged in multivariate analyses adjusting for household marital status household poverty status and household education an adi in quartile 2 was significantly associated with 123 higher odds of physical activity compared to an adi in quartile 1 these results are not significant after bonferroni correction caffeine intake caffeine intake refers to the childs selfreport of any caffeinated beverage during the 12 h prior to providing a saliva sample in univariate analyses significantly higher odds of caffeine intake was observed among lower levels of household poverty compared to high income households lower levels of household education demonstrated a significantly higher odds of caffeine intake compared to households with graduate professional educations households with a less than hs education demonstrated a 288 higher odds of caffeine intake 12 h prior to salivary sampling compared to graduateprofessional households there was a pattern of decreasing odds of caffeine intake with higher education levels households with a hs graduate or some collegeassociate education demonstrated a respective 279 233 150 higher odds of caffeine intake compared to the reference group adi was only significantly associated with caffeine intake in univariate analyses residing in highly deprived neighborhoods was significantly associated with a 159189 higher odds of caffeine intake compared to participants residing in the least deprived neighborhoods multivariate in multivariate analyses adjusting for household marital status education and adi relationships between household poverty status and odds of caffeine intake as well as adi and caffeine intake became fully attenuated however significant relationships between household education and caffeine intake were maintained discussion the findings from this study demonstrate significant associations between several key salivary methodological variables with key socioeconomic factors in general lower levels of household poverty and education were significantly associated with salivary collection methodological variables furthermore household socioeconomic context and neighborhood socioeconomic context were differentially associated with these variables this indicates multiple sources of socioeconomic factors can independently introduce methodological biases when not fully standardized across data collection sites and individual participants together present findings ultimately suggest that analyte levels measured from these samples may be impacted by nonrandom systematic methodological biases particularly among analytes sensitive to variability in ph levels physical activityexercise or circadian patterns leveraging this large salivary data set will require additional care when leveraging salivary analytes in future examination of early life antecedents of health inequities finally only a subset of key socioeconomic factors and salivary sampling methodological variables were assessed in the present analyses therefore other factors that drive health inequities may impact additional salivary methodological variables in addition to those examined in this current study household poverty status was consistently significantly associated with salivary methodological variables in univariate analyses often when comparing highly impoverished households with lesser impoverished households these relationships were maintained in multivariate analyses when specifically predicting time since waking and collection time of day significant relationships between household poverty status and physical activity and caffeine intake were attenuated in multivariate analyses when adjusting for household marital status household education or adi to our knowledge no study has examined direct relationships between household poverty status and salivary collection variables among pediatric populations our measure of poverty status may reflect more proximal measures of material or economic goods that when scarce in impoverished households facilitate longer durations between waking and arriving to the laboratory to provide a saliva sample as well as sampling later in the day with this it may be that a reduction in economic goods associated with an impoverished household leads to unique barriers preventing an early arrival to the study site shortly after waking and earlier in the day thereby performing salivary collections in the tail of diurnal rhythms when levels are low also later sampling times among participants from impoverished households may have been partially or fully driven by sitespecific differences in access alternatively given the semiflexible experimental design of the cohort study it is possible households in poverty selfselected for a later study start time over an earlier start time in anticipation of additional barriers such as prioritizing employment responsibilities geographical or transportation barriers or responsibilities of other children without funds for additional childcare differential preferences to come into the laboratory on a weekday versus a weekend may be another contributing source to this variability and not investigated in the present analysis additionally attenuated relationships with household poverty status predicting physical activity and caffeine intake after accounting for additional socioeconomic factors such as household education or adi suggest that differences in likelihood of physical activity or caffeine intake may be partially attributed to a complex interaction between several socioeconomic constructs it is possible that individual measures of ses may be less apt to capture differences compared to composite forms of ses that include income education and neighborhood characteristics while these are only some explanations these differences in salivary sampling methodological variables may partially yet falsely drive future sesrelated health inequities or null findings in observed salivary analyte levels that are sensitive to variability in sampling methodological variables household education was not significantly associated with time since waking nor collection time of day but was significantly associated with physical activity and caffeine intake in univariate and multivariate analyses again to our knowledge no study has examined direct relationships between household education and onsite salivary collection methodological variables among adolescent populations even with this krieger et al reported weak associations between education level and physical health status however only among those living below the poverty line while this study was performed among adults and examined health status this partially supports our nonsignificant findings between household education and time since waking or collection time of day in addition relationships in our study between household education and physical activity were only significant when comparing households with some collegeassociate education to households with a graduateprofessional education and adjusting for household poverty status these findings are also in line with those of krieger et al where level of education operates on health differentially by poverty status nonetheless this evidence may explain why household education was sparsely related to salivary collection variables the inclusion of both household education and household poverty status in the same statistical models potentiates confounding given evidence of strong positive correlations between ones education level and income however we checked variance inflation factor values for these models and all were below 209 indicating that these variables were not redundant in predicting the outcomes in this study sample when examining neighborhood socioeconomic contexts significant relationships were observed with adi when predicting multivariate odds of physical activity and univariate odds of caffeine intake whereas adi was not significantly associated with time since waking nor collection time of day cerin et al demonstrated complex relationships between environmental factors and individuallevel or householdlevel factors that impact participation in physical activity differences in performing moderate to vigorous physical activity due to arealevel socioeconomic factors were significantly mediated by several individuallevel factors but not significantly mediated by infrastructure nor arealevel crime while adi is a wellvalidated measure of neighborhoodlevel socioeconomic context there are other ways to assess this construct beyond the current version that may miss key characteristics that are important for understanding childhood origins of health inequities the measure of adi used in this study is a composite of multiple forms of area economic and resource deprivation this indicates that relationships between arealevel ses and physical activity may be partially explained by individuallevel factors not recorded as part of this study while limited in the ability to inform individuallevel patterns this adi measure includes factors of basic resources that would not be captured by income and education alone strengths and limitations despite evidence for potential nonrandom systematic bias in salivary sampling methodological variables in the present cohort study several strengths of the study design were observed first the abcd study© achieved coordination among 21 sites for the successful selfcollection of saliva among a large pediatric cohort repeated annually this strength adds to both the salience of the observed findings in this nationally representative pediatric study sample and further highlights the utility of salivary bioscience research on large scales and with pediatric populations second the cohort sample of children was successfully recruited from the general population rather than a convenience sample among those presenting to a clinical site thus adding to the heterogeneity of the cohort sample and thereby increasing the external validity of the present findings for future largescale salivary collections additionally uncovering socioecological relationships using data obtained in a noninvasive way means that salivary biosciences are wellsuited to understand public health issues particularly among children from families underrepresented in research salivary methodological variables examined in this study are often applicable to other forms of biological sample collection measuring acutely fluctuating levels for analytes that vary across time of day yet correlate with salivary levels thus our results may have increased generalizability beyond saliva in this study and may occur in other large biomedical research studies other biological methods measuring chronic levels would not be impacted by these methodological variations nonetheless there are several limitations to the current analyses first part of the exclusion criteria for the current analytical sample was a mismatch between parental report of biological sex at birth and the participant endorsed a binary biological sexgender at the time of saliva collection from baseline unfortunately given that sex at birth determined the hormone panel for testing prior to year 3 this protocol misrepresents associations between estradiol and variants of male sex or gender expression by not assaying saliva samples for the assumed female hormone this experimental strategy potentially excludes important dynamics in gender identification throughout pubertal maturation and may limit our ability to fully understand how hormones emerge across a diversity of gender identities in the current data set in year 3 abcd protocol solicited the participants endorsement of any gender identity at saliva collection however this is not part of the release 30 dataset used in these analyses additional gender identity specific assessments were added to the study at this year 3 timepoint as well after year 3 biological males at birth endorsing a male gender identity were assessed for testosterone and dhea only and all other possible combinations of gender identity endorsement were assessed for testosterone dhea and estradiol future analyses using the abcd dataset for year 3 and later should leverage the gender identity data that better capture the dynamics of gender identification with salivary hormones second there are many ways to capture socioeconomic status including measures of employment or unemployment status wealth type or status of occupation or numeric income level the variables used in this study are mostly reflective of household economic resources and household education previous evidence indicates that education and poverty status represent just two of many overlapping yet distinct dimensions comprising ses rather than being entirely reflective of ses given that ses is a dynamic multidimensional construct the exclusion of other aspects of ses may only provide a partial understanding of socioecological relationships on salivary collection methodological variables another limitation is the relative difference in smaller sample size among the deep poverty and poverty groups compared to the highincome group given that larger sample sizes are more statistically powered to detect small effect sizes thus imbalances in sample sizes can bias the findings of smaller effect sizes between groups especially where the comparison group is a smaller sample size relative to the reference group the deep poverty and poverty groups are likely underpowered to detect small effects and are the most at risk for null findings null findings between deep poverty and poverty with salivary methodological variables in the present study should be interpreted with caution however the deep poverty and poverty sample size were n 798 and n 616 respectively which is relatively robust for pediatric biomedical research in addition for many of the observed findings the effect sizes of the significant results in this analysis are relatively moderate to small these results may not be observable within studies with smaller sample sizes as sample sizes may be underpowered to detect small effect sizes without being contextualized to specific analytes of interest the practical application of current findings is limited in addition an arealevel measure such as adi is subject to an ecological fallacy because aggregatelevel patterns may not actually reflect individuallevel socioeconomic measures although we leverage multilevel models accounting for participant clustering by study site we observed different relationships to salivary collection methodological variables between household incomeeducation and adi one potential explanation as to why adi was not related to timedependent salivary collection variables is that adi may not be as proximal to household level factors and thus would not reflect direct relationships to time since waking or collection time of day another limitation of this analyses is the focus on salivary bioscience methodological variables only the observed relationships discovered in the present analyses were not examined further in relation to specific salivary analytes that have been assayed in the samples associations of socioeconomicbased differences in salivary collection methodological variables with salivary analyte levels were not directly tested in the present analysis further our examination of baseline relationships may also limit interpretability over time especially with longitudinal changes in ses for a participant changes in salivary methodological variables and even longitudinal changes in analyte levels given the breadth of research questions and corresponding analytical approaches with this dataset associations between methodological biases and analyte levels could vary across independent and longitudinal investigations there are important considerations for whether these relationships are stable over time we rely on existing literature that points to interference of accurate analyte measurement due to collection methodological variables rather this analysis encourages researchers examining health inequities to conduct a thorough examination of salivary collection methods prior to leveraging analyte levels while we observed significant relationships between socioeconomic and salivary sampling methodological variables we cannot make conclusions about magnitude and directionality of relationships to specific analytes based on previous literature of neuroendocrine circadian patterns we predict that these differences in salivary sampling methodological variables will become more problematic as participants continue to mature as circadian patterns become more pronounced with maturation and differences in exercise and caffeine intake may grow with age as a function of key socioeconomic factors however not all salivary analytes demonstrate a circadian rhythm or are sensitive to changes in ph of the sample or physical activity thus some specific analytes may be relatively unaffected by the observations discovered in these analyses researchers should evaluate whether their salivary analytes of interest reflect the observed patterns in their own analyses and if so intentionally address them in analyses and interpretation of salivary analyte results examination of socioeconomic factors with other salivary sampling methodological variables that were collected in abcd were out of scope for the current analyses including cotinine levels from first andor secondhand tobacco exposure in the children and medications that may alter salivary flow rates however future studies of biobanked salivary samples could measure cotinine directly from the sample to statistically control for these confounders there are additional salivary sampling methodological considerations that were not fully collected in this large data set such as participant reported factors of the oral environment research assistants used a 5point scale to document visible alterations in the saliva sample including presence of discoloration from food dye or blood and food particles a visual inspection of the salivary sample was also conducted by professional laboratory staff during the time of assaying to note any abnormalities in the sample future studies would benefit from a thorough oral health questionnaire at the time of sample collection to account for salivary sample contamination to achieve the most rigorous use of salivary analytes all of these methodological factors should be controlled for either through upfront experimental design in future studies expansion of questionnaires on oral health or with careful and intentional statistical analyses to fully understand how socioeconomic factors may drive experimental noise and interfere with results this includes maintaining strict protocols for saliva sampling regarding time since waking time of day sample collection duration abstaining from caffeine smoking and rigorous physical activity 12 h prior to sampling lastly the examination of raceethnicity differences was outside of the scope of this analysis however we encourage investigators to consider intentionally integrating upstream measures when investigating research questions pertaining to racial and ethnic minoritized groups for example structural racism has been identified as an important factor of adverse health among racial and ethnic minoritized groups including adolescents future salivary bioscience research studies must acknowledge root causes of racialethnic differences in health and should be integrated in salivary bioscience research when examining raceethnicity particularly through collaboration with experts in structural racism conclusion significant associations were observed between socioeconomic factors and salivary collection methodological variables specifically lower levels of household poverty and education were significantly associated with more sources of potential bias in salivary collection methodological variables these novel findings serve as a thorough cautionary tale for future analyses leveraging analyte levels from these salivary samples to examine early antecedents of health inequities as results may reflect variations in methodological variables of salivary collections and not actual biological mechanisms entangled contributions to biological functioning from socioeconomic factors remain a potential source of nonrandom systematic biases conclusions made about biological functioning using saliva while only accounting for salivary collection methodological variables without the consideration of socioeconomic factors may erroneously attribute group differences to differences in biological functioning rather than the broader upstream socioeconomic environment frontiers in public health 16 frontiersinorg these results advance salivary bioscience research by applying a health equity perspective in considering socioeconomic factors on standardizing salivary methodology these findings highlight the importance of developing an experimental design that standardizes salivary collections to prevent potential unintentional nonrandom systematic biases in saliva sampling methodology specifically our results suggest that future studies ensure participants selfcollect at the same time of day for the same collection duration and in the absence of rigorous physical activity or caffeine consumption 12 h prior to providing a sample if stringent sample collection protocols are not feasible we recommend that future studies collect information on potentially important salivary methodological variables utilize posthoc statistical techniques to cautiously disentangle effects and target analytes that are robust to variability in salivary methodological variables nonetheless salivary samples were collected effectively in participants across 21 sites demonstrating feasibility of guided selfsampling as a noninvasive biological specimen in a largescale pediatric study these samples have strong potential to be leveraged in investigations of biological mechanisms across the entire sample yet more cautiously when leveraging factors in analyses that drive health inequities data availability statement publicly available datasets were analyzed in this study this data can be found in the nimh data archive adolescent brain cognitive development study ethics statement ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements written informed consent to participate in this study was provided by the participants legal guardiannext of kin funding support for the preparation of this manuscript was provided by the national institute on alcohol abuse and alcoholism including gsr supported for hm predoctoral candidate data used in the preparation of this article were obtained from the adolescent brain cognitive development study held in the nimh data archive this is a multisite longitudinal study designed to recruit more than 10000 children aged 910 and follow them over 10 years into early adulthood the abcd study ® was supported by the national institutes of health and additional federal partners under award numbers u01da041048 u01da050989 ue01da051016 u01da041022e u01da051018 u01da051037 u01da050987 u01da041174 u01da041106 u01da041117 u01da041028 u01da041134 u01da050988 u01da051039 u01da041156 u01da041025 u01da041120 u01da051038 u01da041148 u01da041093 u01da041089 u24da041123 u24da041147 a full list of supporters is available at html a listing of participating sites and a complete listing of the study investigators can be found at members abcd consortium investigators designed and implemented the study andor provided data but did not necessarily participate in the analysis or writing of this report this manuscript reflects the views of the authors and may not reflect the opinions or views of the nih or abcd consortium investigators the abcd data repository grows and changes over time the abcd data used in this report came from dois can be found at publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

we observed significant associations between household socioeconomic factors poverty status education and salivary collection methodological variables time since waking time of day of sampling physical activity and caffeine intake moreover lower levels of household poverty and education were significantly associated with more sources of potential bias in salivary collection methodological variables eg longer times since waking collections later in the day higher odds of caffeine consumption and lower odds of physical activity consistent associations were not observed with neighborhood socioeconomic factors and salivary methodological variables discussion previous literature demonstrates associations between collection methodological variables and measurements of salivary analyte levels particularly with analytes that are more sensitive to circadian rhythms ph levels or rigorous physical activity our novel findings suggest that unintended distortions in measured salivary analyte values potentially resulting from the nonrandom systematic biases in salivary methodology need to be intentionally incorporated into analyses and interpretation of results this is particularly salient for future studies interested in examining underlying mechanisms of childhood socioeconomic health inequities in future analyses

introduction type 2 diabetes mellitus is a multifactorial metabolic disease characterized by the development of insulin resistance and subsequently the loss of bcell function the worldwide prevalence was 30 million 70 years ago and 108 million 35 years ago 12 it is known that t2dm is rising faster in lowincome and middleincome than in highincome countries 12 brazil has risen from seventh in 1980 to fourth in 2014 in the worldwide country rank of diabetes prevalence 1 there are important limitations in generalizing determinants of t2dm incidence from different populations 1 2 3 4 5 6 7 this fact is partially explained by differences in obesity rates lifestyle health system resources and access to medications for preventing the disease 38 the association between marital status and various diseases has been investigated especially for t2dm while some results have highlighted the beneficial effect of marriage 9 10 11 a poor marital quality may be a unique risk factor in men 12 or being widowed has been associated with a lower risk in women 13 moreover marriage patterns have changed in the last years people get married later and less often than in the past there are more divorces and gender roles in a marriage have changed 14 all of which could modify these relationships this study aimed to identify the relative importance of sociodemographic variables in particular marriage status associated with t2dm incidence in a brazilian sample from a rural area after a 5year followup period materials and methods study population the baependi heart study is a brazilian cohort that seeks to investigate cardiovascular risk factors and other noncommunicable diseases including both genders aged 18 years old or above at baseline 1695 individuals in 95 families were recruited in baependi located in minas gerais state brazil 15 five years later 2495 individuals from 125 families were evaluated 16 at each examination cycle sociodemographic behaviour medical history and physical characteristics were assessed by a standardized protocol a trained staff collected socioeconomic and clinical data and all participants were examined in the same research center 1516 of those 2495 individuals at cycle 2 1341 individuals were the same assessed at cycle 1 thus 354 participants were lost during the followup period or died and 800 were new participants assessed only at cycle 2 for this study we carried out the analysis in individuals who attended both examination cycles participants who had some missing data were excluded individuals with fasting blood glucose � 126 mgdl or individuals that used hypoglycaemic medications in cycle 1 were also excluded after exclusions data on 1125 diabetesfree individuals in cycle 1 were used to access t2dm incident in cycle 2 the study protocol was approved by the ethics committee of the hospital das clı ´nicas university of são paulo brazil and each individual provided informed written consent before participation sample characteristics sociodemographic characteristics included education marital and occupation status income and skin colorrace those were assessed via interviews using a standardized questionnaire education status included four categories 1 illiterate or never attended school despite reading and writing or attended school for 1 to 4 years 2 attended school for 5 to 8 years 3 attended school for 9 to 11 4 attended school for more than 11 years or finished university for analysis we grouped education into low or high levels marital status was defined as 1 married 2 single and 3 divorcedwidower occupation status was categorized as 1 employed or retired and 2 unemployed since income was very homogeneous in this sample we only included occupation status in our analysis skin colorrace was selfreported and stratified into white and nonwhite for the current analysis social behaviour was also assessed smoking status was dichotomized into currentformer smokers or never smokers alcohol consumption was defined as never drinkers versus current or former drinkers clinical and laboratorial characteristics body mass index was calculated as body weight divided by height squared bmi was categorised as normal weight overweight and obesity waist circumference was measured halfway between the lowest rib and the iliac crest while the subject was at minimal respiration blood pressure was measured using a standard digital sphygmomanometer on the leftarm after 5 minutes of rest in the sitting position systolic blood pressure and diastolic blood pressure were calculated from the mean value of three readings hypertension status was defined by the presence of sbp � 140mmhg or dbp � 90mmhg or by the use of antihypertensive medications dyslipidaemia treatment was defined by the use of lipidlowering drugs diabetes mellitus was defined as fasting blood glucose � 126 mgdl or use of hypoglycaemic medications blood collection was standardized and laboratory assays were conducted in the same clinical chemistry laboratory the fasting status was declared by the participants at the time of blood collection and the duration of 12 hours was requested statistical analysis the incidence of t2dm was assessed after a 5year followup of individuals free of the disease at baseline for the descriptive analysis categorical variables are presented as percentages and only age is summarised as the mean ± standard deviation the comparisons of categorical covariates were performed by the chisquare test and the means were compared by the students ttest mixedeffects logistic regression models were used to assess the incidence of t2dm adjusting for different characteristics and family the choice to use logistic regression models instead of cox proportional hazards models was based on the fact that our study included only two visits with the same time interval for all participants 17 all analyses were corrected for age and sex exploratory analysessensitivity analyses and a model for diabetes incidence adjusted for bmi change were conducted posthoc after identification of marital status as the main sociodemographic predictor for diabetes incidence in order to search for changes in marital status during a 5year followup and the interaction between sex and bmi changes all analyses were performed using r version 342 results general characteristics in the baependi heart study from table 1 we can see that 57 of participants were women approximately 76 of all individuals reported themselves as white and 30 had a familial history of t2dm more men than women were single smoker and had an occupation with own income at baseline the mean age was similar for both sexes obesity and altered waist circumference increased over time in both sexes dyslipidaemia medication use increased approximately 3fold in both sexes and hypertension medication use increased by almost 100 in men type 2 diabetes mellitus status according to sociodemographic characteristics the incidence of t2dm was 67 in the general sample over 5 years and there was no significant difference based on sex based on age groups the t2dm incidence was 6 51 64 68 14 7 in the bhs sample the rate of undiagnosed cases was 30 the incidence of t2dm was also analysed according to sociodemographic variables t2dm was more frequent in individuals with high education status divorced or widower the only sociodemographic variable independently associated with increased odds of presenting diabetes was marital status in our sample 13 of divorced 6 of married and 6 of single individuals developed t2dm after adjusting these estimates for age and sex being married was associated with a 039 odds of developing diabetes being single was associated with an odds of 033 of developing diabetes further investigating this relationship at baseline there was no difference in the glucose levels between these three marital status groups as well as between married and divorcedwidower regarding bmi nor between single and divorcedwidower in addition adding baseline bmi to a model predicting diabetes incidence did not significantly change the estimated effect size of marital status suggesting that the observed association is not being mediated by baseline bmi nonetheless the observed association could be mediated by changes in the marital status between baseline and 5years followup comparing baseline and 5years marital status 63 of individuals remained in their baseline marital status from the 37 that changed their marital status the majority of changes occurred in single individuals that have married in the last 5 years a sensitivity analysis using only individuals that remained in their baseline marital status showed that the estimated effect sizes for being married and being single did not change another analysis based on a model for diabetes incidence adjusted for bmi change in addition to all previous potential confounders showed that the bmi change was highly associated with increased odds of developing diabetes however its addition did not change the estimated effect size of baseline marital status only those that married or remained married presented significant changes towards increased bmi after 5 years despite the increased weight gain individuals from these groups were still significantly less likely to develop diabetes than divorcedwidower individuals discussion this is one of the first studies describing t2dm incidence in a sample from a rural city in brazil the associations between socioeconomic factors and t2dm occurrence were investigated and it was possible to identify among sociodemographic variables the independent effect of marital status on t2dm incidence baependi is a small city whose economy is based on family farming the role of women is predominantly linked to family care the general characteristic of this sample reflects a typical rural brazilian population men had a higher frequency of being single smoking and a higher rate of employment it is known that smoking rates are similar between women and men in highincome countries but the sex difference increases as the countrys income becomes lower 18 as demonstrated in our sample we observed a higher prevalence of overweightobesity among women at baseline followed by a marked increase in men over the next five years this seems to have an important relationship with the lifestyle of the population where in general women execute the more sedentary activities compared to men leading to the early onset of overweightobesity in women in contrast men showed a marked decline in their metabolic health later possibly when they approached the age to retire from rural work although this observation is somewhat predictable it shows the particularities that should be considered in this kind of study and it may indicate practices for obesity and hypertension prevention aimed to specific sex and age ranges that will be more effective since our results are quite different from others who investigated these relationships in urban populations regarding diabetes incidence in a crosssectional study iser and collaborators found a 63 prevalence of selfreported diabetes for the combined population of capitals of brazil 19 however to the best of our knowledge incidence data for t2dm is still missing for the brazilian rural population the framingham heart study examined t2dm incidence over 8 years within three distinct periods 20 the ageadjusted 8year incidence rate of diabetes was higher among men in the 1970s 1980s and 1990s 16 in the bhs sample although there was no statistical difference the incidence rate of diabetes was also higher in men previous studies have assessed the association between t2dm and socioeconomical factors in the brazilian population in an expressive brazilian sample in which the prevalence of selfreported t2dm was 75 after adjustments diabetes remained associated with age education marital status obesity sedentary lifestyle and comorbidity such as hypertension and hypercholesterolemia 21 in a specific brazilian sample assessed to verify the low adherence to antidiabetic treatment including only diabetic patients aged over 20 years age female sex and lower income status were associated to t2dm 22 other findings have shown that some brazilian states with greater poverty and lower levels of education had higher rates of t2dm or hyperglycaemia as well 22 however these were all based on prevalent cases and mostly selfreported here we add data on predictors for the t2dm incidence rate in addition to wellknown risk factors for diabetes such as diet and physical activity the socioeconomic and sociodemographic factors have shown great importance in this context the socioeconomic positionmeasured by educational levels occupation or income is frequently inversely associated with diabetes 2324 smoking especially for people with low socioeconomic status was also identified as a mediator for diabetes development 25 although these factors were investigated in our study the only sociodemographic factor that seemed to have greater importance in predicting the 5year t2dm incidence in the baependi population was marital status the relationship between marriage and improved health outcome has been previously suggested 26 some studies have shown a lower incidence of diabetes 27 and improved adherence to diabetes treatment 28 in partnered patients since marital relationship influences health behaviours and socioeconomic status despite there being no difference in the incidence of t2dm between men and women in our study the influence of marital status on t2dm seems to be modulated by gender in a recent study which investigated the diabetes mortality in a large spanish sample the highest mortality was observed in divorcedwidower women while single men showed highest mortality 29 considering the t2dm incidence another study found that widowed women compared to married women showed lower risk of t2dm development 13 in our study the influence of marital status seemed to be independent of sex our results suggest that only those who remained married or married during the 5years followup have had a significant weight gain which was associated with an increased risk of developing t2dm however the risk associated to marital status did not change even after this adjustment in fact individuals that remained married despite having significantly increased their weight were significantly less likely to develop diabetes than their divorced counterparts there are two primary theories that can explain the beneficial effect of marriage on health the first one is regarding the selection healthier individuals tend to get married and remain married the second hypothesis corresponds to postmarriage effect reduction of stress adoption of healthy behaviours 30 31 32 33 in our study it is not possible to verify which hypothesis was more coherent however probably both have had an effect on dmt2 development in this context cornelis and collaborators conducted an important study with a large number of men for �22 years and after various models of adjustment including lifestyle bmi family history and other variables widowhood was associated with an increased risk for t2dm in a robust way 34 in this study widower and divorcedseparated were analysed separately which is important as the widowhood and divorce can have different stressful effects 35 it was reported that the alcohol consumption increased between men who became widower while both widower and divorcedseparated men showed decreased in their bmi and vegetables consumption 35 since these factors have influence on t2dm more studies are necessary to clarify the possible differences regarding the relationship between marital status and t2dm risk some limitations were important in our study context the lack of adjustment for physical activity as the potentialresidual confounding factor is one of them additionally classification of occupation can be mentioned which may not have been effective in distinguishing participants as well as the marital status since it was not possible to distinguish widower and divorcedseparated individuals conclusions in summary lifestyle influences sexspecific metabolic changes over time marital status appears to be a predictor of t2dm incidence and the underlying factors for this association should be further characterised for they may provide important information in the better design and implementation of preventive programs the data cannot be shared publicly because it contains potentially identifying and sensitive patient information the ethics committee does not provide the availability of data for the public even if in an unidentified manner the study protocol was approved by the ethics committee of the hospital das clı ´nicas university of são paulo brazil data access inquiries may be sent to

many factors influence the incidence of type 2 diabetes mellitus t2dm here we investigated the associations between sociodemographic characteristics and familial history with the 5year incidence of t2dm in a familybased study conducted in brazil t2dm was defined as baseline fasting blood glucose � 126 mgdl or the use of any hypoglycaemic drug we excluded individuals with t2dm at baseline or if they did not attend two examination cycles after exclusions we evaluated a sample of 1125 participants part of the baependi heart study bhs mixedeffects logistic regression models were used to assess t2dm incident given different characteristics at the 5year followup the incidence of t2dm was 67 72 men and 63 women after adjusting for age sex and education status the model that combined marital and occupation status skin color and familial history of t2dm provided the best prediction for t2dm incidence only marital status was independently associated with t2dm incidence individuals that remained married despite having significantly increased their weight were significantly less likely to develop diabetes than their divorced counterparts

introduction education is one of the mechanisms to communicate the islamic religion and the dakwah process to the community towards goodness education based on quranic values has delivered a civil moral generation competent in eclectic worldly sciences in islam the definition of education is exhaustive and integrated encompassing the whole way of human life that incorporates aspects such as faith the central pillar of islam sharia worship morals science and technology sociology and economics it encompasses life in this world and the hereafter in one complete discipline in addition to the education system that constitutes the character and selfidentity of students the social environments help and support can also boost students to achieve success in the world and the hereafter and avoid social issues meanwhile kamarudin commented that formal or informal education primarily impacts the formation of morals and character the support of the social climate always influences the formation of morals and personalities of students therefore students need to be given appropriate education to establish great morals and become future human capital for the country nonetheless social issues among students are alarming various parties are worried about the issues because in the long term it will harm future generations when moral values are declining it yields social problems the system will produce students with a powerful vision and selfidentity through comprehensive education including considering the social environment factors hence the social climate is imperative that needs to be paid attention to in the process of forming a students selfidentity ultimately this article endeavoured to discuss the social environment for the development of morals and personality of students as well as the future issues and challenges faced education and morals education plays a vital role in maintaining the wellbeing of individual and community life education generally means preserving and growing human beings from physical mental language behavioural social and religious facets attas highlighted that education is a process of inculcating manners into a person jasmi and tamuri maintained that education is a process of nurturing and educating defending training purifying controlling passions following the leaders instructions leading adding gathering enhancing constituting obedience to allah swt forming decency polite and civilised attitude attending rules replacing and eliminating reprehensible traits to praiseworthy conditions developing a learning attitude in addition to getting used to the process of teaching and learning something new busyairi explained in the context of personality education determines the personality of a muslim according to ghazali education is a measure to eliminate bad character and instil good character zantany also underlined tarbiyyah ruhiyyah is part of an important aspect of islamic education alongside tarbiyyah jismiyyah tarbiyyah aqliyyah tarbiyyah wijdaniyyah tarbiyyah khuluqiyyah and tarbiyyah ijtimaiyyah ulwan also submitted that personality consists of beliefs worship morals and appearance in the islamic religion education aspires to form a wellrounded human being that is a human being with intellectual and spiritual intelligence in addition to morals as an indicator in the personal formation of noble morals it also relates to worship allah swt said in the quran in surah azzaariyat verse 56 i did not create jinn and humans except to worship me from the objective element education in islam desires to foster good human beings with exemplary morals to generate balanced human capital and to form and develop outstanding morals and identity sourced from alquran and assunnah based on the views of leading scholars one can conclude that personality reflects character behaviour or morals from the formation of human psychology that makes up a persons personality or morals which one can reckon through four leading elements belief worship morals and appearance that distinguishes one person from another methodology research methodology is a critical element in research high quality results from the analysis that uses the suitable research methodology the studys results also depend on the methodology of the analysis data collection in this research employed a qualitative study designed based on a literature review creswell maintained that qualitative research could help researchers comprehend the process and forms of practice more deeply a literature review is attended by reading several books journals and other publications related to the research topic to produce a piece of writing related to a specific topic or issue in this study the researchers collected primary and secondary sources from written materials such as books articles journals and theses the researchers made a text content analysis from the following document sources related to the social environment factors the formation of morals issues and challenges associated with the development of morals and the students personalities the researchers operated a semantic analysis to identify the elements of the social environment than were arranged according to the themes discussed the researchers employed this approach to discover data based on writing and written documentation data collection from primary sources and analysis of text content from documents can provide applicable information to the issues and problems studied issues of student social problems the declining morals happening now among students whether at the school level or institutions of higher education prompts various speculations and questions to the public one of the valuable assets and driving agents of the countrys progress in the future is the youth which is entirely made up of students it establishes that the role and contribution of students are expected to ensure the countrys steady development nonetheless the question of moral decay is becoming more prevalent from time to time the teenage social issue is often discussed nowadays and is becoming increasingly worrying this social issue leads to discipline problems in schools that interfere with the establishment of sound morals and character of students othman et al stated that the moral decay and social issues that are getting worse among school students in malaysia deliver an impact and effect on the effectiveness of the education system in fostering a young generation that has good manners morals and holds and appreciates good values in everyday life the issue of moral decay must be related to forces such as oneself family peers western power surrounding society and mass media this problem is also a result of the present modernisation and cultural shock that has impacted the youth which harms individuals and concerns family institutions society and the country the issue of the moral decay of students implies a substantial threat to achieving the progress and growth of the country jaafar and tamuri asserted that the failure of an institution organisation nation country or civilisation is caused by the individual personality factor that has been tarnished finally various crises arise due to disobedience to religious teachings such as social problems and crime among teenagers in malaysia teenagers social problems show increase almost every year among the issues are adultery baby dumping free mixing rape and drug abuse for drug abuse in 2017 25992 people in malaysia were reported to involve eighteen thousand four hundred forty new cases of drug abuse and 7484 repeated cases of people involved with drugs were recorded of that number 24926 were male addicts while 996 were female addicts addicts from the malays were the most significant at 20956 and the rest were from chinese indian and other bumiputra ethnicities most of those involved were young people aged 1339 years and the leading contributing factor was the influence of 16209 peers while for teenage pregnancies out of wedlock the ministry of health malaysia reported 3938 cases in 2016 and 3694 cases in 2017 there was a slight decrease in 2018 with 2873 cases reported the same situation occurs as per the data recorded in the student personality system as it shows 238790 cases which is five per cent in 2018 increased to 304578 cases which are 64 per cent in 2019 for example criminal behaviour in 2018 recorded 9516 cases grew in 2019 to 11648 cases globalisation has seriously impacted moral and ethical life in society the influence and impact rendered by mixed forces through the medium of information communication technology also have a great impact on society especially among teenagers who are students muslim school students are also experiencing social issues accordingly a favourable social environment needs to be given attention in forming a students selfidentity before the situation worsens accumulates and triggers social issues actions and emphasis on the question of noble values in the education system in malaysia need to be underscored to produce balanced students from various facets social environmental factors the influence of the social environment powerfully shapes student behaviour several factors impact students morals and behaviour among them are the students environment namely the school environment teachers parents peers society and the mass media a good atmosphere in the formation of an individuals identity is critical all of these factors strongly influence the formation of the students selfidentity following are some factors that affect students morals and behavior school and teacher environmental factors sang elaborated that a school climate that is conducive and equipped with advanced teaching and learning facilities will raise the cognitive affective and psychomotor development of students to a higher level rudasil et al stated that environmental factors and a conducive school atmosphere greatly influence the formation and establishment of a positive school climate school climate can portray the social interactions relationships values and beliefs held by students teachers administrators and staff in addition western researchers also concluded that the school atmosphere is essential in shaping positive behaviour and dramatically impacts the success of students and schools school conditions are also the essence of a school the influence of the environment is a fundamental element in the formation of character way of thinking attitude and development of school students furthermore a teacher acts as an advisor consultant motivator and specialist expert and oversees student discipline according to don som and ali shafiq noraini underlined that teachers or educators play the role of implementing agents and groups that play an important position in executing the curriculum and educating students personalities teachers need to have high skills in teaching methods master the content of knowledge in the subjects taught be skilled in applying the theory of human growth and development and be helpful counsellors to students teachers and schools are agents of transformation and mould individual potential comprehensively and integrated abdul muhsien established that the practice of teacherstudent relationships in the establishment of morals was at a moderate level most study participants admitted that the teacherstudent relationship was already practised but it happened informally based on the concerns of a gpi therefore it will become more meaningful if efforts towards empowering the formation of morals in schools take a more holistic approach by strengthening aspects of the teachers role and relationship with students further the conclusions of a study by makhsin indicated that the school environment retains a strong influence on forming a person with noble morals besides jasmi et al stated that teachers are a critical element in education and greatly influence the effectiveness of education the personality and teaching practices of teachers have a significant influence on the mind and souls of students they will perceive and follow the teachers behaviour reactions and words at this young age the teachers attitude and appearance will impact students more strongly than others it is possible as students to spend a lot of time with the teacher hence teachers should improve themselves first before improving their students based on the statements and results of the study it is clear that teachers and schools are the most critical influence in the development of students from a physical intellectual emotional and social point of view parental factors initiatives to produce quality people are closely related to how education is acquired therefore a pleasant family climate plays an essential role in influencing the success of children together with eminent personalities the family institution is imperative in shaping childrens characters in terms of faith morals academics and morals of a person himself parents play an indispensable role in shaping childrens education and forming the foundations of a childs selfdevelopment in religion parents are responsible for instilling religious values at an early stage as the hadith narrated by imam albukhari and imam almuslim translated to no baby is born unless it is born in a state of fitrah so it is the two parents who will shape the child either a jew a christian or a magian according to shaari parents should have suited educational guidance and knowledge so that the children under their care and custody receive proper guidance and education tan et al also stated that the process of teenage moral education that takes place through parental education has an impact on the lives of teenagers in addition parents need to monitor their adolescent children especially their peers the significance of parenting behaviour in the family also needs to be given serious attention in developing and forming a teenagers identity and personality while according to abdullah he underlined that the individuals who most deeply influence childrens personalities are parents parents are the most efficacious community in building childrens morals to behave well and are responsible for establishing their childrens personalities and abilities arshat et al reported that parents must set an example in relationships and be good role models for children this is in line with the opinion of sulaiman which noted that parents need to guide children and be role models for children the peer factor according to abdul latif peers refer to the same group of children or teenagers often having the same age range gender or socioeconomic status and sharing similar interests peers are where they express their troubles and substitute parents at school the influence of peers is the most potent basis in helping selfdevelopment and changing the values and attitudes of teenagers when the power of parents and family decreases in the early stages of adolescence ulwan explained that the religion of ones friend impacts a person thus it is crucial to know who is ones friend it conforms with the words of the prophet muhammad pbuh narrated by bukhari and muslim a persons religion lies in his friends so be careful who you are friends with ulwan also stated that if one befriends lame and corrupt companions they will follow and be affected by damaging behaviour according to abd rahim teenagers adapt to the factors of the family environment social environment and culture that will shape the development of their behaviour therefore students who come from families with family relationship crises can have an impact on the formation of their morals while yahya et al recommended that parents always note who their childrens friends are because they are a substantial contributor to the increase in delinquent behaviour of children in addition kasht mentioned that socialisation like friend mannerisms will bring people closer to allah swt if carried out in the manner ordered by sharia hall remarked that among the methods to monitor children are to know who they are friends with observe the childrens activities see where they are and be selective in choosing their friends suria explained that the media plays a pertinent role starting from adding knowledge and forming attitudes perceptions and trust values the mass media deliver a lot of transition and information to the community especially regarding current affairs and foreign and domestic news in addition the media is also beneficial to the development of education today however at the same time mass media may also contribute towards adverse outcomes the study conducted by tamuri ismail on form 4 students discovered that high exposure to the media hurt the religious beliefs of teenagers wan norina et al stated that one of the reasons for the moral decay of todays youth is the result of mass media exposure and programs observed in the country in the context of dakwah abd hamid noted that media activists should also play the task of delivering dakwah they should utilise media channels to invite people to believe in allah swt and introduce the characteristics of islamic teachings to the community the media should play a role in applying islamic or moral values to educate the community so that they also appreciate these values mass media factors community environmental factors environmental factors have a significant relationship with student achievement che hassan et al reported that environmental factors influence students personalities the transformed structure of society causes todays students to live and mix with a more diverse community therefore environmental support among students is crucial because it produces students who have balanced academically emotionally and morally individuals around them influence students to shape their lives in the future yahya et al documented that the local community needs to work together in the moral maturation of teenagers and the local community are to be mindful of all potentially harmful behaviour teenagers commit one must be frank warn and complain about them to the responsible party if the delinquent behaviour of teenagers transpires and guide them in carrying out their responsibilities as students in addition close relationships with neighbours are necessary and are emphasised by most societies and religions relationships in the neighbourhood can train individuals to help and foster good values in a broader context noble value is exemplary behaviour between human relationships that includes religious social and neighbourhood aspects to form a united society the challenge of moral formation shaping the morals and character of students nowadays is taxing this is due to factors that affect it from various angles among those elements are how parents are raised domestic disorder the management of the school environment the influence of information technology that is readily available today and the impact of a students living circumstances several social investigations analysed the causes of social issues among teenagers are closely related to the factors of the broken family system the failure of the family to educate childrens beliefs and morals and the neglect of parents in the role of providing religious education at home hence the key challenge for parents is to provide proper religious education sulaiman stated that one needs to teach kindness to ones children and family one must too educate them it means that parents must train their children and need to be role models for them while samsuddin sawari asserted that parents have a great responsibility in disciplining and educating children parents play a critical role in educating and shaping childrens beliefs so that they become valuable people in this world and the hereafter parents should be exposed to parenting education parenting education lets parents master the right ways and methods to enlighten their children education as early as birth and continuing until the child matures will produce skilled individuals with good personalities children should realise that they must maintain a robust relationship with their parents to communicate and constantly interact positively to improve their personalities according to the islamic view parents play an essential role and are responsible for educating their children especially in religious moral and physical education further lee kim found that more parental control is required to educate their children well parents who do not emphasise or pay attention to their children lead to moral decay parents must also monitor their childrens movements in every association with their friends peer influence is decisive in adolescent development it is possible as most of their time is spent with friends compared to when they are with their parents thus causing them to be easily influenced by activities and behaviour driven by their peers in addition the principal challenge for teachers and school administrators is to be sensitive to the distinct appreciation of islamic morals of each student therefore complete and exhaustive moral education is vital to overcome the diversity of differences of each student and this needs to be paid attention to by all parties the study by jusoh sharif concluded that implementing educational programs with spiritual development requires a solid organisation to achieve the objective of spiritual growth to form students character while surat rahman claimed that the support of the social environment with the active involvement of students in cocurriculum has an impact on students soft skills the development of holistic human capital and adaptation in learning the school also needs to organise a spiritual program such as religious activities to enhance students personalities likewise the challenge in dealing with the influence of the mass media on teenagers is undeniable teenagers tend to do things they have heard or seen in mass media because they desire to try mass media is a necessity for humans today especially students thus creating the development of the internet which has become a new socialisation agent for humans however failure to control it will cause the issue of addiction in the mass media primarily the internet it harms students negatively such as cyberbullying sexting pornography and physical and mental health meanwhile jamilin et al commented that media exposure can easily influence the culture and thinking of all levels of society especially todays teenagers the mass media can control students morals leading to addiction to mass media such as addiction to online video games and even worse causing depression selfharm and death due to mass media conclusion human value is determined by moral position the higher the moral the higher the human worth and dignity the implementation and formation of morals through education formally or informally hence is a shared responsibility ergo the current education system requires support from all parties in shaping the morals and character of students thus it is suitable for every responsible party in society to play an essential role in developing student morals the influence of the social environment plays a critical role in contributing towards the formation of students morals in line with the development of the modern world today many challenges have implications in their lives including sociological and psychological aspects this situation holds a comprehensive impact on the lives of students the cooperation of all parties especially parents is key in dealing with the challenges faced by students environmental support includes humanitarian elements such as teacher support parental support peer support and community support and nonhumanitarian factors such as the influence of various types of media influencing and affecting student behaviour a person will become good if he appreciates morals in his life and a favourable climate impacts the student in shaping his personality therefore praiseworthy and noble morals can have an excellent and positive effect on students facing issues and challenges this study has contributed a valuable finding regarding the students moral development the application of moral values is fundamental to the formation of a noble personality the existing education system needs support from all parties involved in adolescent moral education it is natural for everyone in the community to play an essential role in the development of adolescent morals environmental support encompasses humanitarian elements such as support from teachers parents peers and the community as well as nonhuman components such as the influence of various types of media that one receives during their life processes that impact student morale and personality this also indicates that developing students potential is not only in the context of schooling it needs to be done holistically by all parties involved through various social learning approaches students need all the support and motivation resources of parents teachers classmates and the community to help promote their soft skills a person will change for the better if he or she recognises noble morals because noble morals produce a positive impression on daily life getting a quality education is a dynamic concept that influences the positive behaviour of a student as a whole

the principal pursuit of islamic education is to produce exceptional and faithful muslims nevertheless todays mass media often demonstrates various issues involving teenagers and school students in social issues that harm society which is worrisome the social environments influence significantly impacts the younger generation especially teenagers and students education is the ground of individual development and advancement and the primary platform for shaping the personality of noble morals morality and character are paramount in islam and are the essence of understanding and practising islamic teachings therefore several social environment factors influence the development of students morals selfidentity and personality social environment factors can nurture and decide students morals if students can adapt well hence this article intended to discuss the social environment that affects and influences the formation of students morals and the issues and challenges faced this study employed the literature review methodology by analysing and discussing the content of the text thematically to identify the elements that impact the development of morals and the issues and challenges to form the students selfidentity ultimately this article concluded that the social environment was identified as having a substantial impact on developing students morals consisting of parents peers teachers schools residential settings and the mass media one must prioritise the roles and responsibilities of parties related to each other to determine student morals this article is relevant for teachers parents schools and interconnected parties to apply good values so that the country can produce a young generation with noble character and deliver awareness to avoid misconduct among this young generation to form individuals who are positivethinkers for their future wellbeing

background alcohol consumption is a leading risk factor for population health worldwide 1 measures of alcoholrelated harm such as hospital admissions and mortality show particularly wide inequalities and reducing inequalities is a focus of governments 1 2 3 4 alcoholrelated harm has been found to be higher in disadvantaged groups despite comparable or even lower reported alcohol consumption than in advantaged groups 56 this phenomenon has been termed the alcohol harm paradox a number of hypotheses to explain it have been suggested in the literature 5 7 8 9 the first hypothesis is that there may be different patterns of alcohol consumption across groups rather than simply unit consumption or whether a threshold of consumption is reached overall average consumption may not differ between groups but if all alcohol is consumed in one sitting peak toxicity is greater in those who binge drink more deprived groups are more likely to drink at extreme levels potentially in part explaining the paradox 8 the type of alcoholic beverage may also offer an explanation consumption of spirits or beer has been associated with worse trouble per litre than wine and consumption of spirits have been associated with increased alcohol poisoning and aggressive behaviour 1011 it has also been suggested that the poorest outcomes are found for beverages chosen by young men 10 a potential mechanism could be the faster absorption of alcohol from stronger drinks or other characteristics of the people with a particular beverage preference but the reasons for differing outcomes by beverage type are not well understood the second hypothesis concerns the combination of challenging health behaviours or comorbidities typically found in more disadvantaged groups this combination causes proportionately poorer outcomes compared to similar alcohol consumption in advantaged groups deprived higher risk drinkers were found to be more likely to drink alcohol combined with other healthchallenging behaviours that include smoking being overweight poor diet and lack of exercise compared to more affluent groups 7 there are also known associations between mental health and alcohol consumption which could affect disadvantaged groups differently 12 the third hypothesis relates to underestimating consumption in disadvantaged groups and the alcohol harm paradox not existing or being an artificial construct response bias may be at work where those who do not respond to the survey could have systematically different consumption levels or worse outcomes compared to responders 13 moreover current drinking may not reflect the life history of harmful drinking which has been found to be associated with deprivation in lower and increased risk drinkers 7 a few recent crosssectional studies have investigated the harm paradox but mostly considered drinking patterns and their influence on the paradox rather than outcomes of harm 78 only one longitudinal study in scotland has employed recordlinkage between consumption patterns and harm investigating socioeconomic status as an effect modifier but did not include the type of beverage or multiple admissions 5 this study aims to investigate whether and to what extent individual alcohol consumption by type of beverage smoking bmi and other factors could account for inequalities in alcoholrelated hospital admission a different risk of harm by socioeconomic group for a given level of individual consumption could be an explanation of the alcoholharm paradox at group level additionally we examine how the patterns of consumption by type of beverage differ by socioeconomic group methods data this analysis was carried out using the electronic longitudinal alcohol study in communities data platform and details on the data and linkage methods are outlined in the study protocol 14 a summary and further specific details for this study are described below welsh health survey our cohort consisted of 11038 people aged 16 and over who responded to the welsh health survey in 2013 and 2014 consenting to have their survey responses linked to routine health data the welsh health survey is an annual population survey on health and healthrelated lifestyle based on a representative sample of people living in private households in wales it consists of a short interview with the head of household and a selfcompleted questionnaire for each individual adult aged 16 years and above in the household a question on consent for data linkage was included from april 2013 to december 2014 and approximately half of the respondents agreed originally 11694 respondents agreed to their data being linked and records were successfully linked and anonymised into the sail databank through standard split file processes for 11320 individuals 14 linkage to records of household residence needed for analysis failed for 282 respondents resulting in the final sample of 11038 people an overview of characteristics of the study population is shown in table 1 measures of socioeconomic status we used an areabased deprivation measure the welsh index of multiple deprivation 2011 15 as well as four individuallevel measures of socioeconomic status from survey responses social class iii employment iv housing tenure and v highest qualification we linked the wimd to each lower layer super output area of residence at survey month we grouped the two more deprived quintiles and three less deprived quintiles because of relatively small numbers alcohol consumption respondents were also asked about the frequency of drinking including whether or not they had drunk alcohol at all during the past year and the number of each type of alcoholic beverage they had consumed on the heaviest drinking day in the past week these include categories of for example small can of strong beer small glass of wine as well as free text for additional drinks not listed these data were converted into units consumed by beverage type and capped at 60 units to deal with a very small number of responses of between 60 and 120 units likely a misreading of units we created three groups 1 beer and cider 2 wine and champagne 3 spirits alcopops fortified wine and others there were relatively small numbers of alcopops fortified wine and others and so we combined these with the spirits our sensitivity analysis showed that the inclusion of these drinks did not alter the results for this category which was predominantly made up of spirits outcome measure of alcoholrelated hospital admission the outcome was alcoholrelated hospital admission we selected the earliest episode in each hospital spell with a wholly attributable diagnosis included in the definition outlined in the study protocol 14 these are similar to the alcoholspecific definition used by public health england with a few additional codes 1416 these could be the primary diagnosis or a secondary diagnosis in any position this included multiple admissions for survey respondents the details of the data source linkage and extraction are outlined in the study protocol 14 other survey measures other measures used based on survey responses were smoking bmi general health and being treated for a mental health condition smoking was coded into three categories 1 regular or current smoker 2 exsmoker and 3 never smoker bmi was readily calculated based on selfreported height and weight respondents were asked about their general health which we coded into the following two groups 1 poor and fair health 2 good very good and excellent health respondents were also asked whether they were currently being treated for depression anxiety or another mental illness this was coded into a binary variable with values of being treated for any mental health condition listed or not treated if none was selected study designprocessing survey responses were recordlinked within the sail databank to hospital admission data mortality data and data containing residence and thus house moves as outlined in the study protocol 14 all data was extracted for eight years before the survey month until the end of the year 2016 the study period ran from three years before the survey in 2013 or 2014 to the end of 2016 with a study period of between five and six years depending on when the survey was undertaken we structured the data so that each person could contribute multiple time periods if they had an admission with the number of admissions up to the current time period counted during the study we also considered the number of historic alcoholrelated admissions during the five years before study start as a covariate in the modelling analysis we censored for death or moving out of the study area an illustration of the study timeline is shown in fig 1 we also performed a sensitivity analysis using the data restricted to time periods after the survey date only for comparison statistical analyses we estimated hazard ratios with 95 confidence intervals for the risk of alcoholrelated hospital admission associated with each socioeconomic group using multilevel cox mixed effects models 17 we used a recurrent event model with admission as the outcome and using age as the underlying timescale rather than calendar time we used cox proportional hazards models stratified by the current count of admission events to date so that each unique admission count has a separate baseline hazard function including admission counts during the study period as strata accounts for covariance within an individuals recurrent events and is similar to a frailty model 18 details of covariates in each model are given below but in every case their hazard ratios were assumed constant across strata additionally a random effect at the household level was used in the multilevel analysis to allow for potential similarities in responses within a household over and above their individual characteristics all analyses were conducted using r 20 specifically using the coxme function 21 to deal with missing observations for bmi unit consumption smoking and individuallevel socioeconomic measure we used 20 iterations of multiple imputation using chained equations using the package mice in r 19 this was chosen for efficiency to avoid reducing the sample size the number of historic events during the 5 years before study start was included as a covariate in all models this was chosen to account for differences in risk of the next admission because people with a prior admission were more likely to have another admission than those who did not the first basic model adjusted for area deprivation sex and the number of historic arha during 5 years before study start model b additionally adjusted for the number of units reported by drink type on the heaviest drinking day in the past week smoking status and bmi we repeated the basic and adjusted model using area deprivation for all other individual measures of socioeconomic status ii social class iii employment iv housing tenure and v highest qualification to compare estimates in the basic model with those of the adjusted model we also included an interaction term in adjusted model b between bmi and total unit consumption model c also based on the adjusted model b additionally included selfreported general health and model d added selfreported treatment for a mental health condition to investigate comorbidities two additional models were used to investigate the contribution of the units for each specific beverage type to inequalities these were based on model a but also included the total units consumed and separately the units for each type of drink as covariates another model included the frequency of drinking for the sensitivity analysis we have rerun all models above on the limited dataset including only the time periods following the survey date the results were compared to the main results using the extended dataset finally we also analysed the mean units of alcohol consumed by beverage type and by age sex and deprivation group including 95 confidence intervals to show the distribution of units in each group we have also included boxplots for any type of beverage results sample characteristics our study sample consisted of 11038 respondents with a total of 636389 personyears of followup there were 279 alcoholrelated admissions during the study period the crude rate per 1000 personyears was 438 an overview of our sample characteristics is shown in table 1 there were more females than males key demographic data was complete in the survey but there were missing responses to some of the individual survey questions ranging from 06 for drinking frequency to 49 for bmi modelling analyses use imputation to deal with missing responses but table 1 shows completed and valid responses only and therefore the sums for each characteristic may be different for example between sums for alcohol consumption and smoking status patterns of consumption deprived groups had larger proportions of people who reported not drinking at all in the past year and also higher proportions who did not drink in the past week but reported some drinking in the past year however those who drank in the deprived group had slightly higher proportions of people who binged on a single occasion with 258 in the deprived group compared to 236 in the less deprived group this suggests that fewer people drank in deprived groups but those who had any alcohol drank more some of those who either did not drink at all in the past year or reported some drinking in the past year but no units in the past week had an alcoholrelated admission at some point during the study period this could suggest that ongoing health concerns might explain their abstinence 22 overall the mean units of total alcohol consumed were similar or slightly higher in the more deprived group than the less deprived group for males but similar or slightly lower for females if only those who drank are compared then men in the more deprived group drank more on average than men in the less deprived group for all age groups with smaller differences in women socioeconomic patterns differed by type of beverage similar to any type mean units of beer were slightly higher in more deprived groups and unit consumption much higher for men than women the pattern for wine was the opposite showing lower consumption in more deprived with the exception of the youngest men more spirits were consumed by younger drinkers with only slightly lower averages for the deprived group there was little difference in the more deprived group in most other age groups of those aged 30 and above compared to less deprived groups the box plots in fig 3 for units of any type of beverage show that the distribution is skewed towards lower reported units reflecting the large proportion of people reporting zero units particularly in the youngest and oldest age groups the medians for younger males in more deprived groups are lower than the less deprived and for females the medians are lower in the more deprived for most age groups factors associated with alcoholrelated hospital admission a total of 131 out of 11038 respondents had at least one arha during the study period women tended to have a lower risk of admission than men although this was only statistically significant in model a and not in the fully adjusted model b smoking had the strongest association with alcoholrelated hospital admission and smokers were 453 times more likely to have an admission than those who were never smokers exsmokers were 150 times more likely to have an admission compared to the same reference group although this was not statistically significant bmi appeared to be slightly protective but it was not statistically significant we also investigated the interaction between bmi and total unit consumption based on model b but we found no evidence for an interaction unit increases of spirits drunk were positively associated with increasing risk of arha higher than for other drink types unit increases for beer and wine were however not statistically significant the reported frequency of consumption suggested an elevated risk of arha for those who did not drink in the past year and those who drank weekly relative to those who drank less than weekly although not statistically significant an increased risk for those who did not drink at all might suggest that these are exdrinkers who have stopped drinking perhaps due to poor health due to the relatively small sample size we could not analyse exdrinkers separately people with poor health had an elevated risk of arha compared to those who considered themselves in good health similarly people who were currently being treated for mental illness had a much higher risk of arha than those who did not although this will need further research relating to interactions and specific conditions it does suggest that comorbidities either relating to alcohol or otherwise could be important the number of historic admissions before study start was significantly associated with a higher risk of arha we treated this not as a risk factor itself but as merely indicative of the likely presence of other risk factors inequalities in the risk of alcoholrelated hospital admission people living in more deprived areas had a higher risk of arha compared to less deprived in an interim model adjusting for units of alcohol drunk only there was little change in the risk of arha for more deprived areas adjustment for smoking status and bmi in model b reduced the risk of arha by 357 we found a similar pattern for all socioeconomic measures areabased or individuallevel of a reduced but still persistently higher risk in disadvantaged groups after adjustment for example using social class people in the routine and manual class had a higher risk of arha compared to the professional and managerial class after adjustment in the full model the risk had slightly reduced but is still substantially higher than the comparison group adjusting for the total number of units regardless of type of beverage gave very similar results to model b with an elevated risk of arha in the most deprived group this suggests that the type of beverage was not important over and above the number of units relating to inequalities for models c and d the risk of arha in the more deprived group was reduced further compared to model b this risk in disadvantaged groups although still elevated was not statistically significant although this will need further research relating to interactions and specific conditions it suggests that comorbidities either relating to alcohol or otherwise could be important sensitivity analysis using limited dataset following the survey date only using the data limited to the time periods following the survey date there were 131 admissions 60 in the less deprived and 71 in the more deprived group there were 33067 personyears of followup the model results and conclusions drawn overall are similar but due to smaller number of events most results were not statistically significant inequalities based on area deprivation were slightly narrower and inequalities based on individuallevel socioeconomic measures slightly wider before adjustment compared to the main analysis shown in the paper adjustment for alcohol consumption by type smoking and bmi reduced inequalities and as before a higher risk of arha in disadvantaged groups remained adjustment resulted in a similar reduction of the hazard ratio in the repeated model a and model b for areadeprivation but due to smaller inequalities yielded a slightly higher percentage reduction than the extended dataset adjustment for poor health or mental health also reduced inequalities further the risk of arha by type of drink was also similar with the highest risk for spirits the sensitivity analysis showed that the results are comparable to those shown in the paper using the extended dataset we decided to sacrifice a small amount of bias relating to the timing of the survey in favour of reducing variance and used the extended analysis as the main analysis in this paper discussion the main aim was to investigate whether and to what extent adjustment for individual alcohol consumption by type of beverage and other factors could explain inequalities in alcoholrelated hospital admissions and therefore help explain the alcohol harm paradox we found that consumption by beverage type did not help to explain inequalities in alcoholrelated harm despite consumption by type being socioeconomically patterned adjustment for individuallevel units by type of alcohol drunk only very slightly reduced inequalities in arha similar to all units combined smoking and bmi accounted for part of the differences reducing inequalities by 357 but deprived groups still had a persistently higher risk of arha having considered multiple admissions this pattern was similar for areabased deprivation or individuallevel socioeconomic measures our findings on inequalities are broadly similar to a previous study 5 which found that disadvantaged groups had consistently higher alcoholattributable outcomes having considered similar total alcohol consumption bmi and smoking they analysed quintiles of deprivation and more subgroups for the individual socioeconomic measures as well as a slightly different definition and so a precise direct comparison of the extent of inequalities and effect of the adjustment is difficult their study design is also different in analysing the time to the first admission whilst excluding those with a prior admission our analysis includes multiple hospital admissions during the study period as well as information on historic admissions we found historic admission to be an important factor for the risk of another admission thus we incorporated people with multiple admissions during the study period who use more health service resources and their exclusion or censoring after one admission could potentially exclude certain patterns for example descriptive statistics issued by government or health services can include the same people in successive time periods in crosssectional analyses including the type of beverage in our analysis was novel unit consumption per type of drink is not usually available in survey data either recordlinked or not whilst beverage type was not important relating to inequalities in arha there were differences in the risk of arha by type of drink spirits had the highest increase of risk of arha per unit increase consumed a finnish study found that consumption of spirits increased in direct proportion to overall consumption as part of binge drinking sessions although not investigating subsequent alcoholrelated harm 11 they suggested that whilst beer was consumed in large quantities at a variety of drinking occasions spirits were needed to get really drunk 11 others have argued that the most harmful drink is whatever young men are drinking 10 in our study the average spirit consumption is highest in the younger age group although higher in young women than in men the mechanism for increased arha for spirits needs further attention and could be due to the faster absorption of alcohol from stronger drinks in one binge drinking session or preloading before going out in younger people if policy sought to tackle stronger drinks in particular they may however be replaced by other types rather than reducing harmful consumption the alcohol harm paradox is based on deprived groups drinking similarly or even less than advantaged groups on average in our study average binge drinking was slightly higher in deprived groups than less deprived the mean units for any type of alcohol however were similar or lower in deprived groups for most age groups there were differences in proportions of nondrinkers between deprivation groups that influence the averages this might suggest that the alcohol harm paradox could in part be an artificial construct particularly when relying on binge drinking measures beyond a threshold instead of individual units related to the third hypothesis in our modelling analysis we focussed on inequalities given similar consumption thereby adjusting for slightly higher average consumption in more deprived groups in our sample and investigating an important part of the alcohol harm paradox the type of beverage showed different socioeconomic patterns in line with international findings on trouble per litre 10 and a study in england 7 the deprived group drank more beer but less wine compared to less deprived the average units of spirits were similar in the deprived and less deprived group in those over the age of 30 but slightly lower in deprived younger people this may support the finding elsewhere that the paradox may be more concentrated in men and younger age groups as the association between consumption and socioeconomic status increased with age 9 whilst there may not be any inherent difference between units by type and resulting harm choices may be indicative of different drinking occasions such as binge drinking or other individual factors in our models we also investigated selfreported health status and separately being treated for a mental health condition either adjustment reduced inequalities in arha further suggesting that comorbidities may explain some of the alcohol harm paradox socioeconomic deprivation has been shown to be associated with multimorbidity particularly mental health conditions 23 these may also include conditions related to smoking which we have accounted for in our models and may explain the relatively small effect of comorbidity reducing inequalities in our models we were restricted by sample size and study design to analyse this in more detail but further research should investigate comorbidities further including specific conditions as with all longitudinal studies following people over time yields detailed information about the dynamics of response to exposures another key strength of our study is the use of recordlinkage of individuallevel alcohol consumption and other factors to alcoholrelated harm as well as multiple measures of socioeconomic disadvantage to our knowledge this is the first longitudinal linkage study on the alcohol harm paradox investigating the type of beverage and considering multiple admissions it takes full advantage of the richness of the data through multilevel multifailure modelling imputation for missing data and censoring for migration and death there are however some limitations relating to the data the main limitation relates to the relatively small study sample of just over 11000 respondents and the fact that only around half of those asked agreed to data linkage this meant that the number of events was also relatively small with 279 admissions in 131 individuals but were reflecting the uncertainty in the models appropriately failure of linkage of survey respondents to residence data was small further details on linkage of this dataset are included in the elastic study protocol 14 we have compared the demographic characteristics of our sample to the total sample for both years outside of the recordlinked environment and found that the distribution by age and sex is fairly similar the reported binge drinking patterns by age and sex were also found to be similar although proportions were slightly lower in our sample whilst we have been able to compare alcohol consumption in our sample and the total sample it is possible that the study sample is different in terms of their arha and potentially not population representative even with higher consent for linkage a scottish study found that underestimation of consumption in surveys was likely to be socioeconomically patterned as was linked alcoholrelated harm 13 the available sample size also meant that we needed to group the more deprived 40 and the less deprived 60 rather than analysing deprivation quintiles this allowed detection of significant effects but meant that we are underestimating the extent of inequalities between the more extreme ends of the deprivation gradient however we were able to repeat the analyses using individuallevel socioeconomic measures allowing some validation of the patterns found and our results were similar to the only other comparable longitudinal study using only conditions wholly attributable to alcohol in our analysis is also underestimating the wider alcoholrelated harms where alcohol is only in part responsible one of the explanations of the alcohol harm paradox relates to the accuracy of the measure of consumption we had to assume that reported consumption and other factors are constant throughout the study period estimated from the survey response in the middle of the study period rather than baseline we acknowledge the possibility that respondents may have changed their drinking or the reporting of their drinking following a hospital admission and thus the possibility of reverse causation to circumvent this possible source of bias we performed a sensitivity analysis using data limited to time periods following the survey date only which showed substantively similar results we therefore decided to sacrifice a small amount of bias relating to the timing of the survey in favour of reducing variance in our study we found a small number of respondents who reported not drinking at all in the past year but having an arha during the study period they could be sick quitters who may drink less due to excessive alcohol use in the past or ill health and likely to have different outcomes to other nondrinkers our main measure is selfreported unit consumption including by type of drink for the heaviest drinking day in the past week it may be more indicative of binge drinking in one session than overall units consumed for example following weekly consumption guidelines whether at baseline or not responders may not recall their actual consumption or give favourable estimates or their drinking in the past week as is commonly asked in many surveys is not representative of their usual or overall consumption there are some respondents who did not drink in the past week or below binge levels but also had an arha reducing inequalities in health is a major goal of governments and included in the united nations sustainable development goals 24 and the wellbeing of future generations act in wales 2 alcohol policy aiming to reduce consumption in populations as a whole including taxation and reducing availability internationally tends to have a greater effect on poorer drinkers than on richer drinkers and may help reduce inequalities in alcohol harm 1 however it is not clear whether heavy drinkers with the worst outcomes are affected equally some have advocated more focus on targeting specific subgroups such as extreme drinkers living in poverty or longterm unemployed men 8 the welsh government are due to introduce a minimum unit pricing policy in wales during 2020 25 which will likely increase the price of very cheap spirits in supermarkets or offlicences but may not change prices of spirits in bars or pubs greatly future research is needed to investigate whether and how alcoholrelated harm may change as a result particularly with respect to inequalities our results relating to increased harm from spirits could help inform policy and the development of interventions around promotions of stronger drinks conclusions considering consumption by type of beverage did not help explain inequalities in alcoholrelated harm despite consumption being socioeconomically patterned smoking and bmi explained part of these differences reducing inequalities by 357 but deprived groups still had a persistently higher risk of arha although more people in deprived areas were abstaining from alcohol those who consumed alcohol drank more heavily deprived drinkers drank more beer and in most age groups also spirits but less wine compared to less deprived drinkers whilst type of beverage was not important relating to inequalities in arha there were differences in the risk of arha by type one potential mechanism for the increased arha for spirits could be the faster absorption of alcohol from stronger drinks in one binge drinking session or preloading before going out in younger people our results could help inform interventions on reducing promotions of stronger drinks the minimum unit pricing policy due to be implemented in wales during 2020 will likely increase the price of some spirits in supermarkets and offlicences and our results may inform research evaluating the effect for type of beverage but also inequalities in alcoholrelated harm future research should also investigate comorbidities further as an additional explanation of the alcohol harm paradox and wider social inequalities hr hazard ratio 95 ci 95 confidence interval n 11038 60 events in less deprived 71 in more deprived protecting safe haven and remote access system referred to as the sail gateway sail has established an application process to be followed by anyone who would like to access data via sail at comapplicationprocess abbreviations 95 ci 95 confidence interval arha alcoholrelated hospital admission bmi body mass index elastic electronic longitudinal alcohol study in communities hr hazard ratio lsoa lower layer super output area sail secure anonymised information linkage authors contributions df and ag designed the study ag performed all analyses and drafted the manuscript aa sp and sm designed the elastic project and aa and lt worked on specifications data linkage and extraction all authors commented on the manuscript and approved the final version appendix table 6 sensitivity analysis using limited dataset following survey date only comparison of model results for each socioeconomic measure ethics approval and consent to participate approval for the use of anonymised data in this study provisioned within the secure anonymised information linkage databank was granted by an independent information governance review panel under project 0336 the igrp has a membership comprised of senior representatives from the british medical association the national research ethics service public health wales and nhs wales informatics service usage of welsh health survey data was approved by welsh government the use of anonymised data for research is outside the scope of the eu general data protection regulations and the uk data protection act consent for publication not applicable competing interests the authors declare that they have no competing interests

background alcoholrelated harm has been found to be higher in disadvantaged groups despite similar alcohol consumption to advantaged groups this is known as the alcohol harm paradox beverage type is reportedly socioeconomically patterned but has not been included in longitudinal studies investigating recordlinked alcohol consumption and harm we aimed to investigate whether and to what extent consumption by beverage type bmi smoking and other factors explain inequalities in alcoholrelated harm methods 11038 respondents to the welsh health survey answered questions on their health and lifestyle responses were recordlinked to wholly attributable alcoholrelated hospital admissions arha eight years before the survey month and until the end of 2016 within the secure anonymised information linkage sail databank we used survival analysis specifically multilevel and multifailure cox mixed effects models to calculate the hazard ratios of arha in adjusted models we included the number of units consumed by beverage type and other factors censoring for death or moving out of wales results people living in more deprived areas had a higher risk of admission hr 175 95 ci 123248 compared to less deprived adjustment for the number of units by type of alcohol consumed only reduced the risk of arha for more deprived areas by 4 hr 172 95 ci 121244 whilst adding smoking and bmi reduced these inequalities by 357 hr 148 95 ci 101217 these social patterns were similar for individuallevel social class employment housing tenure and highest qualification inequalities were further reduced by including either health status 166 or mental health condition 5 unit increases of spirits drunk were positively associated with increasing risk of arha hr 106 95 ci 101112 higher than for other drink types conclusions although consumption by beverage type was socioeconomically patterned it did not help explain inequalities in alcoholrelated harm smoking and bmi explained around a third of inequalities but lower socioeconomic groups had a persistently higher risk of multiple arha comorbidities also explained a further proportion of inequalities and need further investigation including the contribution of specific conditions the increased harms from consumption of stronger alcoholic beverages may inform public health policy

background despite reports on troublesome contents created and shared online by healthcare professionals a systematic inquiry of this potential problem has been missing our objective was to characterize the content of healthcareassociated social media memes in terms of common themes and how patients were portrayed materials and methods this study applied a mixed methods approach to characterize the contents of instagram memes from popular medicineor nursingassociated accounts in norway in total 2269 posts from 18 instagram accounts were included and coded for thematic contents in addition we conducted a comprehensive thematic analysis of 30 selected posts directly related to patients results a fifth of all posts were related to patients including 139 posts related to vulnerable patients work was however the most common theme overall nursingassociated accounts posted more patientrelated contents than medicineassociated accounts but the difference may be partly explained by the former focusing on work life rather than student life patientrelated posts often thematized trust and breach of trust difficulties and discomfort at work and comical aspects of everyday life as a healthcare professional introduction the arrival and spread of online social media have introduced possibilities and challenges for society all around the world for healthcare students and professionals the implications of online presence and behavior are still emerging and eprofessionalism is a construct comprising the attitudes and behaviors reflecting traditional professionalism paradigms that are manifested through digital media unfortunately studies have revealed that eprofessionalism is difficult especially for students and concerns have recently been raised across countries that certain forms of online humor published by healthcare workers conflict with professional values these concerns have however been anecdotal in nature and systematic characterization of such material is lacking humor is a complicated matter in terms of professionalism and serves multiple functions for healthcare professionals it can facilitate communication support therapeutic processes or act as a strategy to cope with demanding situations and difficult emotions by sharing challenging experiences through jokes healthcare workers remind each other that struggling and making mistakes are common without afflicting shame or guilt however not every form of humor aligns with the professional norms in healthcare stigmatized groups seem to be especially vulnerable to ridicule dark humor ridiculing tragic events and suffering can be a useful tool in the face of distress but may appear uncanny hostile or offensive from the outside in some cases humor can become abusive or degrading in respect of vulnerable patients thus there has been a call for the education of healthcare professionals to also address the use of humor as part of the wider hidden curriculum memes constitute a genre of humor that has gained attention in relation to troublesome online contents a meme is typically an image or short video annotated with text shared in social media examples are not reproduced here for legal reasons but illustrative examples have been published by berre and peveri harvey and song and crowder the social media platform instagram which is intended for image and video sharing has about 28 million users in norway corresponding to 67 of the adult population and more than half of those between 18 and 50 years of age report daily use the use is highest among young women where 89 has an instagram account the potential for wide outreach is thus considerable and problematic contents produced by healthcare students have already caused concerns among educators the lack of systematic knowledge regarding the contents of these images and videos makes it impossible to assess the prevalence of problematic material and restricts how educators can thematize this phenomenon in terms of eprofessionalism to address the need for systematic descriptions of social media memes this paper employs a mixed methods approach to characterize norwegian healthcareassociated memes posted on instagram the aim of this study is to provide systematic knowledge to guide and support public discussions regarding healthcare professionalism and humor in social media and to identify areas where social media memes can be used as a resource for professional identity formation in healthcare education materials and methods data collection google was used to search for an initial list of relevant accounts the search was conducted on june 16th 2021 for each account with less than 500 followers the lists of followers and followings were manually reviewed and relevant accounts noted the process was repeated until no more relevant accounts could be identified accounts were included in the study according to the inclusion and exclusion criteria in table 1 and categorized as related to nursing or medicine and the number of followers and followings was recorded from the selected accounts all posts published prior to june 1st 2021 were assessed for eligibility the delay between june 1st and 16th was assumed enough for the posts to receive representative reactions in form of likes and comments images videos date caption and the number of likes and comments were extracted for each post the publication date of the first post from each account was used to calculate account age the study was approved by the norwegian centre for research data and the included accounts were notified and received written information about the study in line with privacy regulations quantitative analysis the quantitative analysis aimed to characterize the popularity of various themes and explore whether specific themes affect the response to the posts codes were developed by two authors in collaboration from a set of 100 randomly selected posts and independently validated by three coders the interrater reliability of each code was assessed by gwets agreement coefficient 1 ac 1 is robust to the kappa paradox where cohens kappa underestimates agreement in the case of skewed data ie when the prevalence of some codes is small the codes were refined and independently tested until satisfactory interrater reliability was reached except for codes that were expected to show large interrater variability next each post was randomly assigned to three independent coders the coders had an option to flag posts for review if they were difficult to code and posts were excluded if all three coders found it difficult to assign suiting themes to improve validity only codes applied by ≥ 2 coders were kept for analysis all posts marked for review were evaluated by two authors in collaboration and recoded the proportion of posts belonging to each theme was calculated by account to compensate for the varying number of published posts these proportions were used to calculate correlation between themes and compare prevalence between professions linear mixed models were used to assess the effect of specific themes on the number of reactions the number of reactions to a post depended on the number of followers of the account at the time of posting to account for this we devised a casecontrol comparison by selecting four control posts for each themerelated post for each post related to a specific theme the two previous and next posts not related to that theme were selected from the same account thus multiple casecontrol groups of 35 posts were created for each theme next the number of reactions was standardized by dividing on the standard deviation of the corresponding control posts the regression coefficient can then be interpreted in terms of how many standard deviations a specific theme will increase or decrease the number of reactions nested clustering was included in the model as a random intercept profession and theme were included as fixed effects as well as their interaction independent models were fitted for the number of likes and comments bootstrapping was used to estimate confidence intervals for the regression coefficients the casecontrol groups were stratified by account and resampled with replacement next new linear mixed model regression coefficients were estimated from the bootstrapped samples finally the 25 and 975 percentiles were extracted and regarded as 95 confidence intervals for the coefficients all calculations were conducted in r version 402 and pvalues were adjusted within test with the benjaminihochberg procedure visualizations were made with the upsetr corrplot and ggplot2 packages for r qualitative analysis qualitative analysis aimed to provide rich descriptions of how the memes portrayed patients and their relatives and to explore characteristics of professionally problematic posts to this end 15 problematic posts and 15 unproblematic posts were systematically selected for focused discussions to identify problematic and unproblematic posts the posts including patientsrelatives were scored by offensiveness on a numerical rating scale from 0 to 10 by at least three authors the 15 posts with highest and lowest mean score were considered most and least offensive respectively and selected for comprehensive qualitative analysis the qualitative analysis was conducted using a methodology originally designed for analysis of press photograph story and later adapted for social media analysis four authors jointly reviewed all selected posts through focused discussions and the following features were detailed for each selected post uninterpreted content text interpreted content humor caption offensiveness and theme two experienced qualitative researchers reviewed the selected posts independently to crosscheck that identified themes corresponded to the overall impression a consensus on the most prominent message in each meme was achieved through thorough discussion results accounts and posts after the initial google search and review of lists of followers and followings 51 accounts were assessed for eligibility of them 18 accounts were included and categorized as related to medicine or nursing account characteristics are shown in table 2 in total 2319 posts had been published prior to june 1st 2021 the median number of posts per account was 96 not all accounts were actively publishing posts at the time of the study the median time span from the first to the latest post was 284 days and the median number of posts per month was 119 in total 16 posts were marked for review by all three coders and excluded from further analysis whereas 227 were flagged for review by one or two coders and recoded by two authors in collaboration thirtyfour posts were excluded during recoding leaving 2269 posts for further analysis of these 14 posts did not reach majority on any codes but have been kept in table 2 as they were not flagged for review during coding a flow chart of post inclusions and exclusion can be found in supplementary figure 2 quantitative analysis eleven general themes were identified and are described in table 3 the posts were coded by three authors resulting in high interrater reliability the occurrence of various themes is illustrated in figure 1 for all accounts and in supplementary figure 3 for medicineand nursingassociated accounts separately most posts were related to work either alone or in combination with patients or private life in total 491 posts were patientrelated of these 116 posts were regarded as offensive 148 posts as depicting vulnerable patients and 67 posts as an offensive depiction of a vulnerable patient there were significant correlations between some themes accounts posting about work tended to post about vulnerable patients and patients in general but not injokes or about student life or exams accounts posting mostly b likes and bcomment refer to standardized regression coefficients estimated from linear mixed models and positive coefficients reflect the theme being associated with an increase in the number of reactions confidence intervals are estimated from bootstrapping and robust effects are indicated in bold about student life on the other hand tended to post injokes and about exams but less about patients or work accounts related to medicine or nursing showed significant differences in the number of posts related to several themes the relative occurrence of various themes is shown in figure 3 posts from medicineassociated accounts were more often about exams student life or injokes in contrast posts from nursingassociated accounts were more frequently related to work private life or patients both vulnerable and in general overall theme had only minor effect on the number of reactions as shown by the regression coefficients given in table 3 and shown by profession in figure 4 with some exceptions the strongest effect was seen for advertisements that had a clear tendency to have more comments than other posts however due to a low number of such posts the effect was not robust to bootstrapping and was only estimable for nursingassociated accounts posts containing injokes or relating to examstests also tended to have more comments but the effect was much weaker than for advertisements although the effect of theme on number of likes was overall weak posts with injokes or relating to vulnerable patients tended to have more likes than other posts in contrast posts depicting academic concepts tended to receive fewer likes when assessed by profession a similar pattern emerged in medicineassociated accounts posts about work or coded as offensive tended to receive fewer likes in contrast posts about work received more comments in both medicineand nursing associated accounts and some more likes in nursingrelated accounts there was a tendency for patientrelated posts to receive more likes and comments in nursingassociated accounts whereas this effect was absent for medicineassociated accounts qualitative analysis 331 the depiction of patients how and who the 30 selected posts showed a rich variation in graphical techniques and the use of symbols the largest portion of posts contained cartoons or snapshots either pictures or videoclips from popular culture with added explanatory text and captions few posts depicted actual situations involving healthcare instead patients and healthcare workers were typically represented by other characters using text captions to convey the setting and the roles both patients and healthcare workers were sometimes depicted as animals there were however examples of what may have been authentic patients in ambulance or in hospital and a photo taken inside a norwegian healthcare institution some posts made use of more advanced symbolism such as the trojan horse some groups of patients were repeatedly depicted in the 30 selected posts these were typically vulnerable patients such as confused or fragile elderly patients patients suffering from psychosis or delirium and drugaffected or agitated patients the number of posts related to common themes the total number of posts related to each theme is shown to the left whereas the upper bar plot shows the intersections between various themes only intersections with ≥5 posts are shown healthcare worker was often anonymous and profession and position were typically not stated explicitly the point of view varied between posts often the character representing a healthcare worker was marked with personal pronouns such as me i or you in others we observed the situation as an unnamed third party another common configuration was a photo or video representing the patients response to an action captioned every time you do something to the patient the patient was referred to as me in only one of the 30 selected posts thematic analysis main themes three overarching and recurring themes emerged during the analysis of posts considered the most or least offensive below we present main themes and related subthemes from the thematic analysis with illustrative examples demonstrating how the themes manifest themselves in distinct ways in posts considered offensive when compared to posts considered innocent trust and the breach thereof many posts involved some form of breach of trust this was thematized in various and diverse ways often in the shape of deception healthcare workers lying omitting pretending among the most offensive posts this theme was frequently connected to administrating medications typically antipsychotics or sedatives an illustrative example a healthcare worker saying i am just flushing your venous catheter whereas the syringes are clearly marked with antipsychotics in one such post the healthcare worker additionally calms the patient by falsely saying yes it is only salt water another form of pretending was demonstrated by a slow number of patientrelated posts coded as vulnerable or offensive the total number of posts related to each theme is shown to the left whereas the upper bar plot shows the intersections between various themes code scenario where an elderly patient receives incomplete and superficial chest compression from a healthcare worker while the relatives are crying in the background some of the more innocent posts also touched upon forms of deception such as concealing feelings in front of the patient or pretending to be working while hiding from tiresome patients or relatives dealing with unprofessional thoughts fantasies and feelings related to patients was considered a distinct aspect of managing trust as a healthcare worker this spanned from expressed desire to hurt and punish patients for being difficult and enjoying that they struggle to frustration over patients not prioritizing what is best for the patient and looking at patients bodies with uncaring eyes difficulties and discomfort at work almost all the discussed posts depicted situations at work that involved some form of difficulty or discomfort in contrast to posts considered offensive innocent posts typically revolved around challenges encountered at work as a healthcare professional and with patients having passive roles such as observers or extras or were just referred to examples include doing heavy lifting alone hiding from and avoiding patients feeling incompetent or as an imposter and struggling with a task in front of a patient one post stood out as more confessionlike than a meme a healthcare worker described being sexually assaulted by a patient and subsequently laughed at by colleagues when searching support in posts considered offensive on the other hand the patients were often portrayed as the direct cause to the discomfort or challenge a post considered offensive depicted a healthcare worker entering a patients room where the patient is lying exhausted on the floor with hands covered by feces which have also been smeared onto the walls a text caption informs that the patient had previously refused to receive assistance many posts thematized how difficulties at work were solved in lessthanoptimal ways often involving breach of trust as described above uncooperative patients and patients using long time to perform basic tasks delaying or creating difficulties for the healthcare worker tended to be met with frustration anger force and deceit the comedy of everyday life as healthcare professionals another distinct theme emerged from worksituated posts that did not involve discomfort or difficulties but rather focusing on absurdity or surprise a subgroup of the posts that were considered innocent which depicted small everyday incidents such as a patient being wakened by the alarm of an infusion pump a healthcare worker telling the same joke to multiple patients or a healthcare effect of theme on the number of likes and comments the regression coefficients are from linear mixed models and represent the deviation from the mean in terms of standard deviations of nearby posts without the specified theme the distribution shows the robustness of the estimates as calculated by bootstrap validation the dotted lines indicate no effect some themes were separated to avoid skewing of scale as indicated by arrows in panel for medicineassociated accounts the number of posts related to advertisements and vulnerable patients were too low to yield interpretable estimates worker accidently making noises when checking up on a sleeping patient these posts often implied deep compassion for the patient or an unspoken alliance between patient and healthcare worker for example several posts showed the administration of medicine where the dosage is far too low to sufficiently help the patient this was however framed as the fault of an absent doctor leaving both the depicted healthcare worker and patient in shared helplessness in the offensive group there were posts where the comedy was entirely on the patients behalf such as psychotic patients doing or saying allegedly strange ridiculous or stupid things or patients angry responses to naloxone these posts were considered more malign an interesting contrast was the depiction of an elderly patient happily and eagerly folding hospital towels despite this being humor on the patients behalf it was perceived as more compassionate than ridicule and was part of the group of posts considered innocent humor based on whose pain systematic differences emerged between posts considered as offensive or not regarding whose expense the posts humor was based in many of the offensive posts the patients were subject to an action by a healthcare worker consequently the humor was at the expense of the patient and the patients vulnerability was an important part of the humorous element of the post this is exemplified by the repeated theme of deceitful administration of medication to patients often depicted as either psychotic or demented in the innocent posts on the other hand the patients were not negatively affected by the actions of the healthcare worker and the patients were mostly supporting characters in the situations depicted here the pain was clearly at the expense of the healthcare worker however the focused discussions revealed that these differences were not always obvious for example some of the posts considered to be offensive and involving pain on the patients expense could be interpreted as displays of the powerand helplessness healthcare workers may experience when facing specific patients discussion despite growing concerns regarding eprofessionalism among healthcare students and professionals the contents of social media humor from these groups have evaded systematic characterization to fill this gap we employed a mixed methods approach to map important themes both quantitatively and qualitatively the examined memes showed diverse yet characteristic forms of humorous contents and clear differences were found between professions while nursingassociated accounts had large audiences and focused on themes related to worklife the medicineassociated accounts had smaller outreach and focused on studentlife theme had only minor effects on the number of reactions and comments the most offensive posts included vulnerable patients such as elderly patients and people with mental disorders or drugaddictions whereas the least offensive posts thematized challenges as a healthcare professional and the comedy of everyday life although the patientrelated content comprised only a minor subset of the material many problematic examples were found and those regarded as most offensive were found to jeopardize the trust between patients and healthcare professionals it should however be noted that none of the included posts broke the duty of patient confidentiality or were found so problematic that further steps were considered the accounts belonging to the different professions were clearly targeting distinct audiences the nursingassociated accounts targeted mainly nurses in working positions whereas the medicineassociated accounts targeted student populations this notion is supported by the medicineassociated account names often referring to universities it is possible that the shorter duration of the nursing education with frequent separation into internships at various places leaves less room for a meme culture to form the relatively small subset of studenttargeted nursing accounts have however caused ethical concerns another possible explanation is that the number of working nurses is larger than the number of nursing student the relative lack of medicineassociated memes from working physicians may reflect professional maturation during the study or that other platforms or private accounts are used shedding light on the hidden curriculum has been recognized as an important step to fully integrate professional identity formation as part of healthcare educations and our findings suggest that refining eprofessionalism cannot be a process isolated to educational institutions but must include professional bodies reaching healthcare practitioners as well the professional tension accompanying social media has manifested itself during the last decade and along with it the discussion of how healthcare professionals should conduct themselves on such platforms socalled eprofessionalism one extreme approach to this may be to conclude that all public online depictions of patients produced by healthcare professionals are dubious being or feeling seen exposed looked at or deprecated by others are central components of shame and reminding the patient that one is constantly observed evaluated thought about and discussed may induce selfconsciousness and perhaps evoke both shame and a sense of betrayal or alienation especially if one is negatively portrayed or the perspective conflicts with ones own experiences we found several examples of this such as healthcare professionals experiencing discomfort when meeting or observing a patient or finding a patient laughable in appearance or behavior depriving patients the control over how they are imagined portrayed and spoken about may add to their powerlessness in face of a healthcare system where their social and bodily control has often already been weakened trust is one of the pillars of professionality and healthcare professionals are obliged to guard patient integrity in all situations and this commitment conflicts with the creation of humorous memes this view invites students of healthcare professions to reflect upon reasons to why collapses in professionalism may occur and why one might be tempted to expose or ridicule a patient in addition one of the expressed concerns relating to the social media memes has been the possible normalization of problematic attitudes among students the memes can become memorable and influential parts of the so called hidden curriculum of healthcare education which is now recognized as an integral part of how professionalism develops the repeated exposure of vulnerable patient groups such as patients suffering from dementia or psychiatric or addiction disorders that was identified in the current study may contribute to an othering process similar to what have been seen during the covid19 pandemic another possible route of harm is that these memes can distort our senses blunting our abilities to detect human vulnerability and in so doing poison the relational ethics of our practice these concerns are however not unique to medical memes and pertain to all use of humor in healthcare settings a contrasting view may be that the production of humorous memes are important forms of selfexpression that if they manage to maintain patient confidentiality are creative ways to identify communicate and cope with problems and challenges arising in professional life creative artmaking is an effective way to explore issues related to professional development and visual arts offer distinct benefits compared to verbal reflection patients are not to be infantilized but should be respectfully treated as ordinary people which may include that unflattering behavior is commented and pointed out not as an act of humiliation but to help refine patients ability to mentalize and know how they appear to others thus the memes can possibly serve honorable causes including as educational tool or as a way to cope or vent the empowering and positive potential of healthcareassociated memes is illustrated by memes produced by or for patients eg this view invites students of healthcare professions to explore how humor and social media can be used in constructive ways to raise awareness about challenges encountered at work and as an alternative and casual way of communicating with patients the fact that most of the memes analyzed by us relate to work or student life and often frustrating sides of these such as workspare time conflicts or exams suggests that the memes are primarily a way to vent especially the memes can be used as vehicle to communicate experiences that are not easily shared otherwise such as shame the embarrassment from making mistakes or being disempowered these are common yet painful and vulnerable experiences among healthcare workers that may be eased by establishing them as shared experiences that can be joked about thus educators may seek to help students and trainees to find an authentic voice based at least in part on the professions ideals that works in both medical and nonmedical lifeworlds so that the memes can remain useful while adhering to professional standards the medical education eprofessionalism framework is a researchbased attempt to define core competencies for healthcare professionals in relation to digital space here developing professionality involves recognizing the mission and social contract of the medical profession and specific competencies are described along the axes of professional values behaviors and identity formation the framework has been shown useful to guide implementation of eprofessionalism education the qualitative analysis revealed that problematic posts often depict conflicts between normative and descriptive ways of providing healthcare services although all healthcare professionals are trained to know the importance of patient respect confidentiality and trust one might find oneself in situations where the highest professional standards cannot be met due to organizational or personal reasons and where techniques such as deceit are found necessary these illustrations may have educational value that can enlighten healthcare professionals and administrators about unpleasant pragmatism arising from how the services are organized from a patient perspective however the unpleasant pragmatism may lower the publics trust in the healthcare services nevertheless healthcare professionals must reconcile human imperfections and organizational limitations with the demands of professionalism and keeping patientdirected humor at spatial and temporal distance from patients such as between colleagues in the lunch room has being suggested as an acceptable but controversial solution with online social media however spatial and temporal distance collapses and the borders between private and public are blurred all the instagram accounts included in this study were public accounts accessible for everyone for some deciding to create a public rather than a private profile may have been a rushed decision not given much thought for others however the meme accounts provide a platform to reach tens of thousands every day although we found few advertisements in our material the potential for economic gain adds yet another ethical dimension to the online presence of healthcare professionals in contrast to the collapse of temporal and spatial distance the memes commonly preserve a social distance by using medical terminology requiring detailed medical knowledge to get it or by referring to situations unique to healthcare professionals it is likely that this exclusiveness makes the memes able to strengthen the sense of group identity among healthcare professionals one may also argue that this social distance mitigates the potential for harm as it makes the contents of the memes less accessible and understandable for people outside healthcare professions the official presence of governmental bodies and healthcare institutions on the same platform possibly serving contents sidebyside the anonymous accounts is yet another example of unclear borders that may give the memes unwarranted legitimacy overall this study has demonstrated that patients play a peripheral role in the healthcareassociated social media memes but unfortunately close to 5 of the included memes were regarded as offensive the characteristic features of these offensive memes were intentionally deceptive practices which may have been deemed necessary at the time mainly in the form of administering medications as well as unflattering depictions of often vulnerable patient populations future studies are however necessary to investigate the concordance between the opinions of fourth year medical students as in this study actual patients and experienced heath care professionals the rapid development of new social media platforms where the borders between private and public are progressively dissolved and where algorithms select for increasingly shocking or eyebrowraising contents urges for further research to enable educational institutions to deal with these aspects of eprofessionalism the diversity revealed by the current study makes an openminded approach necessary rather than abrupt condemnation we hope that our findings can support nuanced reflections regarding positive and negative sides of healthcareassociated memes through empiric knowledge and guide the continuous refinement of eprofessionalism in healthcare so that space can be found for the human sides of both patients and professionals strengths and limitations this study is to our knowledge the first broad and systematic characterization of social media memes produced by healthcare students and professionals norway is a country with a population who possess excellent digital skills and have wide access to social media suggesting that both creators and the audience of the included memes are likely to be diverse and representative for a wider population the combination of quantitative and qualitative methods enabled both broad and deep characterization of the memes however the approach involves important limitations although the study aimed to characterize the content of medical memes in an objective manner the group of coders was small and homogenous which could have influenced the results to ensure consistency and trustworthiness of our results the supervision and active participation of two senior researchers both with experience from qualitative research and either clinical work or medical ethics was necessary nevertheless both the quantitative coding of posts and the thematic analysis involved subjective judgment for example the classification of posts as offensive or not revealed significant differences between coders however interrater agreement was found to be satisfactory and the subjectivity of the general coding was further mitigated by removing codes lacking majority support humor is inherently subjective and individual and shaped by factors such as culture age sex and experience it is therefore likely that medical students view on what is offensive or not that may differ from other groups and it would have been interesting to include coders with other backgrounds such as patients or experienced clinicians to get a more diverse point of view this is also the case in the thematic analysis where it would have been interesting to involve a more heterogenous group in the discussion of the selected memes finally the focused discussion only involved a selection of the posts and may thus have missed themes that were present in the larger material data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement the study was approved by the norwegian centre for research data and the included accounts were notified and received written information about the study in line with privacy regulations publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher supplementary material the supplementary material for this article can be found online at 1069945full supplementarymaterial

characteristics and patients portrayals of norwegian social media memes a mixed methods analysis

introduction stunting is characterized by obstacles to growth and development resulting in a child being shorter than other children a child can be said to be stunted if the child is born with a height of less than 48 cm and a weight of less than 25 kg then this condition is monitored for up to 412 months if there is no change the child is said to be stunted stunting a significant public health problem in indonesia with a prevalence of around 37 stunting is a national health problem therefore the government stipulates stunting as part of the federal development strategy program by establishing an accelerated stunting prevention program which is structured based on studies on the implementation of accelerated nutrition improvements and seeing the success of other countries in preventing stunting the regulation of this program is strengthened by presidential regulation no 72 of the year 2021 through the national strategy program to accelerate stunting prevention the central government intervenes in districts in indonesia to international journal of multidisciplinary approach research and science jointly succeed in this national strategy program so that the stunting rate drops to 14 in 2024 the stunting rate in indonesia in 2022 experienced a decrease of 216 even though it has decreased efforts must still be made to reduce the national stunting rate more drastically stunting concerns a childs height and the quality of indonesias human resources towards golden indonesia 2045 west kalimantan is one of the 12 provinces that has the highest stunting prevalence and the highest number of stunted children under five the stunting prevalence rate in west kalimantan in 2022 is 298 this figure is included in the high category if referring to who the range is between 2030 and the local government has a big task to reduce the stunting rate to at least 17 in 2023 one of the efforts that can be made is to prevent this mempawah regency is one of the regencies in west kalimantan this regency has a stunting rate of 251 in 2022 the district government is committed to reducing stunting rates in 2023 and 2024 various efforts have been made to make this happen especially one of which is the establishment family assistance team in every village that assists the government in preventing stunting government efforts to reduce stunting include nutrition fulfillment outreach to prospective brides pregnant women mothers with children under two years and mothers with toddlers months by conducting routine monitoring the problem of stunting is not only about fulfilling nutrition and height but is a complex problem that needs to be studied in more depth through various studies from various perspectives factors that influence stunting include the condition of the baby such as not breastfeeding for six months low socioeconomic status of the household premature birth height and low mothers education are factors that have contributed to the occurrence of stunting apart from that the condition of the community also influences stunting inadequate access to health and geographic location the causes of stunting in indonesia are multifactorial including inappropriate complementary feeding practices exposure to viruses poor breastfeeding habits inadequate maternal nutrition and regional determinants such as poor water quality and sanitation health services the food system and education these factors contribute to the high prevalence of stunting in indonesia and emphasize the need for interventions that address the immediate and underlying causes understanding the factors contributing to stunting is critical to developing effective prevention strategies because stunting is not solely the result of malnutrition but is also influenced by education and social structure the modern view of growth regulation emphasizes socioeconomicpolitical factors that contribute to stunting based on this research meaning that to address the reduction and prevention of stunting it is necessary to consider a holistic approach that goes beyond health parameters and addresses the sociocultural context in which stunting occurs literatur review several previous studies stated that stunting occurs as a result of a complex interaction of various determinant factors including socioeconomic and cultural influences other researchers argue that politics and the economy as well as society and culture are one of the factors that influence the occurrence of stunting but the study did not provide specific studies and details about these claims this shows a gap in research that focuses on understanding certain cultural factors that contribute to stunting because stunting results from complex interactions of household social environmental and economic based on this explanation this study aims to examine the sociocultural factors in shaping stunting in tanjung village mempawah hilir district and mempawah regency more deeply because understanding social and cultural factors can help develop effective interventions for preventing stunting research method this study used a qualitative research method with a descriptive approach the research location was in tanjung village mempawah hilir district mempawah regency in this study seven informants from elements of the government health workers community leaders and community representatives were stunted the informant determination technique uses a purposive sampling technique the data collection technique uses interview observation and documentation techniques the data sources used are primary and secondary data validation techniques using triangulation of sources result and discussion tanjung district is one of the subdistricts that have a high number of stunting cases the following is the data that the author obtained from the mempawah hilir district health center regarding the number of stunting cases in the tanjung village international journal of multidisciplinary approach research and science table 1 shows that the number of stunting in tanjung subdistrict in june 2022 was 28 cases of stunting if no prevention efforts and solutions are provided the chance of stunting with higher numbers will occur according to the head of the mempawah hilir district health center tanjung subdistrict the number of stunting cases is relatively high following are the results of the authors interview with informants cases of stunting in tanjung village are quite high after kampung pasir village nevertheless we do not just rely on numbers or numbers for cases of stunting we need prevention so that stunting does not happen to the people of mempawah hilir subdistrict case of stunting if the stunting rate reduction is not accelerated stunting cases will snowball indirectly stunting will cause new social problems to arise and impact elements of peoples lives the resulting impact on children who are stunted in health will affect the growth of the brain and nerves of the body and stunting will have an impact on social problems such as poverty education and the economy suppose a child with stunting is not treated and the number is increasing in that case a child cannot study well and absorb lessons to the fullest because balanced nutrition in a childs brain will make the childs ability to think and digest much better in many countries stunting is also related to childrens low cognitive abilities and performance in school stunting affects learning capacity at school age school grades and achievement wages for work as an adult risk of chronic diseases such as diabetes morbidity and mortality and even economic productivity one of the things that this research wants to discuss is how social and cultural influences cause stunting in tanjung village based on the results of stakeholder interviews the social and cultural environment has an influence that causes stunting cases the social and cultural environment namely the level of community education the existence of early marriage and some people still believe in traditional healers and myths in pregnancy and feeding children education education is essential in improving the quality of human resources because of that education is also a reference or benchmark in viewing or considering a phenomenon in the context of health people are expected to have extensive knowledge and be able to think critically so that they have the knowledge to guide their daily activities the total population in tanjung subdistrict in 2020 is 1227 consisting of 614 men and 613 women have different educational backgrounds and the education level is as follows educational level of tanjung districts figure 1 shows that most of the population does nothave not attended school namely as many as 391 people 212 people have not finished elementary school and 271 people have graduated from elementary school of those who continue junior high schooljunior high school to graduate there are 130 people 160 people have graduated from high school 6 d1d2 people 11 people graduated from d3 and 46 people from s1 there are no residents who have continued to masters and doctoral degrees in 2020 there were 418 schoolage residents aged 322 years however the number of residents with student status is only 184 meaning that many schoolage children do not continue their studies the explanation from the head of tanjung lurah namely justifies this assumption residents of tanjung village some are already literate in education but there are still very many who are still at a low level of education so their knowledge about stunting is also limited and it is difficult to accept this understanding the level of education also influences the formation of stunting this was also confirmed by the head of the mempawah hilir district health center who stated that if the educational characteristics of the community were still relatively low it would affect the childcare mechanism following are the results of the authors interview with the head of the mempawah hilir district health center regarding education in the cape area is lacking the average income and education of the downstream mempawah community are in the middle and lower percentages so for the issue of stunting and their knowledge of stunting is also lacking the author sees that the average child who is stunted comes from parents who have not graduated from elementary school or have graduated from elementary school and come from lowincome families the occurrence of stunting in this family is caused by parents knowledge that is not extensive and thinks it is only limited to eating without thinking about nutritional content because limited income no longer pays attention to the adequacy of the intake that their children eat enough to make them complete and cheap low education has an impact on preventing stunting or it can also be said to be an obstacle to handling stunting one of which is the level of education even though socialization has been done the tanjung subdistrict community needs help understanding stunting its causes and how to overcome it this provides homework for the village government health center and posyandu to find alternative new effective ways to provide explanations to the community so that they can easily understand and put them into practice parents with low education are 222 times more likely to have stunted children than parents with higher education a study on early childhood in bangladesh found that children of mothers who had completed senior secondary education had a lower risk of stunting compared to children of mothers who were uneducated as well as children of fathers who had completed secondary education as well have a lower risk of stunting compared to children whose fathers are not educated education is not only crucial for a mother a father figure requires education so that there is international journal of multidisciplinary approach research and science balance in a family if both understand and have concern for childrens nutrition low education also impacts the communitys economy 80 of the people of tanjung kelurahan have livelihoods as farmers with the understanding that they are at a middle economic level and even tend to be lower economic this poverty also influences increasing stunting rates because people cannot afford to buy nutritious food and pay attention to the growth and development of children to the fullest research in yogyakarta suggests that there is a correlation between wealth and the risk of stunting the more affluent a family is the lower the risk of experiencing stunting based on this it can be agreed that education is indeed essential to prevent stunting and improve human resources preventing and dealing with stunting is of course not only with the help of providing nutritious food but also needs to pay attention to the educational aspect of the community because if the level of education is low then human resources will also be low the economy and health will also be low because these circles are interrelated like a cycle earlyage marriage early marriage is a marriage contract that takes place at an underage age because this is not following the provisions of the marriage law no 16 of 2019 which states that marriage in indonesia is only permitted if a man and a woman have reached the age of 19 west kalimantan is the province with the highest number of cases of early marriage in 2021 namely 21 this figure is above the national average of 103 the regencies that have applied the most for dispensation from marrying underage are malawi sintang sambas and ketapang regencies submission of early marriage dispensation is a requirement for children under 19 years of age who want to marry and this is the authority of the religious courts there are also many in the practice of early marriage in mempawah regency however most early marriages in mempawah regency especially in tanjung village do not use state marriage methods so few apply for dispensation for underage marriage they marry underhanded early marriages in tanjung village influence stunting in children children who are not mentally ready to marry and raise children impact childrens health and development this was conveyed by the midwife on duty in the tanjung village in the tanjung village area children are often married under the age determined by the government or based on the law so that at an immature age education is also not completed so that it affects the problem of stunting the tanjung village head said the same thing in which case he confirmed that the stunting problem could have started from marriage the following are the results of the authors interview with the tanjung village head apart from education stunting in the tanjung village area is caused by marriage this marriage occurs to those whose age is not according to the rules or what we usually call early marriage early marriage is the cause of stunting in the tanjung village community because at their age they are immature in making decisions thinking and understanding parenting patterns for children besides that this also affects the reproductive role in children because their reproductive organs are immature when a woman marries under at the age of 18 years the uterine organs have not yet been fully formed so that they have a high risk for fetal development and can cause death in the baby world health organization stated that one of the reasons for the high stunting cases in indonesia was early marriage research in jakarta found a relationship between early marriage and the incidence of stunting in children aged 2459 months the results showed that the age of the mother at marriage had an impact on the risk of stunting in her children cases of early marriage in the kelurahan tanjung mempawah hilir district are caused by several factors first there is an arranged marriage carried out by parents and second the culture adhered to by one ethnic group based on the results of interviews with the tanjung lurah and village midwives parents willingness to marry off their children at an early age is one of the causes of early child marriage besides that there is a culture that is adhered to by one ethnic group that thinks it is normal for their ethnic group to marry early with the rise of early marriages in the mempawah regency area the regional indonesian child protection commission together with the office of social affairs womens protection child protection and pemdes and the mempawah religious court signed a memorandum of understanding regarding the agreement dispensation of child marriage the existence of the mou or the policy is made so that children do not commit adultery so the government makes a dispensation for marriage age however dispensing the marriage age can lead to new more serious social problems one of which is stunting believe in myths the myth that developed in society turned out to be one of the causes of stunting myths are often associated with certain legends stories or stories with mystical or mysterious nuances myths are also ambiguous and have many meanings there are no permanent myths but almost all myths are flexible stories in myths mostly adapt to new knowledge and changes in the human environment some people in kelurahan tanjung still believe in myths about pregnancy birth and feeding babies which are not scientifically proven peoples belief in myths creates obstacles for people to obtain good nutrition knowledge the myth that exists in society indirectly descends or comes from families who socialize it so that the myth develops and survives based on the results of interviews not all of the traditional leaders of the tanjung village believe in myths but some of those whose children are stunted still believe in pregnancy myths and myths about parenting not all people believe in myths but not none some still believe in myths during pregnancy and when raising children so that nutritional information or scientific facts are not absorbed properly some of the myths that are believed by some people and developed in society for generations include international journal of multidisciplinary approach research and science no evolving myth 1 do not drink iced water during pregnancy 2 do not wrap a towel or cloth around the neck which will cause the child to be entangled with the umbilical cord 3 drink more water tofu so that the children born are white 4 drink more coconut water 5 do not eat spicy food during pregnancy so that the child does not get sick 6 if you are pregnant when you go out you have to bring some sharp tools such as safety pins scissors so that you are protected from supernatural beings 7 if not allowed to eat pineapple durian and tape later a miscarriage will occur 8 if the child cannot eat ginger water later the child will be black 9 some types of vegetables are not allowed because they will interfere with the development of the fetus source processed by authors 2022 the myths that are circulating are considered as a form of supervision carried out by the community this is done so that the womb of pregnant women is maintained but there are not many true or false assumptions that cause pregnant women to reduce their nutrition even though this is scientifically permitted and has no effect significant for the content in addition to the myths during pregnancy there are also myths circulating in the parenting process no parenting myths 1 newborn children are given to eat bananas 2 children do not need to be immunized later on adding sick children 3 for children who are sick most of them choose traditional medicine which is not necessarily scientifically correct source processed by authors 2022 parenting parenting is essential when we have children it includes how parents care for their children namely how parents treat and educate guide children and provide important information ideally the childs parents provide complete care to children the impact of early marriages that occurred in tanjung village influenced parenting most of the children who were born were cared for by their grandmothers because the parents of the children worked or because they were young and did not know how to care for babies so the children were cared for by their grandmothers and based on the results of interviews with the head of the mempawah hilir district health center said that some of them namely the childs parents did not provide direct care most of the children are cared for by their grandmothers or relatives because they work so they are cared for by their families moreover this is one of the obstacles because it is difficult to provide an understanding of nutrition or appropriate parenting the grandmother does not know about stunting malnutrition what food is good for babies and the like the grandmother only feeds the children according to what the grandmother and her family eat daily parenting like this can hinder the handling of stunting and its prevention because even though routine stunting socialization is given those present at socialization activities are not the childs parents but the childs grandmother grandfather aunt so it is not uncommon for the results of socialization not to be practiced in everyday life childrens day because the nannies follow the pattern of the childs grandmother or they do the parenting in their way conclusion based on the research conducted it can be concluded that there is an influence of sociocultural sociocultural sociocultural sociocultural linkages on the formation of stunting in children including due to low education so that there is a lack of knowledge and an impact on a low economic level as well both early marriages because they are not ready mentally knowledge and materially so that it will result in parenting patterns of children who are primarily cared for by their grandmothers and finally myths myths that develop in the community influence the occurrence of stunting myths that are believed by the community early on and stunting is something new for them children born short thin depending on height to their parents suggestion if education is low there are still many early marriages myths that develop and wrong parenting patterns continue to develop if no solution is found it can hinder stunting prevention and have the potential for new seeds of stunting to occur in tanjung village

mempawah regency is a regency with high cases of stunting the governments efforts to reduce stunting rates by providing nutritious food assistance to babies at risk of stunting stunting is not only a matter of nutrition but the causes of stunting are complex this study aims to describe the existence of sociocultural linkages as a cause of stunting the research method used descriptive qualitative approaches the informants consisted of 7 people from several government groups health workers traditional shops and communities whose children were stunted the technique for determining informants used a purposive technique and the data collection techniques were interviews observation and documentation the results of the study indicate that there is a relationship between low educations many early marriages

the covid19 pandemic and italys response to it as of september 2020 sarscov2 a coronavirus which likely originated in wuhan chinathat causes covid19 has been ravaging the world causing the deaths of almost 1000000 people 1 the viruss etiology is still notwell understood however it is known that it propagates quickly among humans by close contact air currents by touching contaminated objects or through respiratory droplets produced when an infected patient coughs or sneezes 2 the virus may cause in its strongest manifestations acute respiratory infections that lead to the death of the individual that contracted the virus estimated mortality rate was 34 as of march with significant regional differences 3 the ease of contagion of covid19 and the growing number of deaths along with the collapse of icus has prompted the authorities to adopt measures to prevent the virus from spreading further these measures have caused dramatic effects on the worlds economy such effects are likely to trigger despite governmentsinstitutions attempt to inject money into suffering economies 4 a global recession in this context biomedical experts have acquired an increasingly central role in public debates they acquired such a role by virtue of their epistemic authority which loosely speaking depends on established knowledge combined with an education of excellence success in ones field academic achievements recognition by colleagues and high positions in leading institutions biomedical experts have been elaborating models of contagion strategies for preventing the virus from spreading further and offering precious advice to politicians for implementing public health policies devised to safeguard society in the face of a new aggressive virus for which there was no cure health systems have shown themselves to be remarkably unprepared as a consequence the political authorities have had to rely more and more on the experts to try to formulate health policies suitable to contain the pandemic the public too confronted with the imminent serious threat has not shown any of the recent tendencies of mistrust toward science and scientific reasoning recently observed two different types of approaches to dealing with the covid19 pandemic have as a result of this process emerged one that is exemplified by italy of severity and control based on stateenforced quarantine the other exemplified by sweden of relative relaxation in which quarantine is not implemented for various reasons and relatively lax measures of prevention are deemed to be sufficient to stop the pandemic 5 in this section we briefly look at the italian response to the coronavirus pandemic italys covid19 epidemic which as of july claimed more than 35000 lives on a population of ∼60 million individuals exploded in the wealthy and prosperous north where it put under significant pressure one of europes most developed health care systems in order to prevent mass contagion throughout the country which would have caused catastrophic effects in the less prosperous and developed south the italian government advised by a team of medical experts known as comitato tecnico scientifico implemented a series of measures which involved restriction on movements enforced quarantine bans on travel and assemblies closing of all stores except essential services shutting down all municipal borders uniformed police and armed soldiers setting up checkpoints around the country in accord to the stringency index calculated by the oxford covid19 government response tracker 6 at midmarch italy scored 9048 the most stringent level alongside with spain at that time sweden scored 2857 and it was among the countries with the least stringent measures in the world as of mid of july italy scored 5833 and sweden 3889 the harsh measures implemented by the italian government arguably came in too late and did not manage to prevent the surge of cases that has heavily taxed the capacity of an extremely wellregarded health care system in particular it is deemed that policy makers should have stressed the message dont meet anyone rather than merely stay at home due to the special familiar and relational structure and functioning of italian society however after months of lockdown the situation in italy was gradually getting under control and the countryas of july 2020 seemed to have flattened the curve meaning that it successfully managed to slow down the spread of the infection 7 ic units were readily available and less cases were being discovered on these grounds the italian government ordered a gradual reopening of the country even though the contagion was not zeroed swedens softer approach swedens covid19 pandemic has as of july 2020 caused the death of almost than 6000 people on a population of roughly 10 million individuals at the onset of the pandemic the swedish government decided not to enforce lockdown or to impose strict socialdistancing policies it only implemented a minor set of restrictions and relatively lax trustbased measures to protect and safeguard society this was done for two reasons mostly these are scientificeconomical and constitutional firstly swedens public health agency based on findings it gathered across the country 8 deemed that closingdown all businesses would be useless to stop the pandemic because covid19 had already reached the country in addition the biomedical experts consulted by the government 9 remained adamant that enforced quarantine would be undesirable and even counterproductive secondly according to swedish laws on communicable diseases 10 it is the citizen not the governmentthat has the responsibility not to spread the disease these laws tend to defend acquired constitutional rights and because of them quarantine can only be contemplated for people or small areas but cannot be legally enforced on larger geographical expanses of land swedens less intuitive and more controversial approach can be praised for attempting to safeguard citizens freedom 11 which quarantine seems to threaten however the potential cost in terms of human lives of this approach has also raised many concerns 12 several researchers 13 have criticized the agency for public health and the experts chosen by the government for not having fully acknowledged the role of asymptomatic carriers 14 others 8 1887947af0524fd8b2c6fa71e0332a87skattningavvardplatsbehovfolkhalsomyndighetenpdffbclid iwar3dij1b7jgicxfmrtw7eodymicfo54w0dofz6n3dh7ax9mste9wnorvf4 9 10 11 12 13 a petition was launched by a group of scientists demanding the government to implement stricter measures the petition was signed by over 2000 doctors including the chairman of the nobel foundation carlhenrik heldin 14 were not testing enough were not tracking were not isolating enough we have let the virus loose cecilia söderbergnaucler an epidemiologist at the karolinska institute stated joacim rocklöv a professor of epidemiology and have criticized the increasingly neoliberal turn of the swedish government the dismantling of its health infrastructure and its large business orientation moreover it is not clear whether this softer approach to the pandemic can really bring about the economic benefits it promises recent data have shown that swedishs economy wont dodge economic hit despite its light touch to the pandemic 15 more importantly despite a relatively recent study suggested that swedens limited lockdown measures may have resulted in fewer death than expected evidence is mounting that the swedishs approach to curb the covid19 pandemic has not been as successful as first thought 16 mike ryan executive director of whos health emergencies program recently condemned herd immunity as a strategy to deal with the infection it can lead to a very brutal arithmetic that does not put people and life and suffering at the center of that equation 17 regardless of herd immunity which clearly has not been achieved swedish death raise has become indeed very problematic sweden has a death toll greater than the united states 564 deaths per million inhabitants compared with 444 as of july 27 18 sweden also has a death toll comparable to that of italy 19 but nearly five times greater than that of the other nordic countries combined 20 which seems to suggest that under similar conditions the death toll could have been much lower hence that many lives could have been saved if a different approach had been pursued however as data may quickly change again we ought to preach prudence and avoid drawing sharp conclusions for this reason given the evidence available at the time of writing it seems reasonable to suggest that swedishs approach needsat minimumto be redesigned so as to take into account not just economic parameters but also to protect and defend the lives of swedish citizens in the interest of public health additionally even if swedens approach would turn out to be better than the competing one significant concerns would remain about its possible potential application to other countries such as italy applying the swedish approach to italy would be quite difficult we believe and likely result in a massacre for the following reasons italys density is 206 people per km 2 whereas swedish density is 110 of that 25 people per km 2 swedish population is as noted above 16 public health at umea university added does this mean this is a calculated consequence that the government and public health authority think is okay how many lives are they prepared to sacrifice so as not to risk greater impact on the economy 15 16 17 18 19 20 of the population of italy and the number of single person households amount to ∼2 million whereas in italy is ∼8 million moreover lots of italian towns are characterized by a rather compact layout with aggregates of houses in the city center sweden on the contrary has many us style towns with more space between houses and families and also has a larger surface area sweden is characterized by a high level of social and institutional trust which is significantly lower in italy finally swedish are on average more reserved and less outgoing than italians who are known to live among relatives in large communities where close contact and deep personal interactions are the social glue having briefly reviewed these two approaches to the current covid19 pandemic we next problematise around the epistemological stalemate that seem to arise as a consequence of their implementation in society general disagreement among experts a pressing epistemic problem the two cases we discussed above are particularly instructive and offer us an opportunity to problematise about the role of science in public debates and specifically around its role in the implementation of public health policies in situations of emergency both these approaches are strictly speaking scientifically informed and epistemically justified in brief this seems to be a case where experts disagree and their epistemic authority cannot be taken as the benchmark for making complex political decisions that governments should implement afterwards as in the case of the outbreak in the uk scientists disagreed on herd immunity and its effectiveness as a means of controlling the spread of the sarscov2 but the key point for society was not how effective herd immunity was compared to the lockdown but how many lives the choice of herd immunity could cost 21 now one can be an advocate of science and appreciate both the immense contribution that science has made in the constitution of our democratic states and in the solution of many daily and existential problems our societies certainly cannot do without science in individual lives or in the public square however in some caseslike the one we discussed herethe epistemic justification that underlies scientific expertise seems to be problematic and not solid enough to be uniquely used to model public health policies which have strong normative and axiological implications for many millions of people and may affect how many lives would be spared or lost in this sense both the italian and the swedish cases are paradigmatic examples of this problem in italy the lockdown contributed to save may thousands of lives22 even if the human cost of the infection has been very high biomedical experts insisted on suggesting harsh measures of social distancing arguing that the primary and imperative goal was to save all possible human lives following this approach however could come at the price of impoverishing the country to the point that unemployment and company closures would cause direct and indirect harms to the population not much lower than those caused by covid19 in sweden instead the plan agreed between biomedical experts and government was to keep the infection curve as flat as possible without blocking the country the authorities relied on the swedes compliance with the rules for preventing the contagion without direct impositions and strict sanctions this optimized choice could be defended in terms of costbenefit analysis but it remained unclear what could be the impact of this decision in the weaker sections of society in the case we present here the lack of strong epistemic justification which allowed for different responses to be implemented was due to a number of reasons the most important of which were probably the novelty of the virus its relatively mysterious etiology and the fact that experts were still learning about this infection this means that as we write this paper we are in a sort of paradigm change where hypotheses and theories about novel scientific facts are very fluid and subject to almost immediate falsification this stage both favors and requires consistent disagreement among experts who sometimesbona fide even end up giving ambiguous or contradictory pieces of advice to the population 23 part of the problem therefore seems to be epistemic in character as it lies in the interpretation of what counts as a fact experts in different fields have very different beliefs about what facts are what causes and effects are what counts as reliable data and indeed draw on very different sources of evidence to back their views this again can be easily observed in the interpretations that have formed among experts around the ways to best deal with the pandemic on the one hand mathematical modelers assumed the virus would behave like influenza this assumption makes people think that we may allow the virus to circulate under controlled conditions and may suggest decision makers to adopt a lax response that tries to contain the virus spread without for instance harming economic activities or citizens freedom other scientists and public health experts on the other hand have consistently called for mass testing tracking and adoption of stringent measures of social isolation which are rooted in a very different belief the belief that the virus is not anything like common influenza and shouldnt be allowed to spread even under controlled conditions another part of the problem however is political in nature and has to do with the way certain political decisions are translated into social policies this also relates with the topic of who chooses who and what kind of expertise is invited into those committees responsible for taking crucial decisions on public health in the cases we have analyzed in this paper it is clear that politics has failed to listen to society as a whole and has not used the critical tool of public reason to critically analyse and refine when neededthe medical experts advice the approach we propose here thus suggest that one informed viewpoint isnt necessarily enough or better than another informed one but that a wider range of opinions ought to be listened to in order for effective decision to be implemented especially if such decisions involve normative axiological components and are applied to public health the idea is not just that certain expert recommendations are based on a poorly established factual basis this is a common situation although often overlooked the point is that the biomedical experts are called to advise decisions that are political in character and have enormous consequences on peoples lives based on their specific scientific expertise such scientific expertise in many cases does not include public principles values or public procedures that are instead typical of a pluralist liberal democracy experts typically answer technical questions and provide recommendations that are related to their expertise decisions with more general consequences should be made by representatives of the whole society according to formalized procedures the need of more public discourse in fighting covid19 this means that one might call as we do for a broader and wider conception of expertise as well as for more representativeness especially when scientific agreement has not crystallized yet and like in the case we discussed abovebiomedical experts alone seem unable to formulate broadly shared uncontroversial health policies for this reason in such cases politicians should not uncritically adopt only medical experts opinions rather promote and articulate their discussions in the wider society with attention to ethical and moral principles as well as to constitutional rights and to the rights of minorities in brief in light of public reason as oneills brilliantly put it we have to supply a structure that the members of a wider potentially diverse and unspecified plurality can follow by adopting and following principles of thought and action that an unrestricted audience can follow such discussions should therefore promote a shared procedural and democratic agreement on how to act in situations 24 of emergency with high trust being put on reliable institutions but also on various other forms of expertise we surely welcome the recent adoption of ethical principles in many local regional national and international committees especially in medicine eg we also acknowledge that nowadays nonbiomedical experts tend to be included in many biomedical boards and commissions for example bioethicists had very important roles during the ebola epidemic however with very few exceptions the current covid19 pandemic has highlighted significant underlying epistemic ruptures between medical science other types of expertise the general public and the political response this is because biomedical experts by virtue of their scientific authority have been often uncritically recognized as more authoritative than other epistemic experts or nonepistemic ones this is perhaps a natural assumption to make in cases like the one we discussed in this paper however it may leadas we have attempted to showto undesirable consequences and to a stalemate that may threaten the functioning of our societies it is our opinion that the best strategy to bridge such ruptures and to avoid such problems is to open up science to public discourse and reason and include in any scientific committee responsible for taking crucial decisions on public health ethicists bioethicists psychologists economists moral and legal philosophers 25 more importantly we believe that it may be even more fruitful to bring in and give voice to nonexperts or experts whose expertise is not based solely on epistemic status but rather on either experience or political advocacy of either the homeless the immigrant or other disenfranchised groups this process may also contribute to make the epistemic expertise of experts more representative of society as a whole in order words echoing philosopher and legal scholar melissa williams we argue that a fair and just public discourse needs at least some direct representation of the voices of those who are minorities or live in dependence because the majority groups do not share their particular history and experience conclusion the type of experts recommendations we have considered here although technically flawless are not neutral for individuals and for society and should therefore be evaluated according to procedures that do not merely assess the epistemic authority of their advocates or the adherence of their proposal to scientific criteria the values at stake are different and often conflictingthe right to health political freedom the right to run a businessand the prevalence of one or the other should be entrusted to an assessment typical of decisions taken in the public sphere with the participation of various forms of expertise chosen representatively and just as we should never give up the contribution of experts so the state of emergency and the limited time available to make an effective decision should never prevent an inclusion of normative and axiological elements in the public debate in other words we should be drawing on every type of potentially relevant expertise across the humanities social and natural sciences and on insights from the wider society thus in our view the involvement of nonbiomedical experts and underrepresented categories capable of drawing attention to general values other principles and procedures should be welcomed as it could help making decisions that are more representative of society as a whole data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding authors conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest

we start section the covid19 pandemic and italys response to it by focusing on italys tough response to covid19 pandemic which included total lockdown with very limited possibility of movement for over 60 million individuals we analyse section swedens softer approach swedens softer approach which is based on relatively lax measures and tends to safeguard fundamental constitutional rights we problematise section general disagreement among experts a pressing epistemic problem around the stalemate that arises as a consequence of the implementation of these different approaches both epistemically grounded and equally justified in the face of an unknown virus in society we point out that in some cases like the one we discuss here the epistemic justification that underlies scientific expertise is not enough to direct public debates and that politicians shouldnt exclusively focus on it we claim that especially in situations of emergency when experts disagree decision makers ought to promote broad discussions with attention to public reason as well as to constitutional rights in the attempt to find a shared procedural and democratic agreement on how to act on these grounds section the need of more public discourse in fighting covid19 we call for an increase role of different types of expertise in public debates thus for the inclusion of ethicists bioethicists economists psychologists moral and legal philosophers in any scientific committee responsible for taking important decisions for public health especially during situations like pandemics likewise in the interest of public reason and representativeness we also claim that it may be fruitful to bring in nonexperts or experts whose expertise is not based solely on epistemic status but rather on either experience or political advocacy of either the homeless the immigrant or other disenfranchised groups this in expanding the epistemicexpert pool may also make it more representative of society as a whole

introduction background and justification this article will address and discuss the concepts of professionalism and work ethics in the teaching and learning of agriculture in schools before and after botswana achieved its independence for the progress and development purposes of the education system in this country the study discusses the history of agricultural education documenting evidence of professional work ethics and comparing progress made in preand postindependence progress of agricultural education in the education system of botswana has appeared to be relaxed but a bumpy and unpredictable path worth documenting it can be noted that agricultural education in schools curriculum for botswana was prompted by among other factors the tradition and culture of rearing of livestock and growing of crops by the people of the bechuanaland protectorate since 1885 much of the population of botswana have had the privilege to be traditional subsistent farmers and therefore agricultural education became a highly recognized program in the education system in the context of growth and development with the hope that it would contribute knowledge skills and attitudes as well as employment opportunities studies by rammolai squire baliyan et al moakofi et al show that within agricultural education in the country there are some challenges affecting the teaching and learning of agriculture to include teacher morals values and ethics concerns have also been raised regarding resource availability for school agricultural education programs particularly in the form of inadequately prepared teachers in schools in addition after more than 50 years since the country attained independence in 1966 predictions about its contributions towards human resource development and the global emerging issues of poverty climate change unemployment skill development are not explicitly clear on their progress let alone professionalism and ethical issues where the profession of agricultural education is now one cannot make a supposition because as found by pheko and molefhe research on employability and other socioeconomics issues is negligible and inaccessible thus creating a critical challenge for the country the historical framework of agricultural education shows that it was well supported on sound grounds and justification for its inclusion in the school curriculum during the protectorate and postindependence eras it can be argued that different stakeholders who were instrumental in revolutionizing agricultural education in botswana made effort to integrate professionalism and work ethics in the program agricultural education has since became a component of the education system thus requiring professionalism and work ethics encompassing personal and corporate standards of behaviour expected of any professional body there are no doubt that teacher education programs prepared teachers since its establishment in schools prior and after 1966 what needs to be done is to ensure the integration of professionalism and work ethics principles formalized to enhance teacher education through short courses workshops and inservice training this shows that agricultural education in botswana is one area that is made up of proactive teachers and educators who have been influential in activities of rural development small businesses and extramural curricular in schools who form an active positive group of individuals in primary and secondary schools however as implied in the findings of a study conducted by rammolai it was revealed that agriculture and its image advances in applied sociology has begun to regress because of the inadequacy of trained teachers limited perception that agriculture is basically about food production and very little reinforcement of practical relevance to students needs are exercised rammolai further cautions that practical instruction should not be used as intensive manual labour but should be used to target specific technical and professional skills that are needed in the agricultural industry these include 21 st century skills that encompass professionalism and ethics principles in recent developments administration management and practices of school subjects agriculture is grouped with other practical subjects a motive that minimizes advancement and progress of teachers as managers under the auspices of practical subjects not adding value to the profession of agricultural education by standards teachers should have broad and complete knowledge and skills needed for licensing in the profession to help learners meet the challenges and opportunities of the twentyfirst century at the beginning of the 21 st century two noticeable observations became apparent in agricultural education making it clear to many that professionalism and work ethics in teaching the subjects would be compromised if not a forgone conclusion purpose of study the purpose of this study is to document evidence of professionalism and work ethics in the teaching and learning of agriculture in schools before and after the country achieved its independence the study is an evaluation of the progress of professionalism and work ethics in the field of teaching and learning since agricultural education was introduced in schools specifically this study will explore the following objectives 1 to describereviewdiscuss the history of agricultural education of the preand postindependence era 2 to document the evidence of professionalism and work ethics progress in the teaching and learning of agriculture in botswana 3 to compare progress made before and after independence in the teaching of agriculture design of the study according to serena balfour the founder of tutume mcconnel community between 19681970personal electronic communication january 23 2024 the model of education was meant to sustain the students and teachers who had no regular supply of food serena balfour further explained that the school was established with half of the land intended to grow vegetables and gran crops raise cattle and technical education ms balour further stated that we had some wonderful volunteers young teachers from denmark united kingdom and sweden interested in maintaining the school farm and since we depended on it for our food the farm became a necessity for our students to learn about farming she said this is an historical study compiled through desk research exploring the unadvances in applied sociology derstanding of professionalism and work ethics behaviours in agricultural education during the preand postindependence historical studies as described by coreil are used in social sciences to understand progress and relationships between constructs according to green and cohen desk research design ensured data is derived from secondary sources that do not require direct contact between the researcher and participants the study used data that is perceived to be indirectly not complicated to infringe into human resource subjects the existing literature reviewed included policy documents of the ministry of education such as school agriculture syllabi teacher education for colleges informal discussions with teachers of agriculture and senior citizens of the ministry of education journals and policy documents some examples and illustrations were drawn from experience and previous research into agricultural education stories of the bechuanaland protectorate and after independence experience this study provides evidence of work ethics and professionalism indicators the history of agricultural education of the preand postindependence era in botswana this is described in three stages before during and post missionaries era stage 1 in the period prior to the arrival of missionaries some forms of cultural informal education existed within the bogwera and bojale initiation schools for girls and boys before and after the bechuanaland protectorate were formed in 1885 the informal cultural activities taught to women and children include womanhood skills domestic and agricultural activities sex and behaviour towards men and women home management skills that include sewing cooking carving mortars and making tools like hoes axe handles for cultivating the soil or weeding and weaving beads this type of education lay the basis for values within the professional guiding principles expected from learners the result was that women qualified for motherhood and marriage teaching while boys were introduced to hunting and livestock rearingtraditional living skills based on gender based on this form of education professionalism and work ethics progressed on the basis of ideas and model of education of the era boys and girls developed some ethics through initiation schools stage 2 the period called the bechuanaland protectorate era can be equated to the colonial education during which different missionaries were in the protectorate history shows that missionaries arrived at different times in the protectorate with the goals of teaching the christianity and health services in this period to achieve their goals the majority of the missionaries established schools with small farmsgardens to teach agricultural science vocations and academic skills for food provision to local families hence the introduction of agriculture coupled with the christian curriculum based on moorad the establishment of the teaching and learning of k hulela doi 104236aasoci2024141005 73 advances in applied sociology agriculture in mission schools in this era was not based on professional development knowledge and skills on agriculture this was based on what could be termed request for practical subjects to be offered as the need for curriculum development to go beyond scriptural and into industrial education according to moorad the education was anticipated and perceived to benefit the rural families and community hence it was communitybased education in this period schools were created as a way of socialising children into the accepted values and norms of society and preparing them for their later adult roles for example as pointed out by wass moorad the establishment of moeng college was conceptualized in the 1930s as an initiative of the bamangwato people of the bechuanaland protectorate and became successful after the second world war the goal of this school according to wass was for the advancement of african children through higher education and training hence the establishment of a large farm with agriculture infrastructure regarding moeng college moorad stated that the school offered courses in agriculture animal husbandry mechanics building carpentry bookkeeping and typing it had a farm and typified a real community situation where the students were all expected to take part in the farm activities wass further explained that around 1935 when moeng was being planned for in the then director of education hje dumbrell report of 1935 a proposal for the development of adult schools to cater for the needs of men and women who could only attend in the late afternoons and evenings was made according to wass the dumbrell report referred to the dutch reformed churchs success story in mochudi and the kalahari village areas which had established adult schools successfully without assistance with the desire to learn the report expanded the idea of adult schools to use the services of other departments to ensure adults were taught things of real value specifically mentioning agriculture related fields of agriculture medical and veterinary this marked the birth of agricultural science in schools or the school curriculum in the bechuanaland protectorate nkomazana and setume wrote that of all missionaries the london missionary societies then referred to as the united congregation church of southern africa are believed to have arrived in the southern african region as early as the 1800s they first established tiger kloof educational institution in vryburg south africa before crossing into bechuanaland protectorate to start moeding college at otse in the southeast of botswana in 1962 the curriculum at moeding college in the protectorate was informed by that of tiger kloof in south africa which according to arkoachemfuor applied the principle of education with production raising of vegetable gardens and rearing of cattle agriculture formed the corecurriculum before and after 1966 at moeding college in botswana in 1801 another group of missionaries called the dutch reformed church settled at mochudi founded by rev henri gronin which began working in 1863 to start the first home craft school to prepare women for home living the advances in applied sociology online history of st theresa mission school in lobatse as described by sumani also shows that the zambezi mission by the roman catholic church missionaries decree signed by pope leo xiii in 1879 entrusted to the society of jesus to kickstart the missionary work in bechuanaland protectorate these missionaries arrived in tati in the northeast of the protectorate rear rhodesia now zimbabwe on the 17 th august 1879 this took a while before the establishment of the roman catholic church mission at khale hill in 1923 the missionaries at khale hill then started the adolescent training centre in 1934 as summarized by hulela and miller to teach agriculture with boys only and started a large farm of 1000 acres with livestock orchard trees and crops such as maize peas sorghum potatoes pasture teff and cowpeas according to bayani the lutheran missionaries arrived in botswana as hemansberg missionary society in 1957 as invited by the president andres pretorius of the transvaal in south africa stage 3 the pioneers era also overlaps with the missionary era as mentioned by moorad even though a mention is made that agricultural education was first introduced in schools through missionaries two pioneers such as kgalemang tumediso motsete and pratrick van rensburg also played a significant role in the 1930s and 1960s respectively the first of these pioneers associated with this historiographical or historic role in history during the bechuanaland protectorate era was identified as kgalemang tumediso motsepe this distinguished botswanan citizen established a mixed school called tati training institute as the first secondary school in the northeastern part of the country that later moved to nyewele in tshesebe in 1932 on political grounds according to melczer motsetes mixed school offered agriculture as a key subject in the curriculum occupying onethird of the space in the school curriculum second in this stage of pioneers and movers was henry james edward dumbrell then director of education who proposed agricultural science to be studied as part of the education curriculum third in this notable educational historical venture was patrick van rensburg who arrived in the protectorate in the early 1960s just before the country achieved independence in 1966 van rensburg a south african by birth settled in serowe with the intention to establish a progressive form of education at swaneng hill school madiba secondary school in mahalapye and shashe river schools in tonota near francistown the three schools were started to admit primary school leaving examination standard seven dropouts the schools curriculum and subjects placed emphasis on practical subjects including agriculture building carpentry metalwork technical drawing and typing the van rensburg approach to agricultural education was revolutionary and perceived to be a radical model of education at that time as the three schools established were attached to farms encouraged learning by doing which was modelled as education with production in botswana that included idiosyncratic forms of vocational training onthe job education and active production for the community around schools advances in applied sociology the preindependence era of agricultural education saw some pioneers playing a momentous role in the development of agricultural education throughout the bechuanaland protectorate era as indicated by moorad and rammolai the teaching and learning of agriculture in schools was characterized by the missionaries and some key individual pioneers made significant contributions to the development of agricultural education in the country one historic moment worth noting is the formation of the then university of basutoland bechuanaland and swaziland according to the university of botswana ubbs was formed on january 1 1964 following an agreement reached in the mid1962 between the high commission of the then three british protectorates these schools taught agricultural activities as part of the extramural curriculum which was used for manual work and for punishment of students with no formalized assessment postindependence era when the country reached the close of the bechuanaland protectorate era to become a new independent state called botswana the teaching and learning of agriculture was offered at moeng college moeding college st josephs college and the three schools swaneng hill school madiba school and shashe river school there was a proposal for integration into the new education system modernized and restructured to become an integral part of the school curriculum this occurred because at that point in history agricultural education within the curriculum was scant characterised by minimal assessment in 1970 mcconnell college was established in the rural village of tutume in the central district and agricultural science was strong in the curriculum supported with the brigade education and a farm for the teaching of agriculture during the same year the lms also expanded its mission and set up maun according to hulela and miller the story of agricultural education soon after the independence rapidly started because of the review of the entire education system by the government of botswana that produced the 1977 education for kagisano policy to enhance the balance or imbalance in the school curricu lum through this policy agriculture became compulsory subjects in junior secondary schools an option to senior school students while it remained part of environmental science in primary schools curriculum postindependence developments affecting agricultural education can be outlined on yearly basis to include the following agricultural education developed syllabuses and booklets manuals and textbooks to guide the teaching of agriculture primary junior secondary schools and senior secondary school as well as the vocational agriculture for technical and vocational education this was facilitated from a panel of teachers as they formed the botswana agriculture teacher association to coordinate activities for school agriculture curriculum 8 19911995 the establishment of the diploma programcourse in the agricultural education program at bcabuan and the diploma in secondary education at tonota college of education for training teachers with a component of agriculture 9 1994 approximately sixteen years later botswanas education policy was reviewed leading to the 1994 revised national policy on education this revised policy recommended some diversification of the curriculum by incorporating among others foundational skills the vocational orientation of the academic subjects and practical subjects like agriculture 10 1997 department of teacher training and development was established to provide leadership and direction for inservice and preservice teacher training including teachers to teach agriculture at primary and secondary schools teacher professional development was an emphasis in the rnpe which replaced the education for kagisano important achievements a study by mautle and weeks as alluded by amadi and blessing the role played by agricultural education in societies is countless in the provision of skilled personnel for the workforce and in the establishment of vibrant research for farmers continuous development of new knowledge agricultural education also ensures that young farmers clubs rural development communities remain lively as it provides platform for active discussions and learning environment to meet the national food drive currently it is estimated that each of the 33 senior secondary schools would have at least 7 teachers with bsc or above qualifications in agricultural education the 207 public junior secondary schools would each have approximately 6 teachers of which a total of 1260 teachers with diploma in secondary education and bachelors degree in agricultural education teach agriculture in public junior secondary schools objectives 2 to document the evidence of professionalism and work ethics in the teaching and learning of agriculture in botswana to respond to this objective it is important to note that agricultural education practitioners in the bechuanaland protectorate were not trained nor prepared as educators according to paschal teacher education plays an important role in the teaching and learning process because the profession of teaching is realized as the mother of all the other professions that are proven to happen in the universe according to pansiri et al generally schools were supposed to be a safe place for learners but as found in their study unethical conduct in the education system in botswana is heightened by lack of an africanized ethical code of conduct for educators and doubledipping by the public officers a study conducted by bagwasi which traced the history of the education of botswana from preindependence to present has looked at among others policies that have influenced its development in relation to the western education system the changes as alluded to have occurred in the education system after 1966 were noted to include teacher professional development this study uses conceptualized professional ethics by paschal as studied in tanzania to assess their existence in the preand postindependence analysis of literature revealed evidence of indicators of shortfalls of professionalism and work ethics issues of education as some have progressed from preto postindependence in a study conducted by moswela and gobagoba the findings revealed that teacher trainees were knowledgeable about what ethics and professionalism entail but that did not translate to practice as some teacher trainees still indulge in love affairs with students a situation that shun to professionalism and work ethics professionalism and work ethics in the teaching and learning of agriculture are important critical as participants educators community and historical documents perused through showed that preand postindependence agriculture has always been taught or performed no record evidence attire to boost appearance and confidence one or a combination of the following philosophical beliefs according to participants agricultural education was introduced in botswana education system with the belief that it 1 imparts knowledge and skills to change 2 prepares a child to enter a certain cultures in the society 3 building of existing knowledgeskill acquired at home 4 mastering a skill developed 5 building on needs of a learner 6 usability of practical skills and 7 active learning based on philosophies held by stakeholders the teaching and learning in agriculture was introduced with both practical and theory components administered and supervised during and after class hours professionalism as described by creasy is therefore an ideal situation described through several aspects and characteristics as shown in table 1 which individuals and occupational groups aspire to distinguish themselves from other professional workers according to lea it has been found to have several understandings rooted in disciplines of philosophy sociology and on studies of professions to measure progress in professionalism about agricultural education in the history of botswana to date some characteristics borrowed from a study conducted by anitha and krishnaveni were utilised or drawn on to show evidence or no evidence from pre to post independent era in a study conducted by lashgarara and abadi at azad university in tehran in iran the findings indicated that more than forty characteristics of an effective agriculture teacher were categorised into areas of instruction community relations marketing professionalismprofessional growth program planningmanagement and personal qualities professionalism is also about the excellence and character of a teacher in the teaching environment this would mean teachers having the knowledge skills personality and practices that the teacher must acquire to be effective educator in the career of teaching the subject this should not be seen to refer to wearing a suit or carrying a briefcase but instead should be seen to mean conducting oneself with responsibility integrity accountability and excellence which also implies communicating effectively and appropriately in being productive in a story entitled mishandling agricultural practical projects in secondary schools in botswana it is evident that agriculture is one of the secondary school subjects which to a certain extent has been compromised to what could be termed teacher professionalism the article spells out that teachers of agriculture have raised as a concern the fact that practical assessment was not part of k hulela doi 104236aasoci2024141005 82 advances in applied sociology their job description and therefore it must be removed from their supervising and assessment practical projects teachers perception about their subject or profession is thus an important concept of professionalism teachers roles and responsibilities include conducting instructions to teach students enhance youth leaderships through integration into classroom instruction imparting knowledge and skills creating plans and informing students about development in agriculture osullivan van mook fewtrell and wass view professionalism as having become important in the 21st century because professional values and behaviours are intrinsic to all practices yet remain one of the most difficult subjects to integrate clearly into curricular professionalism and code of ethics in teaching and learning of agriculture as indicated by the uganda ministry of agriculture animal industry and fisheries lies at the centre of development of the profession as alluded to by talbert croom larose vaughn and lee the profession like that of several other fields of education is an occupation that requires a long specific program of preparation and uses a code of ethics to guide the conduct of individuals in the profession teaching is one profession that needs an individual to act with integrity show courtesy respect to students other educators and stakeholders one works with and be responsible and accountable in all you are doing work ethics refer to the accepted morals values and principles of right conduct for a profession or area of service such as teaching agriculture kar states that these are standards or rules that enact obligations to refrain from committing a crime like missing classes failing to listen to learners and colleagues in the job stealing cheating committing malpractices rape murder assault refusal to perform a duty in the profession misconduct or fraud in workplace in botswana teachers of agriculture in secondary schools work with small livestock crops and students as well as the community or parents of these children therefore the issue of ethics in agricultural education is important in the past two or more decades some changes revolutions conflict awareness have emerged coupled with malpractices teacher absenteeism abusive and violent behaviours of refusing with practical marks sexual relationships position abuse and several other factors have come up as forms of concerns in schools zimdahl and holtzer emphasise that the classroom offers an effective starting place for ethical education and unfortunately the curricular offering or focusing on ethical principles their application in agriculture and related fields are rarely available in higher public institutions of learning the authors continue that the courses on ethics should become a key component of agricultural education curriculum because these issues are increasingly a concern for example when taking into consideration the mishap that would occur in education where educators redefine their responsibilities and roles in teaching would explain ethics to mean the rightness or wrongness of actions by an individual or a group of professionals there are three secular ethiadvances in applied sociology cal traditions or what theorists call theories explaining issues to do with civil human rights wrongs and privileges that exist and can be offered in teacher preparation the findings from zimdahl revealed that out of the 59 universities in the united states of america which were surveyed only fifteen were offering agricultural ethics in their curriculum or as a topic in the agricultural curriculum the study advanced several reasons why it is so uncommon for universities to embrace agricultural ethics in their curriculum that include lack of ethics and philosophical knowledge in the concept according to elliott and june ethics education became part of higher education in the past twentyfive years and today there are a good number of universities offering ethics education different courses are offered in different universities in the usa to instil the ethics of teaching and learning agriculture in tanzania for example as alluded to by mfaume and bilinga professionalism in education were attributed to teachers low salaries and remunerations poor living and working conditions influence of science and technology lack of professional knowledge and poor management and infrequent visits and inspections of schools professionalism could be related to educational policy reforms and practices in education on how they are managed to address teachers needs and recruitment procedures supportive policy environment and professional development day sachs also found that teachers engaged in work which has fundamental moral and ethical as well as instrumental purposes in teaching and learning this is so because programs of education are changing professionally and ethically their daytoday practices in school environment conditions for working teachers structures and teachertostudents ratios have also changed as indicated by career development agriculture teacher has a wide range of responsibilities as shown in table 3 summary and conclusions 1 this article is set to address and discuss the progress of the concepts of professionalism and work ethics in the teaching and learning of agriculture in schools before and after botswana achieved its independence for the purposes of the education system in this country the stages in the history of agricultural education are evidence of progress in professional responsibilities of a teacher reflecting teacher education maintenance of accurate records communicating with stakeholders working in and contributing to the school and communities growing and developing the profession teacher education programs agreed upon with the building of dispositions or characteristics on which the teacher candidates would display in the profession 2 progress of agricultural education in the education system of botswana has appeared to be relaxed but a bumpy and unpredictable path due to in adequate resources overall the evidence of professionalism and ethics in agricultural education is key to development of agricultural education in terms of its expansion and contribution to the economy of any country the review has revealed that both preservice and professional education are critical in developing principles of professionalism and work ethics 3 teacher recruitment is the starting point for professionalism and work ethics in teaching in developed nations some assessments strategies and standards apart from the degree qualifications that the potential teachers hold would also be standards to be met used for teacher selection to ensure only individuals with high capability would enter the profession and used to control the degree of selfregulation and credentials 4 finally teachers recruitment criteria for example would be strongly recommended to build on teacher professionalism and further develop guiding standards for recruitment according to calvin and pense there are five factors which appear to be a challenge and solutions to issues relating to recruitment into a career in agricultural educationtime the economy family technology and image 5 in conclusion although its easy to trace the history of agricultural education it is not obvious on how professionalism progressed as there are no ethical standards and policies to measure the advancement the program has already made some contributions socially economically and culturally and it is the governments responsibility to monitor and maintain its strongholds while improving the weak areas that have to do with human resource development limited capacity for policy development as well as infrastructure upgrading in education conclusion this paper has traced the progress of professionalism and work ethics in the history of agricultural education in preand postindependence botswana it has been evidently shown that the teaching of agriculture in preindependence as advances in applied sociology conflicts of interest the author declares no conflicts of interest regarding the publication of this paper

highlighting the importance of concepts of professionalism and work ethics in agricultural education in botswana before and after the country achieved its independence is crucial in the education system the purpose of this study is to explore the concept of professionalism and work ethics in the history of teaching and learning of agriculture in botswana the paper focuses on using the discussions raised in agricultural education development capturing the period prior to 1966 bechuanaland protectorate and immediately after 1966 to the period of the 21 st century professionalism and work ethics in agricultural education provides an analysis on growth and progress in the profession it can be safely argued that different stakeholders who were instrumental in revolutionizing the evolution of agricultural education in botswana needed to integrate professionalism and work ethics in the program

introduction key populations are the groups that have a high burden of acquiring human immunodeficiency virus in many settings men who have sex with men are identified as one kp in both international and sri lankan settings united nations programme on hivaids 1 they have been classified due to their key sexual behavior which has made them more prone to acquiring hiv men who have sex with men are a hidden population in both international and sri lankan settings having unprotected anal intercourse with male partners mainly contributes to the high risk of contracting hiv by msm 2 a combination of behavioral socioeconomic and structural factors contributes to the increased risk vulnerability andor burden of acquiring hiv infection access to relevant health care and other services is significantly lower in this group than in the rest of the population 3 the stigma vested upon msm due to their homosexual behavior is a key contributory factor for their reduced access to health care services 4 stigma is an attribute behavior or reputation that is socially discrediting in a particular way 5 when stigma is acted upon the result is discrimination 6 stigma and discrimination adversely affect the social psychological and medical aspects of the affected ones life they get deserted from their families get rejected from school and become school dropouts these factors lead them to a more vulnerable life further multiple health complications also occur they are anxiety depression selfharm suicidal attempts poor selfimage and low selfesteem stigma and discrimination are identified as key obstacles to universal access to hiv prevention treatment and care 7 also stigma and discrimination lead to feelings of shame worthlessness and fear of being rejected in sri lankan settings msm are discriminated against by police legal professionals armed forces and other government officers due to lack of understanding and existing legal provisions there is global as well as local evidence that proves that msm faces discrimination from society 89 it has been evident in a local qualitative study that they are discriminated against by known people such as family friends and neighbors 10 it has been understood that medical mistrust mediates the relationship between stigma and engagement in care 11 men who have sex with men are being stigmatized in society mainly due to their sexual orientation they are being forced into heteronormative marriages which ultimately leads to disruption of their family lives 12 their marital status plays a significant role in the stigma vested upon them they face different types of harassment from society they can be nonverbal verbal physical and sexual these harassments contribute to the development of selfstigma which keeps them separated from the mainstream 13 reducing stigma and discrimination is identified as one of the four critical enablers that help to overcome major barriers to service uptake including social exclusion and marginalization criminalization stigma and inequity among msm 14 ending the aids epidemic in 2030 has been identified as a key mandate to achieve sustainable development goals 15 ministry of health sri lanka is targeting to end the aids epidemic by 2025 five years in advance of the targets set by the united nations 16 measures can be taken to reduce the behaviorrelated stigma among msm by minimizing their exposure to modifiable determinants which are identified in the study to determine the correlates of behaviorrelated stigma among men who have sex with men in western province methods study design a crosssectional analytical study was conducted among msm in the western province of sri lanka participants and data collection data collection was carried out from july to november 2018 the sample size was 564 which was calculated scientifically and the number from each district was taken proportionate to the msm population in each district participants aged more than 18 years residing in the study setting for more than six months and who had a valid peer recruitment coupon were included in the study individuals diagnosed with a mental disorder were excluded respondentdriven sampling was used as the sampling technique eleven seeds were selected data was collected to assess the correlates using an intervieweradministered questionnaire developed and validated by the investigators behavior related stigma scale which was developed and validated by the same investigators was used to assess the level of stigma data collection was done by four sociology graduates data analysis sample proportions and population proportions were analyzed using rds a version 70 package since they were almost similar the unweighted analysis was done to identify the correlates of behaviorrelated stigma among msm for the analysis of correlates of behaviorrelated stigma each correlate was analyzed using bivariate crosstabulations using spss version 220 the chisquare test was used to identify significant correlates the possible variables were dichotomized and unadjusted odds ratios were calculated multivariate analysis was used to identify the unconfounded correlates of behaviorrelated stigma by entering correlates with pvalue 02 into a logistic regression model ethical approval ethical clearance was obtained from the ethics review committee of the faculty of medicine university of kelaniya sri lanka and administrative clearance was obtained from the provincial and the regional directors of health services offices results the majority of the study participants were 30 years or older with a mean of 352 and sd of 123 nearly threequarters of the participants were sinhalese and 729 were buddhists socioeconomic demographic and special characteristics related to msm are shown in table 1 among them only advancing age was significantly associated with statistical significance factors such as ethnicity religion marital status monthly personal income residence or being a formal worker were not vol 4 iss 4 year 2023 mednext journal of medical and health sciences significantly associated with a high level of behaviorrelated stigma among msm while having an educational level up to grade 10 was statistically significant engagement in other work in the last six months was significantly associated with a high level of behaviorrelated stigma the majority of those who were forced into a heteronormative marriage had a high level of behaviorrelated stigma and they were significantly associated the belief of family members that homosexuality is a mental disorder being harassed by society in their lifetime verbal harassment from the police and being arrested by police during lifetime were statistically significant associations the proportion of msm participants who had been having samesex relationships within the past 10 years and had a high level of behaviorrelated stigma was 741 with a statistically significant association of p 004 having anal sex with a male partner and a high level of behaviorrelated stigma was associated with statistical significance similarly 615 of the participants who had oral sex with a male partner had a high level of behaviorrelated stigma with a statistical significance of p 0001 however having more than one male partner was not statistically significant with a high level of behaviorrelated stigma there was a statistically significant difference between having vaginal sex with a female partner and a high level of behaviorrelated stigma having oral sex with a female partner was also statistically significant with a high level of behaviorrelated stigma there was no significant association between receiving benefits for sex as money goods or drugs not using condoms with a casual partner always when having sex during the past three months and unaffordability as a reason for not carrying condoms were significantly associated with behaviorrelated stigma among msm participants almost twothirds of the participants who stated that they didnt carry condoms due to unaffordability had a high level of behaviorrelated stigma among the different groups of people to whom the key behavior is revealed there was a statistically significant association between revealing to healthcare workers at both std clinic settings and non vol 4 iss 4 year 2023 mednext journal of medical and health sciences std clinic settings among the participants who had ever heard of hivaids the majority of them had high levels of behaviorrelated stigma nevertheless the association between the status of ever heard of hvaids was not statistically significant the association of getting knowledge regarding hivaids from health services was significantly associated with a high level of behaviorrelated stigma among msm there was no statistically significant difference between the usage of counseling services and is useful to solve problems related to samesex behavior ever use of alcohol and using alcohol once a week or more use of illicit psychoactive substances ever using illicit psychoactive substances orally through inhalation were significantly associated with a high level of behavior related stigma among msm there was no statistical association between not being aware of laws regarding homosexuality and a high level of behaviorrelated stigma among msm all the participants who were aware of laws affecting msm thought that they were being discriminated against by those laws among the variables considered in the lr analysis 13 factors were independently significantly associated with a high level of behaviorrelated stigma among msm after controlling for confounders as shown in table 2 they were age more than 29 years being educated up to grade 10 engagement in a mode of income other than the main occupation family and friends considering having sex as a mental illness experience of sexual abuse in childhood nonverbal harassment by relatives being arrested by police in lifetime having oral sex with a male partner not using condoms because didnt receive them from anybody gaining knowledge regarding hivaids from health sector and media consuming alcohol once a week or more during the past one month and inhalation of psycho active substances discussion there were several significant factors associated with behaviorrelated stigma among msm identified in the study most of them were modifiable among the sociodemographic characteristics studied msm who were educated up to grade 10 have been identified as being associated with a high risk of having behaviorrelated stigma which is consistent with the finding of a study conducted in south africa 17 although the advancing age of msm was independently associated with a high level of behaviorrelated stigma among msm in the current study a similar study conducted among vietnamese homosexuals in 2011 has not identified age as a significant correlate in multivariate analysis with significance values more than 005 18 further the vietnamese study has identified that msm who had ever been married were more likely to have a high level of selfstigma whereas the current study did not identify current marital status as a predictor variable for behavior related stigma among msm the possible reasons for the abovementioned difference could be that the current study measured behaviorrelated personal stigma which is a combination of self and perceived stigma whereas the compared study has measured selfstigma only another possible reason could be the social and cultural differences in the two study settings homosexuality is considered a crime in vietnam although men having sex with men is criminalized by section 365a of the penal code 19 the conversation regarding repealing these laws is being carried out in sri lanka using alcohol once a week or more frequently and inhalation of psychoactive drugs other than alcohol have been significantly associated with high levels of behaviorrelated stigma in this study even though the use of alcohol and drugs has been assessed by ha et al in vietnam they have not shown a significant association 18 men having sex with men is considered a mental illness by family friends having experienced sexual abuse in childhood were more likely to have a high level of behaviourrelated stigma among msm which was consistent with the findings of a chinese study 20 no studies have been conducted to assess the association between revealing the same sex behavior to either a family member close friend hcw at an std clinic setting or hcw at a nonstd clinic setting and a high level of behaviorrelated stigma among msm therefore the results of the current study could not be compared among the msm participants those who have gained knowledge of hiv either from the health sector or from media were less likely to have a high level of behaviorrelated stigma compared to those who did not gain knowledge on hiv from the sources mentioned above although ha et al have assessed the association between knowledge of hiv and stigma among msm in hanoi vietnam the source of knowledge has not been assessed however the most probable reason for the above finding of the current study could be that gaining knowledge regarding hivaids through the health sector is considered as the most reliable source for gaining knowledge regarding hivaids in sri lankan settings in the meantime gaining knowledge regarding hivaids through media increases awareness not only among the msm but also among the general public as well receiving counseling services to discuss problems related to samesex behavior among men was not significantly associated with behaviorrelated stigma similarly there were no previous studies that provided evidence for such association at both international and local level although there are punitive laws that criminalize samesex behavior among men awareness and perception regarding these laws were not significantly associated with behaviorrelated stigma among msm in this study no studies have been published with evidence regarding above mentioned expected correlation as well strengths and limitations of the study since a detailed study to explore the correlates of stigma among msm has not been conducted in sri lanka the findings of the study will be useful in planning programs to minimize stigma among msm and improve their access to health care this will eventually help to reduce the burden of hiv infection in the community the value of a crosssectional study design is limited whenever there is a possibility that the dependent variable may change with the participants risk behavior therefore the absence of information on temporal relationships may render it difficult to separate the predictor variables from their outcomes 21 conclusions consideration of same sexual activities among men as a psychiatric illness by friends and family experience of sexual abuse in childhood and nonverbal harassment by relatives being arrested by police during a lifetime not carrying condoms because they were not received from anybody consumption of alcohol once a week or more frequently and inhalation of psychoactive substances were significantly associated with behavior related stigma among msm gaining knowledge regarding hivaids from the health sector and media was negatively associated with a high level of behaviorrelated stigma among msm proper awareness and sensitization of the public regarding male homosexuality and appropriate education regarding hivaids through the health sector and media is of prime importance to minimize stigma among msm public health implications of the study stigma due to homophobia in society reduces access to services by men who have sex with men therefore proper awareness of the public regarding nondiscriminatory interaction with the msm is of prime importance it should be emphasized that samesex behavior is not identified as a psychiatric condition by mental health professionals further ageappropriate education sensitization on hivaids and their relationship to unprotected anal intercourse are essential to minimize stigma among msm std data sharing statement no additional data are available ethical approval ethics clearance was granted by the ethics review committee of faculty of medicine university of kelaniya sri lanka informed written consent was obtained from each patient prior to data collection informed consent not applicable

introduction men who have sex with men msm are one of the key population groups who have a high risk of transmitting and acquiring hiv they are being stigmatized due to their behavior therefore it is of prime importance to identify those correlates of stigma among msm to take measures to minimize them objective to determine the correlates of behaviorrelated stigma among msm in western province sri lanka methods a crosssectional study with an analytical component was conducted among msm in the western province of sri lanka the sample size was 564 participants were recruited using respondentdriven sampling data collection was done using two intervieweradministered questionnaires the behavior related stigma scale a tool developed and validated by the investigators was used to assess the level of stigma and a separate questionnaire to assess the correlates of stigma which was also developed by the investigators correlates of behaviorrelated stigma among msm were determined by multivariate analysis using an adjusted odds ratio results advancing age 29 years p 001 being educated up to grade 10 p 0039 family and friends considering homosexuality as a psychiatric disease p 0018 the experience of sexual abuse in childhood p 0001 the experience of nonverbal harassment from relatives p 0001 being arrested by police during lifetime p 0001 not carrying condoms as they were not supplied p0007 were positively associated statistical significance with a high level of behavior related stigma among msm being educated regarding hivaids from the health sector and media were negatively associated conclusions there are modifiable factors associated with behaviorrelated stigma among msm awareness programs should be conducted for the public to sensitize them regarding samesex behavior thus minimizing harassment from society

introduction smoking with an average of 7 million deaths per year is currently the leading cause of preventable death in the world 1 and causes a significant burden of oral and other cancers 2 literature pertaining to smoking cessation has shown that around two thirds of cigarette smokers are interested in quitting with more than 50 reporting making a quit attempt in the past year 3 however fewer than one third of smokers who tried to quit used proven cessation methods with only one in 10 smokers being able to quit successfully 3 a uk based study showed that one third of quitting attempts were not preplanned and around half of those were made without the use of any support and thus were less likely to be successful 4 documented and validated supportbased methods and thus by extension a plan beforehand contribute towards the success of any quit attempt 4 to facilitate those with the intention to quit smoking it is imperative to identify factors motivating successful cessation in former smokers and use these to support others quit attempts 5 cessationaid interventions that are designed according to specific motivations to quit smoking are likely to increase chances of successful cessation 6 factors motivating smoking cessation range from internalindividual factors and external factors 7 the importance of internalindividual factors must not be undermined as they have been shown to affect the efficacy of smoking cessation programs 78 while there is extensive literature exploring factors motivating smoking cessation amongst populations in developed countries 9 such research is scarce from lowermiddleincome countries such as pakistan around 191 of pakistans adult population are tobacco users with the majority being smokers 10 and approximately 10 of deaths in pakistan annually are attributable to smoking 11 apart from devastating consequences on population health smoking also costs pakistan approximately rs 192 billion annually due to costs associated with smokingassociated cancers respiratory disease and cardiovascular disease 12 however according to the world health organization global adult tobacco survey a much lower percentage of smokers in pakistan make attempts to quit smoking as compared to other countries 1314 in addition the success rates of quit attempts are also lower for smokers in pakistan as compared to those reported by international literature 13 almost half of the smokers attempting to quit did so without assistance and were hence less likely to be successful with only 91 making use of pharmacotherapy and 147 of counseling 14 the huge gap between the number of smokers attempting to quit and those actually successful highlights the ineffectiveness or absence of adequate motivators of smoking cessation and interventions designed to motivate and support successful cessation attempts in pakistan 15 the gats survey also found that almost twothirds of smokers were individuals without any education and around 598 were not interested in quitting 14 this calls into question the benefit of mass media campaigns for smoking cessation particularly those using a textual medium in a country where the majority of smokers are illiterate 14 in addition since most smokers in pakistan belong from lower socioeconomic backgrounds 16 cessation aids such as pharmacotherapy and counseling may be out of the financial reach of many individuals lastly cultural and religious influences on smoking practices 17 may contribute to cessation patterns that differ from those seen in western countries although the 2014 gats survey 14 provides highly generalizable nationallevel data regarding the sociodemographic distribution of exsmokers and their use of cessation aids it did not explore factors driving cessation itself this gap in knowledge represents a niche that invites further research moreover though the gats survey reported that 297 of current smokers thought of quitting because of warning labels on cigarette packages 14 the impact of other public health interventions to promote cessation was largely unexplored thus this study aims to describe factors motivating successful smoking cessation attempts in pakistan so that these may be incorporated towards the development of smoking cessation interventions that are targeted to the population of the country in addition this study also aims to identify motivators and strategies that are associated with successful cessation on ones first attempt lastly our study also reports the perceived usefulness of public health interventions in motivating cessation and resisting relapse amongst exsmokers methods study setting and population this crosssectional survey was carried out in karachi pakistan after approval from the institutional review board at the aga khan university hospital the target population for this survey was adult former smokers who were defined as adult individuals who had smoked at least 100 cigarettes in their lifetime but who had successfully quit smoking at the time of survey 18 a quit attempt was defined as deliberately stopping smoking for 1 week while successful quitting was defined as having deliberately stopped smoking for 1 month 18 a quit attempt was categorized as unsuccessful if any smoking relapse took place after a quit attempt survey characteristics data was collected by means of a questionnaire that was available in both english and urdu the national language of pakistan in the absence of a prior questionnaire suitable for our population a comprehensive questionnaire was developed using elements from various sources 91920 in close association with faculty with expertise in tobacco cessation research at the section of pulmonary and critical care medicine at akuh and the university of york content validity was assessed by calculating a content validity index for relevance and clarity based on the ratings of three subject experts and a biostatistician a cvi for relevance of 092 and for clarity of 089 indicated good content validity for the tool the english questionnaire was then translated to urdu which is the national language of pakistan by an independent translator fluent in both languages and with experience in questionnaire translation to ensure face validity the english and urdu versions of the survey underwent pilot testing amongst 30 respondents and any ambiguous questions were subsequently modified as appropriate the final survey contained the following five sections demographics and job characteristics age sex marital status and monthly family income history of smoking and smoking cessation age at starting smoking duration of smoking number of quit attempts cigarettesday before cessation time since quitting age at cessation difficulty of cessation and perceived selfefficacy in quitting 9 strategies employed in smoking cessation mode of quitting used in successful attempt use of a cessation aid 9 strategies for selfdiscipline 20 strategies for selfdistraction from smoking and positive reinforcement strategies 20 factors motivating smoking cessation major reasons for quitting smoking sources of awareness regarding need to quit smoking 19 social factors motivating cessation factors related to selfimage 20 and existence of smokingrelated health problems 9 usefulness of public health interventions in aiding smoking cessation the helpfulness of public health interventions in motivating cessation and resisting relapse the survey was preceded by a consent form explaining the nature and scope of the survey in addition preliminary screening questions based on current smoking status ensured that current smokers or those who had quit for 1 month were not allowed to proceed with answering the survey sample size calculation since no published literature reports factors motivating smoking cessation in pakistan it was assumed that approximately 75 of former smokers will have quit for health purposes which will be the most common reason this figure is based on a study by gallus et al in 2013 that was conducted amongst 3075 former smokers in a european population 21 the sample size required for our study was calculated using openepi using a 95 confidence level the minimum required sample size was determined to be 288 adult former smokers sampling technique in order to achieve a representative sample for this study data collection was conducted on the premises of five tertiary care hospitals in karachi including akuh nonprobability convenience sampling was used to recruit participants for the survey data collectors approached patients attendants for participation in the survey individuals who had presented to the hospital for reasons pertaining to their own health were not considered for inclusion patients attendants are assumed to be representative of the general population after initially introducing the study and obtaining consent from the individual the data collectors screened potential participants according to the inclusion criteria and exclusion criteria if the individual were suitable for inclusion an informed consent was obtained a copy of the consent form was provided to the participant next the data collectors verbally administered the survey in english or urdu according to the participants preference ethical considerations to ensure privacy the interaction of administering the survey took place in the nearest quiet location on the hospital premises according to the participants comfort moreover to maintain anonymity the questionnaire did not record respondents names there were no risks immediate benefits or incentives for participation in the survey statistical analysis statistical analysis was performed using ibm spss version 23 continuous data was presented using mean and standard deviation median and compared using independent sample ttestsmann whitney tests as appropriate categorical data was presented using frequencies and percentages and compared using chisquared testsfischers exact tests content validity indices were calculated for clarity and relevance based on the ratings of three content experts and a biostatistician multivariable logistic regression age sex monthly family income years smoked cigarettesday before quitting and having suffered from a smokingrelated health problem was performed with number of quit attempts as the dependent variable a pvalue 005 was considered statistically significant for all analyses results a total of 330 former smokers were included with the majority male and aged between 18 and 30 years and 3145 year monthly family income was rs 25000 in 497 of respondents and rs 75 000 in 182 the mean age at which respondents at started smoking was 1805 years while the mean age at successful quitting was 3137 years around half of the respondents reported having successfully quit smoking in their first attempt while 179 reported 6 quit attempts most respondents reported smoking 10 cigarettes a day at the time they began their successful quit attempt the majority of respondents reported that they had abruptly stopped smoking however only 36 of respondents reported using a cessation aid during their successful quit attempt nicotine replacement therapy was the most common cessation aid used additionally 3 respondents reported using mint gums while only 2 reported using pharmacological cessation therapy and 1 reported having attended psychotherapy counselling sessions for smoking cessation respondents also reported avoiding social company that encouraged smoking as well as triggers that caused an urge to smoke the majority of respondents believed that they had quit smoking definitively although the majority felt that giving up smoking was very difficultdifficult respondents reported using a variety of ways to discipline or distract themselves when they felt the urge to smoke as well as various positive reinforcement strategies to aid cessation the most frequently reported reason for quitting smoking was to improve or protect ones own health which also served to justify our earlier estimate of 75 for sample size calculation other common reasons included promptings by ones family and to improveprotect the health of family members 388 of respondents reported suffering from a smokingrelated health problem common sources of awareness regarding the need to quit smoking included familyfriendscolleagues doctors and social mediaonline platforms certain social pressures to quit smoking such as peerpressure to quit smoking and social avoidance by nonsmokers were also reported respondents also reported having felt the need to give up smoking to be content with themselves and having felt upset whenever they felt the urge to smoke the various factors that encouraged smoking cessation are shown in table 3 the majority of respondents felt that antismoking public health interventions were not helpful at all consumer warnings on cigarette packs increased pricestaxes on cigarettes and smokefree public recreational places were most commonly reported to be helpful to a great extent in motivating cessation similarly increased pricestaxes on cigarettes and consumer warnings on cigarette packs were most frequently reported to be help to a great extent in resisting relapse on multivariable logistic regression discussion this study was conducted to explore factors associated with successful smoking cessation in former smokers in pakistan a lowermiddleincome country in south asia our study identified personal health promptings from ones family and ones familys health as the most important motivating factors social pressures to quit smoking included peerpressure to quit and social avoidance by nonsmokers lastly successful cessation on ones first quit attempt was associated with being married quitting cold turkey having a negative selfimage of oneself due to smoking and having strong willpower to quit the commonest reasons for quitting smoking were to improveprotect own health familys promptings to improveprotect the health of family members and to save money respondents reported receiving awareness regarding the need to quit smoking most commonly from their family friends and colleagues moreover social pressures such as peerpressure to quit smoking social avoidance by nonsmokers and nonsmokers asserting rights to smokeless public spaces were also major deterrents studies from the united states poland and france have demonstrated similar results with health concerns discouragement of smoking at home and the high cost of cigarettes being important deterrents 22 23 24 in addition social pressure such as having a smokefree social network that pressurizes towards cessation has also been found to be a strong motivator of cessation across different populations 23 24 25 it is interesting that promptings by doctors were reported as being a reason for quitting by only 13 of respondents and only one quarter of respondents received cessationrelated awareness from their doctors a study from the united kingdom revealed that most patients were skeptical about doctors smoking cessation advice which was often generic and of a preaching nature and suggested that doctors should practice a more personalized approach to cessation counseling 26 around half of the respondents in our study reported quitting successfully on their first attempt while the remaining reported needing 25 attempts and 6 attempts these findings are in great contrast with what is usually suggested by smoking cessation programs these vary from 8 to 14 attempts as suggested by the american cancer society the australian cancer council and the centers for disease control 27 28 29 however there is some literature that aligns with our findings as it has been suggested that though the number of quit attempts may be quite high on average between 40 and 52 may be successful on their first serious attempt 3031 on multivariable regression successful cessation on first attempt was associated with being married quitting cold turkey having a negative selfimage on oneself because of being a smoker telling oneself they have the willpower to resist the urge to smoke and quit definitively and consciously diverting ones thoughts to distract oneself from smoking while the concept of willpower has been debated for a long time for its actual contribution to smoking cessation 32 it has been demonstrated to be an important factor in pakistan previously 13 moreover personal willpower is an essential feature of the 5as model in treating tobacco use and dependence 33 of which the first three as build towards willingness to quit and the last two as facilitate those willing to quit to take the final decision to quit this concept of personal willpower being an important factor in singleattempt cessation is strengthened by how familys promptings as a major reason for cessation was negatively associated with singleattempt cessation in our study this suggests how personal motivation that arises from within the individual is more likely to lead to successful cessation than when it arises externally additionally quitting cold turkey has been recommended as more successful in smoking cessation as compared to gradually tapering off cigarette use 34 interestingly in our study use of a smoking cessation aid was negatively associated with quitting on the first attempt a finding corroborated by a survey by manis et al in switzerland 35 with regards to selfimage while having a negative selfimage due to ones addiction may cause distress to the smoker 36 it can also function as a powerful motivator to quit smoking as it negates the perceived benefits of smoking 37 lastly being with a spouse or partner who is a nonsmoker a former smoker or who encourages and motivates quitting is associated with a greater likelihood of success on cessation attempts 38 39 40 selfdistraction by consciously diverting ones thoughts to other matters trying to keep ones hands and fingers occupied and engaging in work were useful strategies reportedly used by respondents moreover consciously diverting ones thoughts to other matters was significantly associated with singleattempt cessation on multivariable regression these are encouraging findings as they are simple yet effective more technological methods of distraction such as mobile phone applications and games 4142 that have been piloted in the setting of developed countries may not be feasible for a resourceconstrained like pakistan in addition positive reinforcement strategies such as expecting rewards and receiving rewards from others for resisting the urge to smoke were also employed by respondents rewards and incentives often monetary are helpful in motivating smoking cessation especially when individualized 4344 lastly none of the public health interventions mentioned in our survey were perceived by respondents as particularly useful for helping smoking cessation or resisting relapse with less than 5 of respondents rating any intervention as helpful to a great extent this is in direct contrast with studies from developed countries such as the united states 4546 and may be explained by several reasons firstly interventions such as government or private sector mass media antismoking campaigns antismoking advertisements and health warnings precedingduring films may not effectively be effective amongst those of lower socioeconomic and less educated backgrounds secondly although pakistan subscribes to the mpower model of tobacco control outlined by the world health organization 47 it is possible that these interventions are not practically implemented in an optimal manner thirdly since our results highlight how former smokers predominantly attribute the success of their cessation to personal factors such as willpower selfdiscipline and distraction strategies they are perhaps unable or hesitant to acknowledge the potentially subconscious impact of external motivators nevertheless further studies are required to determine the efficacy of such largescale public health interventions in the setting of a lmic like pakistan in terms of both improving cessation and costeffectiveness despite the major burden of tobacco consumption in the country pakistan lacks any major smoking cessation programs or clinics facilitating rehabilitation which along with the low cost and easy availability of tobacco can prove the difficult task of quitting even more challenging 13 the results of our study provide a comprehensive and unique understanding of the factors that motivate smoking cessation in pakistan however despite the varied distribution of sociodemographic characteristics achieved by targeting five different settings for data collection the convenience sampling methodology used may limit the degree of generalizability of our findings to other populations in pakistan nevertheless our findings can help guide the development of evidencebased programs for smoking cessation in pakistan and lay the foundation for similar largerscale national research other potential limitations include the selfreported nature of our data as well as the possibility of social desirability bias future research must investigate motivators strategies and patterns specific to sex age socioeconomic status education level and other demographics conclusion major motivations for smoking cessation in a pakistani population include to protect the health of oneself or family members and due to promptings from family members selfdiscipline personal willpower distraction strategies and positive reinforcement play an important role in a population where smoking cessation aids may be inaccessible to many moreover peerpressure to quit and social exclusion also motivate smokers towards quitting as does the negative selfimage one associates with themselves because of their addiction to smoking lastly most public health interventions such as mass media campaigns and antitobacco advertisements were not perceived as being helpful for motivating cessation authors contributions rsm conceptualized and supervised the investigation along with devising the methodology and analyzing the data rsm was a major contributor in writing and editing the manuscript muj conceptualized the investigation along with devising the methodology and analyzing the data muj was a major contributor in writing and editing the manuscript msk supervised the investigation along with devising the methodology and analyzing the data msk was a major contributor in writing the manuscript na collected the data by verbally administering the survey na also contributed to analyzing the data and writing the manuscript zzf collected the data by verbally administering the survey zzf also contributed writing the manuscript mu collected the data by verbally administering the survey mu also contributed to analyzing the data fs collected the data by verbally administering the survey and supervised the investigation jak supervised the investigation and contributed to editing the manuscript the author read and approved the final manuscript competing interests none of the authors have any conflicts of interest to declare

introduction only onequarter of smokers in pakistan attempt to quit smoking and less than 3 are successful in the absence of any literature from the country this study aimed to explore factors motivating and strategies employed in successful smoking cessation attempts in pakistan a lowermiddleincome country methods a survey was carried out in karachi pakistan amongst adult ≥ 18 years former smokers individuals who had smoked ≥100 cigarettes in their lifetime but who had successfully quit smoking for 1 month at the time of survey multivariable logistic regression with number of quit attempts single vs multiple as the dependent variable was performed while adjusting for age sex monthly family income years smoked cigarettesday before quitting and having suffered from a smokingrelated health problem results out of 330 former smokers 503 quit successfully on their first attempt with 621 quitting cold turkey only 109 used a cessation aid most commonly nicotine replacement therapy 82 motivations for quitting included selfhealth 745 promptings by ones family 43 and familys health 148 other social pressures included peerpressure to quit smoking 312 and social avoidance by nonsmokers 227 successful smoking cessation on ones first attempt was associated with being married or 447 95 ci 232861 employing an abrupt cessation mode of quitting 412 248684 and telling oneself that one has the willpower to quit 168 104271 in pakistan smoking cessation is motivated by concern for selfhealth and familys health familys support and social pressures our results lay a comprehensive foundation for the development of smokingcessation interventions tailored to the population of the country

introduction datasets of largescale online behavior and digital traces are growing more sensitive as privacy expectations and regulations mature to address such concerns data providers are turning to differential privacy to balance largescale data releases with maintaining privacy guarantees for individuals whose data may be included in these releases differential privacy techniques operate by injecting noise into observations to prevent identification of individuals in these datasets for an introduction to these methods these protections come at a cost however as standard analyses may produce biased or erroneous results if they do not account for such protections this issue is particularly evident in the release of the facebook privacy protected full urls dataset referred to as the condor dataset where facebook and the ss1 consortium have released a massive collection of 635 million links shared on the facebook platform along with differentialprivacyprotected engagement data on age gender location and political preference condor is the largest dataset of linklevel engagement released to date and holds marked potential for studying largescale online behaviors but researchers lack guidance in and examples of methods that account for differential privacy protections this paper provides this guidance by 1 examining a simple weightedaverage metric for calculating ideological positions of audiences for web domains1 based on linksharing in facebook in the presence of differentialprivacy protections 2 showing how differential privacy impacts this metric 3 establishing bounds on how this metric should be used and 4 validating this metric against similar domainlevel sharingbased measures while similar metrics have been proposed those efforts rely on highly sensitive data such as internal facebook data or twitter profiles aligned with sensitive voterfile information in contrast this papers metric can be calculated solely from this differentially private public dataset after establishing constraints for our differentialprivacyresilient metric we use it to extract novel insights about individual hyperlinks where sparsity issues have forced previous approaches to use domainlevel measures we then assess how different types of engagementviews and likesimpact our measures for individual hyperlinks we estimate distributions of linklevel ideology measures for several thousand individual links across six popular domains including youtubecom providing insight into longstanding questions about partisan audiences on that platform for different types of engagement we measure differences in domains audience ideologies using linksharing viewing and liking behaviors also answering open questions about consistency in measurement across engagement types results show no significant deviation in domainlevel estimates across these activitiesthough a domains viewing audience is on average more moderate than its sharing or liking audiences given the commercial value of viewing data in online platforms this result is particularly encouraging for the generalizability of sharebased studies and for future efforts that leverage protected versions of this sensitive data this works core contributions are • a demonstration of how a simple metric for estimating ideology of a domains audience can be made robust to differential privacy protections • an examination of linklevel distributions of ideology across six major news sources and • new insight into how varied forms of engagement impact audience ideology estimates related work this paper engages with two main communities first a large body of research exists on inferring ideology of audiences in studies of media bias and polarization especially in online spaces which both motivates this work and provides sources for validation second much of the data that could be useful for similar studies is often restricted and sensitive recent work has explored methods for providing data protections of such sensitive data while still enabling inference on this data which directly informs our work before describing contributions to these communities we first provide an overview of differential privacy to situate this work a brief primer on differential privacy at its core differential privacy is an approach to collecting and disseminating aggregate statistics in a way that guarantees some level of privacy for individuals whose data is used to generate these statistics while wood et al provides an overview of differential privacy for nontechnical audiences such protections generally provide a form of plausible deniability for individuals whose data is included in these statistics this deniability comes from the property that a thirdparty cannot learn anything about a single individual whose data contributes to these statistics that could not be learned if that individuals data were excluded hence an individual could claim their data was never included in the released statistics at all allowing them to deny potential allegations derived from the data digital trace data can therefore benefit from applications of differential privacy as largescale aggregate datasets can be released in privacyprotected forms that reduce potential harm to the populations from which the data is collected d orazio honaker and king these protections are also consistent with calls for and regulations on enhanced protections of digital consumer data and groups like the us census bureau are using similar ways to protect sensitive data these protections are generally applied by adding noise into the computations of aggregate statistics researchers can tune characteristics of this noise to quantify potential privacy loss and by tracking this loss over subsequent dataset releases those creating these datasets can maintain privacy guarantees characteristics of this noise can be shared as part of the release process without risking these privacy guarantees so researchers can account for this noise without identifying individuals within the dataset in the context of the condor dataset facebook bounds privacy loss by adding noise to the aggregated engagement statistics prior to releasing the dataset to external researchers that is if a hyperlink has been shared x times in a given month facebook adds noise ϵ drawn from a gaussian distribution to this value and external researchers only ever see x ϵ measuring political ideology methods for estimating ideology partisan lean media slant or similar aspects of information sources are wellstudied and generally fall into one of two categories contentor homophilybased approaches contentbased approaches generally analyze language while homophilybased methods propagate individuals ideological preferences to the information sources these individuals share or consume contentbased analyses like the study of media slant in gentzkow and shapiro or media bias in budak goel and rao are powerful but require content analysis and either manual assessment or information about political preferences of people sharing that content to learn mappings of particular language to political preference in contrast while homophilybased methods need information about political preferences they do not require analysis of actual content and instead rely on interactions among nodes in a network through these interactions one can propagate political preferences to neighboring nodes making these methods particularly amenable to algorithmic assessment in online social networks such interactions are often computationally cheap to collect through apis or found data making these approaches popular in research homophilybased methods for inferring political ideology have been used to measure onlineoffline ideological segregation diversity in online news ideological biases in search engines and even political lean of disinformation agents despite the clear utility and popularity of such homophilybased approaches when these methods use social media data to measure ideology of a news sources or web domains audience as in robertson et al golovchenko et al eady et al and othersthey commonly rely on easily collectable sharing behavior while sharing behavior is easy to collect from sources like twitter and reddit prior research on social media spaces and online communities shows that the vast majority of users on the platform do not actively share or produce content benevenuto et al in particular suggests that 92 of all behavior in one social network was comprised of content viewing alone which does not produce collectable artifacts in many public apis data about these viewing behaviors however is commercially sensitive and most social media platforms do not make this data publicly available for studies of viewing behavior in facebook for example up to the release of ss1s condor dataset one has had to rely on researchers employed by facebook as in bakshy messing and adamic or partner with researchers at facebook this reliance on content production and sharing leads to a problematic implication a media sources ideological slant is significantly affected by the sources audience and as sharebased metrics omit activity from a significant portion of the viewing audience measures of the media sources audience may differ significantly from the true distribution gentzkow and shapiro a unique aspect of the condor dataset provided by ss1 however is that it provides engagement data across both sharing and viewing behaviors binned across several politicalpreference buckets hence the work in this paper can shed some needed light on the differences in estimates based on shares versus views that is by first comparing results from our sharebased audience ideology metric to existing work in this area we can validate our metric despite the privacyprotecting noise injected into condor observations then by comparing results from our sharebased estimator to estimators based on views and indeed other behavior such as facebooks like reaction which is similar to twitters favorite affordance we can evaluate whether differences in shareand viewbased estimates differ significantly inference and protected data while the above context on measures of media bias and audience ideology show a clear need for understanding the impacts of shareversusviewbased metrics as mentioned view data is both commercially sensitive and highly private facebook has endeavored to help researchers in this need by releasing the condor dataset and protecting it with differentially private noise as described in messing et al while works such as d orazio honaker and king and evans and king outline how differential privacy can support inference in social sciences how these protections impact on researcher utility remains an open question evans and king even shows ignoring differential privacy can lead to unpredictable biases in results including biasing estimated effects towards zero or in some particularly problematic cases inverting the sign of the estimates despite these risks evans and king shows corrections are feasible in certain scenarios as the noise added to data for establishing differential privacy guarantees is equivalent to increasing standard measurement error and for linear systems one can correct for noise if details of the noisegenerating distribution are known for nonlinear systems like the weightedaverage metric we present however analytically based corrections are not readily available we instead build on evans and king which outlines the context in which bias in a ratio metric can be bounded evans and king claims that if the noise introduced is generally much smaller than true observations bias in the noisy metric is minimal while this result is valuable no guidance is provided regarding how large observations should be relative to noise nor how to evaluate whether one is in this regime hence this paper provides this muchneeded guidance for using these noisy observations in the condor dataset to study media and ideology in a robust manner we further validate these methods against extant results where such privacy protections are not in place condor the facebook privacy protected full urls dataset as a brief overview the privacy protected full urls dataset provided to academic researchers by facebook and the ss1 consortium is a largescale collection of urls and associated engagement data for 63574836 hyperlinks shared on the facebook platform this dataset exists to provide researchers new insight into how individuals engage with hyperlinks on the facebook platform while simultaneously maintaining strong privacy guarantees for facebook users for a url to be included in this dataset it must have been publicly shared by approximately 100 unique individuals for more details as of this writing the dataset is on its ninth iteration and contains monthly engagement metrics for all months between 1 january 2017 and 31 december 2021 for each of these urls the dataset contains counts for 11 actions one can take on the facebook platform broken down by month and audience demographics these demographics cover an individuals country age and gender from one of 45 countries seven age groups and three gender groups in the us condor further decomposes these counts across six bins representing individuallevel political preference using a political page affinity metric a homophilybased measure defined by barberá et al and described in messing et al ppa measures an individuals political ideology on a scale b ∈ 2 1 0 1 2 with an additional bin for individuals whose ppa is unknownwe exclude this sixth group from our analyses in this manner the condor dataset contains makes available highly sensitive but valuable engagement data for large volumes of online information sharing and consumption behavior given the sensitivity of this data and to protect users of the facebook platform from potential deidentification researchers using the condor dataset do not have direct access to the raw monthly counts of these activities instead researchers can only observe counts of these activities after facebook has added zerocentered gaussian noise to them in accordance with zeroconcentrated differential privacy by controlling the amount of noise relative to the amount of engagement across these demographic bins condor provides privacy guarantees about the probability of an individual persons single action being attributed to that person that is more noise can be injected into counts of views compared to counts of shares or clicks while noise added across a single action comes from the same normal distribution table 1 summary of notation in audiencelevel ideology estimates x denotes estimates of x using differentially private data for this work we focus on urls shared primarily in the us all access to this data is allowed through the ss1 approval process and is conducted on the facebook open research and transparency platform a robust metric for audience ideology we now turn to a metric for estimating the ideology of a domains audience from this dataset prior work on media slant has shown audiences political preferences have a marked relationship with the message topic selection and framing of news sources in this context bakshy messing and adamic propose a homophilybased metric of the degree to which a news article is aligned with a partisan audience by averaging the ideological affiliation of each user who shared the article in the differentialprivacyprotected condor dataset we can replicate this metric at the web domain level by measuring the average political ideology of the individuals who share content from this domain table 1 summarizes the notation we use in defining our version of this metric while condor includes engagement metrics we focus on sharing for consistent comparison with other work on ideology estimation as condor provides engagement data for each ppa bin we can interpret these counts as the frequencies for which an individual who is very liberal liberal etc has engaged with this content to estimate a domains audience ideology ζ d from this ppa metric we calculate the weighted average across these five ppa bins omitting the sixth ppa bin that contains audience engagement with unknown ideological affinity eq 1 shows this metric as the product of each ppa value with the count of individuals who have shared that domain and have that ppa value in eq 1 s b represents the number of individuals with the ppa value b who have shared the domain d in condor however engagement frequencies are at the urlhyperlink ℓ level not the domain level so we must first aggregate s b over all links ℓ in domain d as shown in eq 2 ζ d 1 b s b b∈ 22 b • s b s b ℓ∈d s b in the absence of differentially private data protections eq 1 is fundamentally the same metric as in bakshy messing and adamic and is similar to robertson et al with the introduction of zerocentered gaussian noise however these metrics are illbehaved and can result in discontinuities as we explain below how noise impacts this metric analytically while the metric ζ d in eq 1 is a straightforward calculation differential privacy protections preclude observing the actual number of shares for a given ppa value directly instead we observe a noised version of this value shown in eq 3 where ϵ sb is drawn from a zerocentered gaussian distribution with standard deviation σ this σ is constant for a single action and reported in the condor codebook hence when calculating the number of individuals in ppa bin b who have shared a domain d we can only construct a noisy estimate of this quantity s b substituting this value into eq 1 yields a noisy estimate of domainlevel ideology ζ d as shown in eq 7 s b s b ϵ sb s b ℓ∈d s b ℓ∈d ϵ sb s b ϵ sb ζ d 1 b s b b∈ 22 b • s b critically the ratio in eq 7 is illbehaved when the magnitudes of actual shares s b and the noise ϵ sb are similar in such cases because the gaussian noise is zerocentered and can be negative the denominator can approach zero which inflates the metric this scenario can also lead to pathological cases in which denominator is exactly zero resulting in discontinuities in the ideology estimate given the number of urls in the dataset these rare cases occur sufficiently often as to be problematic analytically eq 7 can be viewed as a ratio of gaussian distributions but these pathological cases results in this ratio having a cauchy distribution which has an undefined expected value it is consequently difficult to isolate and correct for bias introduced by differentially private noise analytically fortunately other work has examined this bias and we rely on hayya armstrong and gressis evans et al and evans and king for their discussion of weighted averages in the face of noise in particular if counts are normally distributed we could treat this instance as a ratio of correlated noncentral normal distributions and use the result from hayya armstrong and gressis to find the expected value of this ratio in that case as long as mean of the denominators distribution is sufficiently large compared to the mean of numerator bias in this expectation goes to zero while we cannot assume normally distributed counts in this dataset for a discussion of lognormal distributions in social media engagement data accounting for bias when the denominator is sufficiently large is supported by evans and king evans and king relies on taylor approximation to expand a ratio of noised observations leading to an upper bound on potential bias in this estimate shown in eq 8 following from eq 2 of evans and king where we replace k with the number of ppa bins specifically as long as the number of shares s b is sufficiently greater than the variance of the noise added eq 8 goes to zero restated as long as s b σ s or equivalently s b σ s 1 bias in this metric should be negligible borrowing from signal processing we refer to this ratio of engagement to noise as the signaltonoise ratio defined in 9 bias 4 • σ 2 2 sn r 2 σ 2 impacts of noise via simulation as we show above for a sufficiently high snr bias in our metric is negligible but that analysis does not tell us what a sufficientsnr regime might be we thus turn to simulation to evaluate potential bias in the environment specific to the condor dataset and construct two experiments first we evaluate whether the environment observed for popular domains in the condor dataset are sufficient for our metric to be unbiased second we examine the relationship between snr and bias to get a sense for what levels of snr and observed sharing are necessary to produce tight estimates of political ideology estimating bias for popular domains in the first simulation experiment we test the hypothesis that ζ d ζ d 0 or whether the noise in condor drives a significant difference in our estimates of ideology we perform this analysis after observing engagement data for the top 1 most shared domains in the condor dataset which we select under the expectation that these popular domains achieve the necessary sharetonoise ratio in the alternative case ie that these domains do not have sufficient shares to be in the highsnr regime the noise added to this dataset may overwhelm any useful signal at a high level each run in the simulation starts by drawing ideology scores ζ d for a given number of domain observations n obs for each domain we sample a count of the links to this domain u d from a lognormal distribution and sample linklevel ideology estimates for each link ζ ℓ according to a normal distribution centered at ζ d for this domain we then sample the number of shares for each link s in this domain also from a lognormal distribution and distribute these shares across the five ppa bins according to ζ ℓ this process yields a collection of domains with associated links and shares across ppa bins for each link mirroring the facebook collection prior to noise injection to simulate the noisegenerate process we add noise to each links simulated shares s b using the exact process outlined in the condor codebook we aggregate these linklevel shares up to the domain level and estimate ideology ζ d from these noisy observations comparing this estimate from noisy sharing counts to the actual ideology yields an estimate of the bias added by the differentially private noise parameters for this simulation come from qualitative assessment of the condor dataset and are shown in table 2 we then run the simulation with n sim 100 iterations sampling n obs 100 domains per iteration and calculate the mean bias ζ d ζ d and montecarlo standard error for each iteration simulation results produce an estimated bias of 4006 × 10 5 with a montecarlo standard error of 54940 × 10 5 variance across simulation iterations is also small at 30485 × 10 7 these results shows the proposed estimators bias is neither statistically significant nor is this difference practically significant on the 2 2 scale of ppa a note on aggregation one may be tempted to first estimate ideology by calculating ζ ℓ at the link level and taking the mean across all links in domain d to calculate ζ d which is more consistent with the metric provided in bakshy messing and adamic this approach produces a much higher mc standard error in this case however as the sharing signal in a given link is generally much lower compared to the additive noise than in the aggregate we provide guidance on when such linklevel estimates are reasonable in a later section relationships between snr and bias in the second simulation experiment we examine the relationship between snr and variance in our ideology estimator this experiment fixes the number of links a domain has and varies the number of shares necessary to achieve a target snr defined in eq 9 we run this experiment with two fixed values for the number of links in a domain first setting u d 1024 to evaluate snr for domainlevel aggregates and then setting u d 1 for cases where researchers want to study a single link varying snr on the interval 11024 shows that an sn r ≥ 16 results in tight estimates on ideology regardless of whether we aggregate over many or few links these metrics derive from n sim 500 runs of n obs 100 000 domains with uniformly distributed ideologies for each snr parameter description ζd audiencelevel ideology of a domain d drawn from a threecomponent gaussian mixture model ζ ℓ the mean political page affinity for a given link ℓ ∈ d drawn from n with σ 05 to provide separation between bins ud the number of hyperlinks to domain d for which we have sharing data drawn from a lognormal distribution ln as estimated from the condor dataset s the number of shares for link ℓ drawn from a lognormal distribution ln as observed within the condor dataset s b the number of shares in political page affinity bin b for link ℓ which we allocate from s by drawing 100 samples from n and scaling up σ 075 is chosen so most mass is ±15 from the mean ϵ b noise added in to sharing in political page affinity bin b for domain d drawn from n a remaining question concerns the level of observed sharing needed for tight estimates to this end we have explored the maximal number of observed sharing averaged over several linksharing counts and privacyprotecting noise levels necessary for tight bounds this exploration suggests the relationship between sufficient observed sharing and aggregate noise is linear in loglog space for a fixed snr using this framework we then estimate the relationship between this noise and a target observed sharing volume needed for tight estimates at sn r 16 this model is shown in eq 10 where 16 is the snr 5 3 and 7 are number of ppa bins gender bins and age bins respectively m is the number of months the aggregation covers u d is the number of links over which one is aggregating and σ dp is the noise added for differential privacy this equation for s or the amount of observed sharing allows us to set a lower bound on the volume of observed sharing necessary for stable estimates this model also allows us to vary injected noise σ dp meaning we can estimate the minimum quantity of engagement one should observe for other types of activity in condor as well s ≳ 1578 • audience ideology for popular domains we now use this metric and bounds on sharing to examine the distribution of audience ideologies among facebooks top 1 most popular us domains among politically engaged facebook users this analysis covers 2629 domains out of a possible 2644 as 15 domains were excluded for having insufficient activity to achieve the target snr relative to the number of links u d these excluded domains include soundcloudcom and reverbnationcom which both have high numbers of unique links in condor leading to high differences between observed and needed sharing making their estimates suspect figure 1 presents distributions of our estimated domainlevel ideologies with a selection of domain annotations divided into news and nonnews domains for news domains we select domains that have ratings from the newsguard 2 trust rating service and exist in our top1 set resulting in 1279 newsoriented domains this collection shows a trimodal distribution with traditionally liberal news sources on the left conservative news on the right and more centrist reporting such as cspan around the center for nonnews sites we see many centrally oriented domains are primarily shopping social networking crowdfunding and sports sites whereas nonnews domains in the ideological extremes are primarily activist organizations as our metric captures ideological leans of a domains audience in the context of news sources gentzkow and shapiro suggests this measure should be highly correlated with the slant of these sources for national news like the new york times breitbart etc these sources are consistent with traditionally accepted partisan placement at the local level we find localaffiliate news stations are aligned with more ideologically moderate audiences with kqed in berkeley ca having the most liberal and partisan audience of the local affiliates the national media outlets on the other hand are more wellseparated this alignment among local affiliates is consistent with the literature as berkeley ca leaned heavily liberal in the 2016 presidential election and lafayette la leaned heavily conservative the data also suggests as seen in other work a wider gap between the moderate and conservative components compared to the moderate and liberal components suggesting the conservative media sites are more insulated from mainstream media comparisons to other ideology measures to validate the audience ideology metric calculated from differentially private sharing data we compare our results which uses ratios of shares from registered republicans and democrats twitter accounts we find a significant pearsons correlation ρ 09295 here for 1675 domains our second comparison is with a homophilybased measure introduced by eady et al where we achieve a strong correlation ρ 09386 across 154 domains our third comparison is with the similarly defined ideology scores introduced in bakshy messing and adamic where we find the highest correlation for 112 domains lastly we compare against a contentbased media slant estimate for 16 newspapers analyzed in budak goel and rao where we find our lowest but still strong correlation despite the complexity introduced by differential privacy protections in condor our estimates are strongly correlated across all four of these comparison beyond the most popular domains above we focus on the top 1 of domains as these domains are more likely to exceed the threshold established in eq 10 and because these domains are wellcaptured in other works on audience ideology our method is not restricted to only popular domains however as domains that are shared less often may still have sufficient signal to exceed our threshold eg using eq 10 if we observe a domain with a single link and use only one month of data that domain need only have about 906 observed shares to provide stable estimates as the most recent iteration of the condor dataset contains 363738 domains over five years one may then ask how many of these similarly exceed the thresholds we establish for this stability this quantity is also important for the creators of the condor dataset as it can shed light on the tradeoff between differential privacy protections and data utility in downstream analysis to answer this question we randomly sample 1024 domains from the condor dataset and measure the proportion that exceed the threshold of observed shares in eq 10 for all domains we use the same σ 2 dp 14 value and set m and u d to the number of months for which the domain has data in condor and the number of unique hyperlinks to that domain respectively of these 1024 domains 43 exceed this threshold accounting for the top 42 of the domains in this set in comparison over 994 of the top1 of domains exceed this threshold while this proportion is low that still leaves in excess of 15 thousand domains that will produce stable ideology estimates using the method described above this result also has an important implication for the condor datasets construction more generally while we note a couple of ways one might increase this proportion through relaxing constraints or focusing on linklevel estimates it is also true that the application of differentially private noise to the condor dataset is done with limited insight into the downstream impact this noise has on analyses hence this finding motivates a call to facebook to revisit its privacy budget and investigate the balance between adding noise and reducing utility of this large dataset linklevel audience ideology estimates in the preceding section we have focused on demonstrating the validity of the audienceideology metric by showing the bounds in snr for which ideology estimates are tight and comparing our domainlevel metrics to several extant nondifferentialprivacyprotected datasets this metric is not specific to domainlevel metrics however and is equally amenable to estimating audience ideology at the individual link level as in bakshy messing and adamic this linklevel analysis is a major advantage of the condor dataset as the scale at which it provides these engagement metrics alleviates sparsity issues which are a major barrier to linklevel analyses in other sources that is the condor dataset provides a much larger volume of linklevel data than academic researchers are generally able to access allowing for novel insights into ideological distribu tions across individual links rather than domainlevel aggregates that said noise added to engagement metrics for individual links may be relatively high compared to domainlevel aggregates as many individual links likely do not receive sufficient engagement alone to support ideology estimates using our proposed metric to illustrate this point we estimate audience ideologies for individual links to six popular domains across the ideological spectrum of these domains five are news sources which we order from left to rightliberal to conservative huff post the new york times cspan fox news and breitbart traditionally huff post and the new york times are considered leftleaning sources whereas fox news and breitbart are rightand farright sources in contrast cspan is a nonprofit nonpartisan source that primarily covers the us house of representatives we also include youtube as our sixth domain given its substantial role in the online news ecosystem for each of these domains we calculate audience estimates using the ninth iteration of the condor dataset covering 20172021 and show linklevel distributions for all links in each domain and only for those links with sufficient engagement as estimated by eq 10 ie s 7 014 tables 3a and3b show summaries of these figures as well distributions of audience ideology when we use all links from each domain consistently show extreme variation with youtube showing the widest range from 57600 to 5167 in contrast focusing only on links with with snr 16 yield more stable averages and more informative distributions interestingly links to youtube videos appear symmetrically distributed in their audience ideologies and cspan shows wider variation the remaining four domains traditionally considered partisanleaning exhibit the expected partisan distributions with the majority of links falling on one side of the ideological spectrum some links from these domains do cross the ideological divide though eg 1169 of the links in figure 3b from the new york times have an audience ideology measure ζ ℓ 0 one article in particular i wanted to be a good mom so i got a gun was shared by a solidly rightleaning audience table 3 summary statistics for linklevel audience ideology for six major domains consistent with figure 3 ideology measures using all links exhibits high variance potentially masking useful structure which emerges when we constrain links to those that are sufficiently popular comparing shares likes and views prior sections use sharing as the primary mode of engagement so we can compare against similar methods on facebook and twitter concerns with these measures include 1 sharing as a proxy for viewership and 2 counterattitudinal sharing wherein an individual shares a particular article to criticize it often exposure to information is more important than who is sharing information but sharing activity is more readily available so it is used in place of exposure similarly while prior work shows criticism is one of the primary motivations to share content in political discourse counterattitudinal sharing is relatively rare so it is generally ignored the condor dataset is not limited to sharing though as it contains mea2015whataboutdisney sures of likes views and other activity though the added noise varies for these actions we can therefore compare whether the population sharing a particular domain is significantly different from the population who likes or views this content potentially mitigating concerns around sharebased measures we thus compute audience ideology metrics for 2227 domains across three engagement typessharing viewing and likingand compare them in figure 4 this figure demonstrates limited statistically significant differences in ideological distributions exist among share view and likebased measures supported by a oneway anova test 1899 p 01498 that is in comparing the distributions of inferred domainlevel ideology metrics using the three activity types we see no significant differences in these audienceideology values correlation among all three metrics is also very strong suggesting differences based on engagement are less impactful than the crossmethod analysis shown in figure 2 hence despite potential concerns around sharebased measures as proxies for exposure and counterattitudinal sharing the ideological alignment of audiences sharing viewing and liking these domains are statistically indistinguishable separate from these concerns one may expect differences in the extremes of these ideology distributions as political sharing on facebook is relatively rare we therefore test an alternative measure by taking the absolute value of the ideology metric ζ d to measure potential partisanship rather than liberalconservative ideology comparing this partisanship metric based on shares views and likes shows a more significant difference among these three distributions 1795 p 0001 a posthoc tukey test shows a moderating effect in viewership in that a domains viewing audience appears significantly more moderate than its sharing and liking audiences a note on views we note that the interpretation of views in condor does not directly capture the volume of individuals who have visited and viewed a given url outside of the facebook platform instead the condor codebook defines views as the number of users who viewed a post containing the url that is an individual may view a link outside the facebook platform and this view would not be captured in condors view count conversely an individual may view a post in facebook containing a specific link without visiting the link and this interaction would be captured in condors view countactually visiting the link is captured by the click count while this interpretation omits offplatform engagement condors operationalization of views still captures important networkdriven exposure aspects that other work largely is forced to omit given the commercial sensitivity of this measure hence the result above should be interpreted as the audience exposed to a particular domain within facebook is significantly more moderate the audience that shares and likes that domain threats to validity though the condor dataset is a milestone in the availability and transparency of social media data concerns remain around how such data is collected and protected first the process by which the condor dataset is constructed is opaque to researchers in that parties outside of facebook are not allowed to inspect the code used to select urls or calculate the metrics like ppa as a result researchers are forced to trust that facebooks url selection process is correct likewise researchers are given limited insight into how much data is omitted from the condor dataset because the links do not meet the 100uniqueuser threshold on public shares while internal facebook developers have made some data available about this thresholds relation to the distribution of onplatform links external review of the data preand postapplication of the privacyprotecting noise remains unavailable this latter issue is of particular concern as in the fall of 2021 external researchers identified a flaw in the condor dataset that significantly undercounted engagement in the us this flaw led to condors omission of engagement from us users whose political preferences could not be identified that is while other demographic bins could be null to capture shares from say individuals with an unknown gender no data existed in the dataset for the many users who did not follow sufficient political pages to have an identifiable ppa value though this paper was unaffected by this error and facebook has since corrected this issue the lack of transparency around condors creation and population remains a problem second while the privacy protections applied to the condor dataset serve a crucial purpose how these protections impact research methods remains an open question our proposed metric requires a sufficient level of activity to overcome additive noise which means many important but rare phenomena may be masked consequently domains and links shared among extreme partisan audiences may be included in the dataset but have insufficient signal for useful analyses more worryingly this masking could be asymmetric and result in ideological bias in what links are included to examine this possibility we have examined 500 domainlevel ideology scores from bakshy messing and adamic and assess the overlap between that work and our set using a logistic regression model to assess whether a domains audience ideology scores predict its inclusion in our dataset we find no statistically significant relationship between the two factors for less popular phenomena however this question of bias remains open but a fundamental tension exists between these rare instances and the differential privacy protections as these protections add more noise to these rare instances to prevent identification how these two factors interact needs to be a subject of future work third we stress our ideology metrics measure the audience of a domainlink not the actual content of the domain or link itself while much of the related work in this area makes similar assessments robertson et al it is important to note that content in some of these sites may not be overtly partisan but are more attractive or known to partisan audiences as noted in gentzkow and shapiro the ideological slant of a media outlets audience does affect choices of what that outlet covers and how it does so but this distinction between content and audience is important for interpreting this work ethics and competing interests this works intent is to provide a broader audience with an example for working with social media and digital trace data that has been protected with differential privacy techniques though this work is focused on audience ideology the methods are equally applicable to aggregations across other demographic bins or activities similarly our focus on ideology results in a usoriented analysis as the condor dataset only provides ideologyrelevant ppa assessments for us users while a clear limitation of this work it does hint at the need for broader perspectives on how such leftright scales can be generalized to other national contexts as discussed in lo proksch and gschwend ultimately though teams internal to facebook would have to extend the condor dataset to include pageaffinity scores for nonus audiences regarding ethics in research this work and the condor dataset more generally has some considerations worth noting condors privacy protections provide value in preventing identification of individual users actions on the platform but at the cost of obfuscating rare phenomena vulnerable and minority groups who might be overrepresented in these rare instances are potentially disproportionately impacted by these protections as researchers balance preserving privacy with studying how behaviors on the platform may impact these groups more work is needed to assess how platforms like facebook interact with these populations and how we might study these interactions while still providing a reasonable level of protection for these users while we claim no conflicts of interest for transparency we note that one of the authors of this work has received funding from facebook related to the social science one initiative this funding was not for this work and while facebook has had the opportunity to review this work prior to publication as part of the social science one agreement they do not have authority to prevent publication finally this work was reviewed by university internal review boards as a prerequisite for gaining access to the condor dataset conclusions through the above assessments of our proposed audienceideology measure based on a simple weighted average of online behavior across ideologically grouped audiences this paper presents three core contributions first this measure and its assessment provide guidance for researchers seeking to use differential privacyprotected digital trace data in analyses of online political behaviors which we make more compelling by demonstrating agreement with other published measures that do not have these protections second we extend this work on domainlevel analyses to demonstrate how our proposed metric can provide insights at the individual link level which is often made difficult by concerns of sparsity in other datasets third we contribute to studies of media slant and online political engagement by extending this analysis to other online types of online activity beyond just sharing ie views and likes as condor is the largest dataset of its kind and the primary mode of access to facebook data for researchers unaffiliated with facebook the endogenous metric for audience ideology we providealong with the related insights for ss1 researchers looking to leverage this unique dataset may accelerate research in this space data availability access to the social science one dataset used in this analysis is governed by the research data agreement made available as a joint effort between facebook and the social science one consortium

this paper demonstrates the use of differentially private hyperlinklevel engagement data for measuring ideologies of audiences for web domains individual links or aggregations thereof we examine a simple metric for measuring this ideological position and assess the conditions under which the metric is robust to injected privacypreserving noise this assessment provides insight into and constraints on the level of activity one should observe when applying this metric to privacyprotected data grounding this work is a massive dataset of social media engagement activity provided by facebook and the social science one ss1 consortium where privacypreserving noise has been injected into the data prior to release we validate our ideology measures in this dataset by comparing to similar work on sharingbased homophilyand contentoriented measures where we show consistently high correlation 087 we then apply this metric to individual links from six popular news domains and construct linklevel distributions of audience ideology we further show this estimator is robust to engagement types besides sharing where domainlevel audienceideology assessments based on views and likes show no significant difference compared to sharingbased estimates estimates of partisanship however suggest the viewing audience is more moderate than the audiences who share and like these domains beyond providing thresholds on sufficient activity for measuring audience ideology and comparing three types of engagement this analysis provides a blueprint for ensuring robustness of future work to differential privacy protections

introduction in december 2019 a new viral infection emerged in wuhan china 1 named novel coronavirus disease by the world health organization 2 the unknown nature of the virus has led to alarming death rates in many countries worldwide putting strain on health systems 23 studies comparing covid19 to previous epidemics like sars or mers reveal that the virus has a much broader dispersal capacity 4 indicating a higher potential risk and potentially surpassing infection and death rates previously reported 24 according to the world health organization the number of confirmed cases worldwide is around 17 million 5 covid19 has rapidly spread across geographical boundaries prompting various countries to implement public health protocols to control its spread social distancing hand washing and city lockdowns have been implemented this critical situation has elicited various reactions among the population causing anxiety and fear particularly among those unaffected by the virus 6 in latin america covid19 represents an unprecedented challenge as similar viruses like sars and mers have not been experienced in the region before many latin american countries find their public healthcare systems unprepared to handle the epidemic in peru the viruss rapid spread even among mildly symptomatic or asymptomatic individuals highlights the need to understand the populations behavioral responses to the situation limited studies on knowledge and attitudes during epidemics exist in south america earlier studies in the region suggest that the population tends to be hesitant in adopting control measures during outbreaks of diseases like chikungunya zika and dengue 78 noncompliance with government measures during these outbreaks was possibly due to the limited impact on some geographical regions with favorable climatic conditions for those mosquitoborne diseases 8 9 10 in response to covid19 countries have imposed strict control measures to prevent mortality rates from escalating after confirming its first case on 6 march 2020 peru implemented strategies like social distancing continuous hygiene practices and limiting public movement and access to nonessential places 11 however despite the mandatory nature of these protective measures adherence among the population needs to improve signaling an alarming lack of commitment among certain groups 6101213 studies analyzing attitudes and knowledge about covid19 in hubei china show that attitudes towards government containment measures are closely associated with the level of knowledge about the virus 12 individuals with higher information and education levels tend to have more positive attitudes toward preventive practices 612 the perception of risk plays a significant role in the commitment to preventive behaviors during global epidemics 610 14 15 16 17 perception of risk may be influenced by the type of information individuals have lack of information or misinformation can be a barrier increasing the likelihood of infection 14 however peoples judgments are often based on their perception of risk rather than actual risk 16 during the sars epidemic psychological responses generated massive distress leading to disproportionate reactions in the population 18 experts in australia found that poor public communication policies during the h1n1 influenza epidemic contributed to mass panic in the population and noncompliance with containment measures 19 individual attitudes toward public policies significantly influence the effectiveness of containment measures 619 despite government efforts the passive attitude towards implemented policies continues to impact the populations health and that of their close relatives the lack of knowledge about covid19 may mediate increased virus infection rates similar cases like the ebola virus outbreak showed that a poor understanding of the disease and its transmission contributed to higher case rates 20 knowledge of infection processes and precautions can influence citizens adherence to government guidelines systematic reviews stress the importance of educating affected populations to increase their understanding of the disease cycle and facilitate the adoption of preventive measures 10 however studies in developed countries like singapore indicate that citizens may require less information to comply with government measures suggesting high trust in their leaders 21 it is crucial to consider potential biases in these studies as they mainly assess individuals with higher education levels during the epidemic given the lack of previous studies on outbreaks knowledge or risk perception in peru our survey aims to assess the populations level of knowledge regarding covid19 its symptoms transmission and severity additionally we aim to evaluate the perceived risk and seriousness among the peruvian population and their behaviors in response to the disease materials and methods ethical statement all participants were informed about the aims of this study and gave written informed consent this study followed ethics guidelines and was approved by the local ethics committee all data were collected in an anonymous database data analysis the sociodemographic characteristics of the participants included in the study sample were compared with χ 2 tests the χ 2 test compared the percentages of answers the effect of age gender marital status occupation and education was assessed with a linear regression analysis using the total punctuation of the six previous sections statistical analysis was performed through the spss software version 24 results were significant with p 005 and p 001 results background characteristics the study sample included 225 subjects most of the study sample was female and it is found a statistically significant difference between age groups by gender from the females six adolescents were considered in the group 18 and included in the analysis regarding the age close to the age of majority and independence a situation usually seen in peru where adolescents do not live with their parents under different conditions more than half of the respondents were between 18 to 29 years old 693 of the sample are graduates single professional and independent workers displaying a similar percent distribution between males and females knowledge about symptoms and transmission ways of covid19 disease the sample does not discriminate between the most frequent symptoms of the disease and includes other manifestations thus more than half of the study sample correctly identified the most frequent symptoms like fever fatigue and dry cough along with others as just as sore throat joint and muscle pain a certain consensus is also observed among the subjects in recognizing as a manifestation of the disease the shortness of breathshortness of breath however this has not been confirmed as part of the diagnosis 30 diarrhea runny nose and nasal congestion were not recognized as part of the disease despite being more frequent than other symptoms such as shortness of breathshortness of breath most of the population knew the incubation period in the same way the situations considered means of transmissionspread of covid19 include in order of importance touching objects or surfaces that have been in contact with someone who has the virus going to areascountries affected by covid19 shake hands with someone who has an active case of coronavirus like the most important also subjects identified situations unrelated to contagion participating in blood transfusions and relating to people in a hospital or emergency room the severity of covid19 and prevention measures regarding the severity of the disease 916 consider covid19 as highly contagious with symptoms like flu and influenza on the other hand when evaluating the mortality ratio they do not assess that it is worse than influenza or tuberculosis or causes permanent physical damage to patients however when comparing the impact of covid19 with influenza or the common cold more than half of the interviewees indicated that the coronavirus would cause a more significant effect the results also revealed insufficient confidence in the national or local authorities preparedness for the disease and the lack of adequate measures to deal with it the results evidence an inappropriate understanding of the precautionary measures at the same time hand washing has been recognized as the most efficient form of prevention among respondents followed by personal hygiene conversely other vital measures were not considered such as daily temperature control and the use of a mask even though the who recommends its use in healthy subjects in combination with frequent hand cleaning 32 furthermore antibiotics are not recognized as the first line of action against the disease a sign of the populations knowledge of the treatment perceived susceptibility to covid19 on the other hand around 591 consider that there is a stigma about covid19 724 respond to preventive measures to avoid the disease and 458 value that the problems derived from the pandemic will not pass quickly compared to the 356 who do not know about it one of the greatest fears among the evaluated population is being in contact with people who have returned from abroad followed by eating out visiting hospitals and having contact with people with flu symptoms concern for the family is evident considering that one of the groups most susceptible to contagion is the people over 60 years of age in addition to health services personnel children are considered in the last place of the possible infected subjects health institutions and domestic settings are considered places of infectiousness in addition the effectiveness of treatments and the effectiveness of available medication or remedies against the disease pose a highrisk vulnerability 5 and6 finally a multivariate analysis is used to analyze the weight of each proposed variable in the total score this result shows that knowledge has a slight but significant correlation with education occupation and age and explains less than 10 of the variance in the case of perception occupation has a slightly significant relationship but explains less than 52 of the conflict the remaining variables do not have substantial results besides we analyze sociodemographics impact on the variables studied we found that age was a critical positive covariable in severity perception and prevention with a decreased effect on knowledge similarly for knowledge education and occupation show an effect finally the scores reached by the sample on knowledge of covid19 was 2240 ± 3131 where 104 subjects obtained low knowledge 72 medium knowledge and 49 high knowledge regarding perception vulnerability the medium score was 1895 ± 486 where 56 subjects had low vulnerability perception 96 had medium vulnerability perception and 73 had high vulnerability perception in the case of attitudes against covid19 the medium score reached by the sample was 2204 ± 302 where 83 had low attitudes against covid19 67 had medium levels and 75 has high levels of attitude against covid19 discussion considering the spread of covid19 in latin american countries and the higher incidence of people infected in peru this study aimed to measure the level of knowledge perceived vulnerability and attitude of the peruvian population against covid19 however different public health policies and the mandatory nature of these protective measures were implemented in the last months the adherence of peruvians to each of them was limited previous reports of psychological adherence to protective standards display that level of information and education are related to a positive attitude toward covid19 preventive practices 12 covid19 has a higher rate of contagious properties than previous coronaviruses and affects multiple organs the absence of awareness of hospital infection control and international air travel facilitated rapid global dissemination 33 in addition psychological elements such as fearinduced behavior misinformation and economicrelated concerns would exert significant pressure on the population limiting compliance with these government measures 34 at the time this paper was sent for publication the peruvian ministry of health had reported more than 97 thousand cases by covid19 infected patients since the first case was reported on march 6 and the total number of deaths is the second highest in latin america with 216 34 nonetheless the behavioral response of peruvians was not sufficient behavioral responses such as intense fear of infection or coronaphobia 35 are among the most significant indicators in the evaluated sampling the findings identify that as long as there is knowledge about dealing with the epidemic the degree of susceptibility to infection is lower as described in a study in pakistan the failure to follow precautionary measures against pathogens is explained by insufficient knowledge 14 given the impact of such magnitude in latin american contexts further analysis is suggested to establish better response and epidemic control strategies from the standpoint of the population understanding peoples risk perception is critical to ensure efficient health protection practices during virus outbreaks 10 regarding knowledge perhaps some symptoms are recognized as covid19related but our participants do not discriminate correctly other significant symptoms such as nasal congestion runny nose dry cough or diarrhea are usually more frequent in initial states the incubation period is well recognized in 86 of the population we found that knowledge was associated with education occupation and age which indicates that people with a higher educational level tend to have greater access to information sources and educational resources allowing them better to understand scientific and medical materials on the disease in addition it highlights that education and occupation may be related to a greater willingness to learn and adapt to new situations such as the need to understand and act against covid19 age was also associated with knowledge showing that older people due to their experience and recollection of past events may be more aware of infectious disease risks and therefore more interested in learning about covid19 to protect themselves and their loved ones routes of transmission of covid19 are well recognized nevertheless other medical circumstances were identified relating increased perception vulnerability to a specific context and medical conditions this affirmation can promote stigma among sanitary personnel 525 of participants are unaware of or recognize transmission routes additionally more than 20 do not realize that being in touch with people identified by doctors is a potential vector of transmission perception of covid19 severity in the community showed that 769 believe that the authorities are unprepared to face the disease and 627 think that the authorities response is ineffective this result may be related to less participation in dictated measures by the government such as social isolation and gender segregation different preventive measures are well recognized by participants such as personal hygiene washing hands or a clean environment notwithstanding other practical efforts such as using a mask or monitoring temperature are not considered regarding perceived susceptibility 724 believe that nothing i do can stop the risk of catching me this vulnerable state may be related to poor participation in ineffective measures to avoid contagious like social distancing or mask faces on the other hand 742 believe that if i contracted the coronavirus it would have serious consequences for me or my relatives despite different epidemiological studies pointing out that mortality is lower than 5 3637 even in peru current data indicates a mortality rate of over 10 and recovery is one of the highest in latin america 34 participants evidence an elevated fear of being in contact with others in correspondence of personal susceptibility of getting the infection and a high likelihood of having a significant outbreak of coronavirus from person to person in my community regarding multivariate analysis it shows that educational level and occupation have an impact on knowledge besides age was the most critical covariable affecting most variables in this way it is shown that age and probably the emotional maturity reached have been better mediators of these variables finally we concluded that insufficient understanding of covid19 seems to mediate unsafe behaviors affecting effective prevention measures and the failure to reduce the rate of people infected moreover the perception of vulnerability is high towards certain risky behaviors regardless of other possible transmission routes limitations this study has some constraints first causal inferences may not be established since the methodology is derived from a crosssectional design second it is related to the sample because the study was only focused on the outbreak of covid19 we used a webbased survey method to avoid possible transmission causing the sampling of our research to be voluntary and conducted by an online system given this circumstance the possibility of selection bias must be considered additionally much of the sample have access to the internet connection in their computers or cellphones because of this participants may have higher income or better educational access also in the absence of lowincome people less education is needed to know their responses to the covid19 pandemic the sample size is another limitation and the current wave of misinformation in social media would affect poorer responses 16 third due to the sudden disaster we could not assess other sociopsychological conditions of the participants before the outbreak recommendations due to fearful attitudes and the significant impact on population mental health towards the pandemic and new demands for surveillance and control of current covid19 outbreaks some previous studies identified appropriate suggestions to facilitate compliance with control measures by the population 1415 and increase knowledge 27 especially enfaces in psychological coping 3839 some of these are described below first educational intervention should be tailored to vulnerable communities including teaching preventive measures and practical identification of risks in nontechnical language 40 the population must be educated to choose wisely regarding reliable news such as facts and evidencebased data 41 on the other hand it is important to consider the knowledge and attitudes toward possible treatments since some studies conclude that the fear of becoming infected with covid19 helps the intention to get vaccinated however conversely conspiracy theories about vaccines arise about their effectiveness hence disseminating knowledge that is easy to understand to the population is essential for better reception and greater acceptance of the vaccine 4243 likewise the population must be educated about the postcovid19 syndrome and the possible consequences of the infection for this it is important to follow up on patients however there are few studies regarding it 44 second consideration should be given to guiding the population on protecting their mental health by limiting the time they are exposed to information related to covid19 during the day 4546 as well as the need to implement preventive actions in the general population to reduce the prevalence of depressive anxious and fearful symptoms related to covid19 47 third it is crucial to encourage people to return to their usual work and rest schedule as much as possible to mitigate anguish and fear and ensure sleep quality before going to sleep 1840 besides these recommendations we believe that clear communication between the government and the ministry of health with the population is crucial with relevant preventivebasedevidence programs mental health services and health education could be implemented in the communities including byphone therapy and emotional care data availability statement not applicable informed consent statement informed consent was obtained from all subjects involved in the study

background latin american countries have been profoundly affected by covid19 due to the alarming incidence of identified cases we intended to explore which psychosocial elements may influence poor adherence to the mandatory control measures among the population objective we aimed to assess peruvians knowledge attitudes and vulnerability perception during the coronavirus outbreak method we collected data from 225 selfselected participants using a webbased crosssectional survey results the overall respondents were between 18 and 29 years old 568 female 595 belonged to educated groups and graduated professionals 693 most of them logistic regression showed that knowledge is highly associated with education p 0031 occupation p 0002 and age p 0016 our study identified that although people reported adequate knowledge by identifying expected symptoms and virus transmission ways in covid19 disease there is a significant perceived susceptibility to contracting the mentioned virus displaying stigmatized behavior 591 and fear of contracting the virus from others 702 additionally it is reported to lack peoples confidence in national health authorities regarding sanitary responses 627 preparedness for the disease 769 and the lack of adequate measures to deal with it 511 conclusion we found that age education and occupation modulate knowledge at the same time only age affected perception and attitude public policies should consider specific guidelines on knowledge translation and risk communication strategies for both containing psychological responses promptly and ensuring compliance with general control measures by the population

introduction the development of the internet and information technologies has changed peoples lives in innumerable ways citizens are able to work more efficiently purchase goods from the comfort of their homes access any kind of information and knowledge communicate instantly with people all around the globe and so on thanks to the technology they are able to live healthier longer safer and happier lives in todays modern world one needs to know how to utilize technologies to their advantage it has become the requirement for the active participation in society in other words digital literacy has become a life skill or a key competence the covid19 pandemic that we are yet to see the end of has transformed virtually every aspect of peoples lives in some fields the shifts have been subtle some others have been changed drastically and people may still be in the process of adapting to the new reality one of the major changed consisted in transferring business schooling and commerce to the online domain to an unprecedented scale hardly anybody was prepared for this change the results of it were difficult to predict too after a number of months passed the time came for some initial reflections upon the consequences thus the multidisciplinary research team has decided to conduct a series of studies and scientifically check whether the pandemics side effect has indeed been the increase in the level of digital literacy and if the malicious activity of hackers during the crisis have made people be more aware of the dangers and threats that using the cyberspace may pose additionally the factors influencing both aspects were to be uncovered the rationale behind the selected topic study group and methods will be presented in the further part of this paper the study included two major steps firstly the team has conducted a broad campaign involving as many as 380 women working at polish universities in order to construct a dataset then an association rule mining experiment was conducted revealing the actual relationships between the studied items in order to answer the research questions stated in sect 2 the remainder of this paper is structured as follows the remainder of sect 2 provides the rationale and context for the study whilst sect 3the theoretical background for the study the materials methods and the course of the study are presented in detail in sect 4 then the results of the study have been outlined followed by the discussion of the results and threats to validity in sect 5 finally the closing remarks are presented in sect refs6 2 the research questions and the rationale and the context for the study research questions the study aimed at answering four research questions they will be presented in this section whilst the rationale and the motives will be explained thereafter research question 1 does the compulsory remote work make the perceived level of ones digital competence increase the assumed answer yes it does in order to build up a more comprehensive picture of the matter the research team wished to know if the workplaceemployer of the respondent provided any kind of training or support for the workers doing remote job and if its presence or lack thereof influences the perceived level of ones digital literacy research question 2 does the compulsory remote work make the perceived level of ones cybersecurity awareness increase the assumed answer yes it does additionally the team wished to see whether employers help remote workers gain knowledge of the cyberspace threats and the ways of preventing them research question 3 is the level of perceived digital literacy related to the age of the respondent the assumed answer yes it does based on the quoted study by eurostat the younger the person the higher their level of digital literacy the study aimed at checking whether younger people would assess their skills in a significantly better way than the older ones or if the oldest respondents would assess their skills lower than the younger ones research question 4 does a higher level of cybersecurity awareness relate to feeling safer when working online or vice versa does training at ones workplace contribute to the feeling of security the research questions have been summed up in table 1 current context for digital literacy of women in the republic of poland despite digital skills being deemed a necessity in the twentyfirst century according to the most recent study by eurostat merely 58 of europeans aged 1674 possess basic or above basic digital skills there is the difference to be noticed between genders 60 of males possess the skills whilst the percentage of women is 4 lower in poland while the overall percentage of the people having basic or above basic digital skills may not be drastically lower than the european average there again exists the difference between genders and only 43 women aged 1674 are digitally literate in addition to this it must be noted that another study has shown that the individuals possessing digital skills are mostly the very young ones aged 1619 although the study has encompassed only the people aged up to 29 years old it can be clearly visible that the older the individuals the fewer of them possess the digital skills for the group aged 2024 it was 81 for europe and 76 for poland whilst in the group aged 2529 it was 78 and 69 respectively taking the abovementioned into consideration it may thus be concluded that the group which may possess the lowest digital skills are the middle aged and elderly women in the light of the fact that digital literacy is considered one of the life skills the lack thereof may make ones enjoying civic rights harder or even lead to social exclusion current context of the covid19 pandemic when who first declared the outbreak of the covid19 disease a public health emergency of international concern in january 2020 and then subsequently a pandemic in march 2020 no person probably imagined how life was going to change in the upcoming weeks and months in the struggle to prevent the disease from spreading many drastic measures have been taken including lockdowns and compulsory social distancing this meant that schools businesses and countless other organizations had to start working remotely utilizing cyberspace and digital tools millions of people were forced to turn to the online mode overnight no matter if they had the skills to do it or not and no matter if they even had a computer or access to the internet for many this meant they suddenly lost the ability to perform their professional duties or their access to education was denied after several months have passed and governments companies and individuals have tried to get a grip on the new hard reality it has been suggested that the pandemic might have made people more digitally literate however the tense difficult situation attracted many wrongdoers and criminals who have abused the fact that so many people were bound to use the internet for work learning training communication purchasing necessities etc that they have become utterly dependent on the internet along with the massive increase in the number of videoconferences the popularity of online shopping banking and so on the amount of malicious software phishing emails and ransomware attacks along with the staggering amount of covid19related fake news has been disturbingly rising with the occurrence of some types of attack increasing fivefold since the beginning of the pandemic again the people with the lowest levels of digital literacy who already might have been experiencing some forms of exclusion have become the most vulnerable group and their security and privacy may be compromised by various malicious cyberspace actors legal background currently there is still an ongoing debate tending towards stating that the same human rights that apply offline should also be protected online and that access to the internet should be considered a human right in particular in the context of the freedom of expression covered under article 19 of the universal declaration of human rights one of the first documents in which the access to the internet was considered as a human right was the report of the special rapporteur on the promotion and protection of the right to freedom of opinion and expression human rights council later in 2016 the human rights council published the resolution on the promotion protection and enjoyment of human rights on the internet in this document the importance of empowering all women and girls by enhancing their access to information and communications technology promoting digital literacy and the participation of women and girls in education and training on information and communications technology and encouraging women and girls to embark on careers in the sciences and information and communications technology was directly emphasized the article 5 of the resolution suggested that the states should make efforts to bridge the gaps of digital divides including those of gender the problem of gender in this respect was already expressed in 2017 by the united nations high commissioner for human rights in the general assembly report on promotion protection and enjoyment of human rights on the internet ways to bridge the gender digital divide from a human rights perspective in the report it was stated that lower digital skills and lower digital literacy can directly influence lower position of women in the labour market and in leadership positions in 2018 the human rights council approved yet another document concerning the rights to the internet access namely the resolution on the promotion protection and enjoyment of human rights on the internet at the 38 th session of the human rights council in geneva in this document the emphasis is also put on the need to address the genderbased digital divides point 5 of the resolution encourages all the countries to put efforts into bridging digital divides including the gender digital divide the resolution also calls for enabling online environment that is safe for all and facilitates affordable and inclusive education theoretical background digital competences as a key factor in order to construct and design the research study and tool the concept of digital skills had to be defined for the sake of this study the notions of digital skills digital competences and digital literacy have been used interchangeably when building the tool the definitions by the european parliament and the council has been assumed they have come up with a set of eight key competencies for lifelong learning the competencies have been described as a mixture of knowledge skills and attitudes that every person requires to derive personal fulfilment develop as a person and be an active upright citizen they are also necessary for employment and prevent being socially excluded the eight key competences comprise 1 communication in the mother tongue 2 communication in foreign languages 3 mathematical competence and basic competences in science and technology 4 digital competence 5 learning to learn 6 social and civic competences 7 sense of initiative and entrepreneurship 8 cultural awareness and expression european parliament and the council have recommended the member states provided these competencies in all their strategies of lifelong learning as a way of preparing young people for adulthood and being a basis for further learning and working life and updating and developing the competencies of all the adults it has also been recommended to make adequate provision for the citizens who require particular assistance in order to realize their potential whether it be owing to personal cultural social or economyrelated circumstances the digital competence is defined as involving the confident and critical use of information society technology for work leisure and communication according to the recommendations possessing digital competence means the individuals can understand the nature role and opportunities of digital environment in their daily lives both in the professional and personal contexts digital competence is a broad and vague term therefore the skills it encompasses have been organized into a clear conceptual frameworkdigital competence framework for citizens called digcomp pursuant to the updated version of the model the skills that digital literacy comprises fall into five categories altogether there are 21 particular skills in this model they have been shown in table 2 stateoftheart of digital literacy studies the literature sources present a number of studies related to digital literacy and competences in the context of universities or higher education in their research scrutinised the levels of digital literacy amongst students although digital competences were deemed crucial for enhancing the learning process the majority of young people who took part in the experiment lacked many of the much needed skills such the only work which touched upon the digital literacy of teachers in the pandemic was the paper by santi susanti rachmaniar it checked if and how the digital competence levels shifted in the teachers of an elementary school since the onset of the covid19 pandemic indeed some of the studied people reported that they gained new digital skills whilst preparing their lessons for students still a number of teachers still had difficulty in this domain and had to ask the students parents for assistance however to date to the authors best knowledge no study of the level of digital literacy of university teachers educators amidst the pandemic has been conducted data mining data mining sometimes referred to as kdd consists in extracting unrevealed information from substantially vast datasets in order to extract patterns and find order in the historical data intelligent methods are often applied association rule mining is a kind of data mining it is utilised in order to discover association relationships between the items belonging to big datasets the basic association rule is x → y it means that if x is true of an instance in a dataset then y is true of it too in this relation x is called an antecedent and ythe consequent antecedents are understood as the items that appear first and all the consequents as the ones that follow them the level of significance of the association is measured using three indicatorssupport confidence and lift support explains the level of popularity of a given combination of items within a dataset it is the proportion of the number of occurrences of the itemset of x and y to the total number of items in it it is expressed by the formula 1 confidence is the measure of how likely the item y is to appear together with the item x it is expressed by the proportion of the number of instances when x and y appear together vs the number of times x appears the formula of confidence is support freq n as this measure may misrepresent the significance of an association the third measure is applied namely the lift lift says how likely the item y is to appear together with item x taking into account the popularity of the item y as well lift is expressed by the formula in other words lift is the measure which assesses the strength of the association if the lift is higher than 1 it means that the occurrence of x does lead to y the higher the lift the stronger the association a lift value close to 1 shows that one item does not affect the other consequently if the lift is lower than 1 then the occurrence of x has a negative effect on the occurrence of the item y for the sake of this particular study it has been decided apply the apriori algorithm the algorithm is one of the most popular ones used for association rule mining it was first introduced by agrawal and described in detail by bhargava and selwal apriori assumes that all subsets of a frequent itemset must be frequent conversely if an itemset is not frequent then its supersets will be infrequent too it is worth noting that the thresholds levels of frequency are decided upon by the person using the algorithm based on experience experiment expert advice needs etc the apriori algorithm has been often used for the socalled market basket analysis that is analysisng transactions in search for the items frequently bought together it allows one to find interesting often surprising associations within large datasets it is also said to be userfriendly and easy to use however it may require a lot of resources and computation time if applied on a large dataset and with minim measures thresholds kept very low the particular algorithm was chosen for this experiment in hope it would yield interesting results help confirm or reject the research assumptions and answer the following research questions materials and methods part 1 the dataset and research group it was decided that the first study of the series will be conducted on women who are university teachers educators andor scientists by profession confidence freq freq lift support support × this selection was made based on the fact that women score more poorly in digital literacy tests moreover teachers have been reported not to utilise the available digital tools which would enhance the learning outcomes the lack of proper digital skills was pointed out as one the reasons for such a situation finally universities in poland were made to go online by law since 12 th march 2020 thus the women working at universities known to be forced to work remotely should show the increase in their levels of digital literacy and cybersecurity awareness the research methodology and the design of the data gathering process in order to conduct the study a questionnaire was constructed it consisted of three parts the first one asking the questions about the scientific title the scientific field the studied person worked in their age place of residence as well as if they worked as university teacherseducators scientists or both the subsequent section concerned the fact if they worked remotely and if they did not the survey finished then there were the questions on the perceived level of the digital skills of the studied individual ie the question about the perceived general level the five components of digital literacy according to the digicomp 20 framework and if the employer helpedsupported them in gaining the necessary skills the section finished with the question if the person felt their perceived level of digital literacy increased during the covid19 pandemic the last section of the questionnaire touched upon the aspects of cybersecurity the first question aimed at checking whether the studied person felt safe when using the cyberspace and its tools then it was checked whether the persons employer had made them aware of the possible threats to their assets and privacy that may come with their remote work finally in the last question the individual was to assess if their perceived level of cybersecurity awareness increased during the covid19 pandemic the primary version of the questionnaire was an online tool it was distributed amongst the people belonging to the target group by various means using instant messages facebook groups or asking the individuals personally and then sending them the link to the questionnaire via email each person was informed of the fact that the study was anonymous gdpr compliant and no personal data was collectedsaved this broad information gathering campaign took place in october 2020 the dataset at a glance altogether 380 women responded to the questionnaire to the authors knowledge this has been the first scientific study of the digital skills and cybersecurity awareness of women academics and scientist in the times of the pandemic and one of the largest studies of digital competences and cybersecurity awareness of women academics in general subjects from whom data was collected scientific title the majority of respondents hold the doctoral degree 18 of them has the phdscd hab title 17 ma 2 are full professors and 1 of them hold other titles scientific field the majority of the studied women deal with social sciences almost a quarter of the respondents work in exact or natural sciences the third largest group belongs to humanities 198 the remaining fields were engineering or technical studies87 agriculture41 art 2 and theological studies03 age of the respondents the studied women were aged from 25 to 70 years old the average age was 388 years old the median age was 38 place of residence the vast majority of respondents live in the city digital competence general level most respondents assess their perceived level of digital competence in a positive way as they chose either very high or high only 1 of the respondents believe their overall level of digital competence is low it is worth noting that no respondent found the level of their digital literacy to be very low the rest of the studied women believe they have average digital competence then the level of the particular components of digital competence was measured each of the respondents was given the description of the component along with the examples of practicing it they were supposed to assess the level of competence within a particular component using the grade from 1 to 5 where 5 meantvery high 4 high 3 it is hard to tell 2 low and 1 very low the assessment of the digital literacy components figure 1 shows the imbalance in respondents digital skills there are distinct differences between the perceived levels of particular components of digital literacy communication and collaboration skills scored the highest whilst the average score for safety was almost a point lower the employers support the next question concerned the fact if the respondents employers have supported them in their transitioning to working remotely using the internet by providing various forms of training educational materials tutorials or by providing access to resourceshelpdesks almost three quarters of employers have done it the pandemic and the increase in the perceived level of ones digital skill when asked if their perceived overall level of digital competence had increased during the covid19 pandemic almost two thirds of the respondents answered definitely yes or rather yes only about a quarter of the studied group believe their digital skill levels have not increased the rest is not able to assess if their skills have increased or not the level of cybersecurity awareness the following part of the study concerned the aspects of cybersecurity feeling safe when working online most respondents feel that both them and their property are safe when they use the internet for working online about a quarter of them cannot decide whether they feel safe or not the remaining 17 do not feel safe when working online the employers role in raising the cybersecurity awareness level when asked if their employer had made them aware of any cybersecurity measures or possible cyber threats most respondents denied the last question concerned the fact if the respondents felt their level of cybersecurity awareness had increased during the covid19 pandemic the greatest group believes it has not raised about a quarter of the respondents find the awareness level to have increased almost one third of the studied women cannot decide whether cybersecurity awareness level has shifted or not part ii the data mining process as evident from the data gathered most respondents believe their digital skill level has raised during the pandemic one may believe that this shift is caused by people having to deal with the digital issues by themselves as suggested in jeleński however in almost 75 cases people admitted to having been supported by their employers in transitioning to working online too at the same time only about a quarter of them believe their cybersecurity awareness level has increased when working remotely via the internet and most respondents claimed that their employers had not made them aware enough of the cybersecurity matters in order to find out whether there actually is any relation between these factors the data was processed with the association rule mining algorithm experimental setup and preparing the dataset in order for the dataset to be ready for applying the algorithm all the data items were changed to categorical ones the values for minimum support confidence and lift were selected in an experimental way in order to reflect the associations in the most accurate way possible and economise on the computational time the final values were minimum support 0025 minimum confidence 03 minimum lift 6 the results after the data was processed by the apriori algorithm a list of 11 association rules was created then it was sorted according to the lift value ie the higher the value the stronger the association according to the algorithm the results have been presented in table 3 discussion of the results the covid19 pandemic has influenced almost every aspect of peoples lives many routines and activities have moved to the online domain and may remain this way for a longer time maybe even forever this shift has challenged peoples digital literacy and made them think about their online assets being secure the conducted study aimed at checking if both the aspects improved as a surprising side effect of the lifethreatening global pandemic and which factors are associated with the selfreported digital skill the average score of a given component level and cybersecurity awareness levelfeeling safe when working online the answer to the research question 1 as anticipated the perceived level of peoples general digital literacy has raised during the covid19 pandemic over 60 of the respondents believed so the association rule mining study however did not find a significant association between having to work remotely and the actual increase in the level rather it was related to the employers support and workplace trainings the answer to the research question 2 despite being forced to utilize online services in almost every aspects of their lives and becoming almost totally dependent on the internet people do not seem to have become more aware of the possible cyberthreats and the cybersecurity measures aimed at preventing them this should be worrisome as the study of the particular components of digital literacy had shown safety is the aspect which people know the least about there is a concern to be had as at the same time they feel relatively safe which might lead to them not being alert enough and falling victim to various types of cyber exploits only about a quarter of the respondents believe their cybersecurity awareness level has increased when working remotely via the internet this may be related to the fact that as it turns out of the study most employers seem not to put enough emphasis on the cybersecurityrelated matters a similar conclusion was reached as a result of the association mining studythe respondents who were made aware of the cybersecurity matters by their employers reported to be feeling safe and secure when working online this is the clear hint for the employers that they need to include the cybersecurity awarenessenhancing frameworks if a person feels definitely safe then they definitely had considered their online safety definitely try to protect themselves online and had never fallen victim to cyberattacks 0028871391 047826087 8677018634 2 2 if a person feels definitely safe then they definitely try to protect themselves online and their employer had made them aware of the cybersafety issues 0028871391 047826087 7592391304 3 9 if a person feels definitely safe then they definitely try to protect themselves online their employer had provided them with support andor training of their digital skills and their employer had made them aware of the cybersafety issues if a person feels definitely safe then they then they definitely had considered their online safety they live in a city definitely try to protect themselves online their employer had provided them with support andor training of their digital skills 0026246719 0434782609 61352657 11 5 if a person feels definitely safe then they then they definitely had considered their online safety definitely try to protect themselves online their employer had provided them with support andor training of their digital skills 0028871391 047826087 6073913043 in their trainingworkplace education agenda in the long run this will help people protect their data and property when working online the answer to the research question 3 as expected the youngest respondents were the ones who reported to be having the highest level of digital skills this goes in accordance with the previous findings the algorithm also found a strong the association between the age and being a ma this came as no surprise as the respondents aged 2629 are usually in the process of gaining their phds and further titles the answer to the research question 4 the level of ones perceived security when working online is strongly associated with the fact if their employer provides digital skills and cybersecurityrelated training and support if they consider their safety and make active efforts in order to protect themselves threats to validity and the limitations of the study as for construct validity it is believed that the language of the questionnaire and questions were well understood this aspect was evaluated by asking 510 first subjects to answer the survey regarding external validity the study was conducted amongst women who are educated and mostly dwell in cities the authors are aware that the study did not encompass the representatives for lower classeseducation level in order to obtain the fullest picture of the matter the study would need to include the people belonging to the lowest class living in the country as well as female primary school teachers the authors have already planned to conduct such a study in the upcoming time and employ other data mining algorithms and will share the updated results afterwards conclusions practical and theoretical implications there is no doubt that the pandemicrelated crisis which has also resulted in an economic crisis and increased unemployment has revealed digital and technical skills deficits in the case of this work they were uncovered among women working in such an important area as science women employed in this sector need to acquire digital competences if they want to retain their job posts but also if they wish to teach todays young people generation z igen igeneration generation xdthese are the terms used to describe the digital generation now entering adulthood who do not know a world without the internet and prefer to spend their time on the phone rather than amongst other people this generation is composed of the people born after 1995 or 2000 they are the first generation to have permanent access to the internet in complementing and upgrading their digital competences some of the female scientists surveyed are able to cope on their own but others need immediate help in the form of action from employers this issue implies further analysis on the educational role of organisations complementing qualifications and skills in this area is also necessary due to the phenomenon of technological exclusion which increases dramatically during the pandemic period the women surveyed need to intensify their professional development in this area in order to equalise opportunities there is no other way to keep a job the article also highlights aspects related to digital security the insufficient level of competence in dealing with digital threats points to the need for awareness and education especially since the scale of threats from the digital world is constantly increasing not everyone is able to increase their competences quickly enough through individual selfeducation which is necessary to deal effectively with multifaceted erisks education in digital competences including education in digital safety is an action which should be taken as soon as possible in the polish higher education environment in order to mitigate the negative effects of the crisis but also to use this moment to equalise the chances of women on the labour market in the digital economy of the future sparta a horizon 2020 cybersecurity pilot project funded by the european commission is an example of such a desired initiative as a significant effort is placed in it to help tackle both of the challenges presented in this study a range of actions undertaken and systems are being put in place to help mitigate the gender gap this starts with embedding actions inside the project itself and then communicating the principles and values outside the project to help specifically address the female public in both dissemination and communication activities the female participation in all training related activities during the project is prioritized so as to focus on and incentive female participation involvement and uptake female mentorships programs within sparta partner cybersecurity research teams are being created the project also strives to understand and correct social barriers related to female participation in all levels of the cybersecurity workforce the results of this investigation illustrate the immense importance of innovative initiatives like the women in cyber campaign implemented in sparta final remarks this particular study concerned womenscientists andor university teachers thousands of whom had been forced to start working online when the pandemic broke out most of the respondents report that their digital literacy has increased as women used to score more poorly in the digital skills tests before the pandemic it may turn out that the global crisis contributed to their gaining more competence it might even turn out that this will be one of the very few benefits of this terrifying situation however the shift did not happen by itself the association rule mining study has shed some light on the significance of the workplace training and support there is a strong relation between the employees feeling their competence rises and the fact if their employers provided them with the opportunity to gain the skills moreover peoples cybersecuritysafety skills scoring the lowest along with the lack of emphasis on the cybersecurity matters at workplace are alarming cybersecurity skills need to be addressed more as the lack thereof may lead to disastrous results like personal harm or financial losses even after the pandemic finishes finally cybersecurity awareness is not something which appeared alongside the pandemicrelated spike in the amounts of cybermischief apart from the support at ones workplace a person does need to make active efforts in minding and protecting their cybersecurity level in order to feel as safe and confident as possible when working in a remote manner publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

digital literacy has been included in the set of the eight key competences which are necessary to enjoy life to the full in the twentyfirst century according to the previous studies women tend to possess lower digital competence than men the older the person the lower the level of digital literacy to date polish citizens in general have worse skills than the european average this may lead to people being socially excluded and vulnerable to cybersecurity threats especially in the times of the covid19 pandemic which requires them to work study and shop using the internet the study concerned polish women who work at universities as scientists and teachers their perceived level of their digital literacy has been studied in the broad campaign along with their awareness of the cybersecurity matters then the collected results were processed with an association rules mining algorithm uncovering the factors related to the shifts in them

introduction in the twentiethfirstcentury whenever we think about health disease health care system the images of physician medical care hospital have appeared in front of us the scientific approach of studying health and medicine is called biomedicine the explicit application of biomedicine is found at hospital and clinic where doctor and surgeon directly apply their biomedical knowledge on patients body to identify disease they try to connect it with scientific and natural causes and apparently its effects biomedicine is referred as scientific medicine that is implicated with biological principles of health practices hospitals and clinics are suitable places to practice of biomedicine a significant links can be traces out between human health and healing places like hospitals clinics and dispensaries the hospitalbased health service was originated in ancient rome and europe where the honorable priest had played an important role serving sick and dying patients one of the main duties of them were to deliver health care services on the basis of religious touch with spiritual causes they tried properly to heal the patients at their guesthouse after renaissance the nature of treatment system had been changed on that time in the cases of disease observation only the physical and worldly causes were found discoursing the spiritual causes and beliefs after the enlightenment hospital based medical services had promoted as prestigious where the professional doctor and biomedical surgeon played a vital role they had achieved authoritative position in health seeking in western and nonwestern countries over the time biomedicine began to play a dominative role and it began to change its nature because of its multiple forms biomedicine health and women health seeking biomedicine disease sickness health and health seeking process are strong concepts of medical anthropology whose occupy a vital space not only in academic world of knowledge but these are confounded with our diurnal life biomedicine is a name of western biological and scientific medicine that emphasizes on biology and fact scientific medicine allopathy cosmopolitan medicine and technologybased medicine are named as biomedicine the term biomedicine was first appeared in britain 1923 in dorlands medical dictionary it indicated the clinical medicine on the basis of the biochemistry and physiological principles in the late 19th century various scientific technology shaped reshaped and influenced western medicine system which are widely known as biomedicine biomedicine refers to western and modern medical systems according to anthropologist hahn these types of modern treatment methods are called biomedicine biomedicine revolves around anatomy pathology diagnosis administration of drugs administration of therapy and surgery biomedical treatment service is very close to biomedicine biomedical also relating to medical physiological and scientific knowledge it is the process of modern medical services provided through the use of scientific and modern equipment biomedicine also including biomedical doctors pathologists and neurologists the physicians and doctors consider disease only in the light of pathology they studied disease based on the cartesian duality of body and mind biomedicine originated in america in the 19th century and it had recognized as the authoritative medical system in western society health means being healthy and well both of physically and mentally health refers to the healthy living and absence of disease and illness in human body and mind who refers health does not only mean the absence of disease but refers to the physical social and psychological wellbeing womens health refers to their physical and mental health indicating the absence of sickness in their body reproductive health is a much larger part of female body the protection and wellness of reproductive health also involved with health of women in patrilineal rural household health is not determined only by the women but health seeking behavior is guided by men men have their authority over women for their higher social status in a patrilineal society this notion is also relevant to edwin ardeners view that is considered as muted group theory it indicates the women in patrilineal society belong to muted group and their expression of worlds views feelings and independence are blocked ascribed by the dominant structure and the views of society in bangladesh womens health is determined by socioeconomic and political factors besides gender inequality in health sectors and different services accelerate and entitled women to poor health worldly 43 women and 65 pregnant women are suffered from anemia the observable women fall in low blood pressure anemia lack of vitamins and minerals they recall biomedical doctor when they face any accidental facts like broken limbs disease caused by pain stroke and different complexities related to puberty and reproductive health among the respondents there are 75 sick women though they have interest to take biomedicine but they cannot receive it at the primary level of sickness without the permission assistance and the proper guidance of male members of family it is observed that the women taking permission from husband or the elder male person to go to the biomedical doctors chambers clinics and hospital in the nearest bazaar they go to the district level health sectors to take biomedical treatment along with their male companion and their direct or indirect supervision besides there are many sociocultural and political factors that influence their decision are taken into a consideration for the sick women whether they will take biomedicine or not medicalization possession of medical knowledge on womens physical and mental health according to conrad and bergey they state that medicalization refers to the process by which various aspects of human beings are considered as medical problems the adoption of modern medicine the process of medical care where power relations are involved called as medicalization in sociology the term medicalization was first appeared that examined human condition in sociology and anthropological perspective medicalization is a process that refers some nonbiomedical problems as medical problems which requires medical treatment medicalization refers to the role and power of control of medicine on humans body feminists anthropologists refer that medicalization is a patriarchal process in which womens bodies are intervened by modern technology and trained male doctors in biomedical services disease is understood only in the light of biology anatomy and pathology social and structural elements of the disease are not considered as a result of receiving biomedical services the patients body comes under the control and monitor of certain medical knowledge technology and modern equipment the female body is not free from this subordination subordination indicates the low status and showing something as weak inferior by superior rank and position biomedical knowledge considers its own knowledge to be superior and prestigious the knowledge of other health care services such as traditional health care knowledge natural knowledge of disease etc as inferior biomedicine has such a controlling power and hegemony under the biomedical knowledge womans reproductive health is thought and treated as a machine biomedicine undermines womens natural knowledge and experience of childbirth it has reshaped the birth by caesarean section the knowledge of biomedicine has taught women that if they have fever headache and rheumatism then they will not just be taking rest or taking health care from home or traditional medical care because it will not cure them from sickness so they should go to the hospital to see a biomedical doctor and take medicine besides various tests like blood test body temperature test medicine and medical care should be taken thus the females body is subjected to biomedicine and the control of biomedicine is observed in their body it has brought about some sort of interference in the normal movement and living of women besides the technological fault brings negative impact on patients body sometimes it increases the outbreak of disease rather than minimizes it the authoritative knowledge of biomedicine has not only taught the rural women but also has to believe all of us that if you face disease you will go to doctor you must have to take biomedicine with biomedical treatment most of the cases biomedicine has informed both of rural and urban women that at present they are unable to give birth baby in natural way which is known as normal delivery it claims that if they accept the labor pain of normal delivery and try to give birth at home without going to hospital or clinic not to take biomedical treatment it will put their health at stake biomedicine has brought authority on the natural world of women and also controls their normal thinking of daily life obviously it has a control on observable womens mental and physical health so they are afraid to give birth at home to avoid the risk of life they go to doctor in hospital and clinic but they are at stake there too moreover the high cost of biomedicine makes women anxious that not only affects womens body but also their mind after all the controlling nature of biomedicine cuts and wounds on studied womens body some technical errors due to technological faults in local hospitals and clinics are pushing the rural womens health at dire straits motif of research this study has observed that the local nature practice and perception of western biomedicine in a rural area of bangladesh how the rural women perceive and practices of it what kinds of challenges risks and crises they are facing to take it are analyzed here after taking biomedical treatment at local hospital and clinics what are the ultimate result of it are analyzed how the authority and power of biomedicine imply some controls on rural womens health are explored here this study has analyzed the political economy of health to understand the impact of biomedicine on rural womens health in a broader context beyond the doctorpatients unequal relationship that exits in rural hospital and clinics also analyzed the internal political environment of local hospital and clinics are not conducive to womens health this article describes the rural womens experience of sickness and health seeking behavior this research has tried to depict all of these issues from a critical medical anthropological perspective field research fieldwork is the vitality of anthropological research this study is primarily based on fieldwork that was completed from july to september in 2017 this research was conducted for academic purposes the research field was located in sharsha upazila of jashore district that is far about 270 kilometers away from the capital city of dhaka in bangladesh i choose this village as a field because of my former acquaintances of the villagers as a result it was very easy for me to build a good relationship with them after entering field i supported informal strategy and engage myself to talk with the villagers that helps me collect huge data about womens health and the uses of biomedicine i observed that the villagers take biomedical treatment including other medical systems like homeopath ayurveda natural remedy herbal remedy and religion base treatment i used to gossip with the women of different ages like adolescent young middle aged and older about various issues it was important for me to capture a clear thought about their health seeking behavior on the basis of their different experiences i had talked not only with the women but also with the men with whom those were important and possible for me to talk it was a village area and i was conscious about local norms and values to collect profound data the informal strategy is suitable and the acceptability of researcher gets easier the anthropologists called this approach as big net approach about 370 household i randomly selected 40 households i selected 40 participant informants using purposive sampling method out of which 10 were male and 30 were female since the study is focused on womens health i selected more female informants in the selection of informants i selected male informants to understand how men hold their view on womens sickness in the household i did not used fully participant observation method but carefully observe their activities participating observation is the method of participating in their lifestyle and then profoundly observing their activities their emotions feelings and experiences toward health seeking behavior were realized through the anthropological lens and of participants of this study i talked to different patients who were admitted in local clinics and hospital they share their experiences and feelings about biomedicine and biomedical treatment structured strategy was taken for me with some specific questions for the persons who were busy with their respective profession like doctor nurse hospital attendants etc in semistructure interview i prepared a written list of questions i interviewed informants according to a list of written questions along with a little anecdote village men usually left for work early in the morning thats why i take semistructured interviews from them unstructured interview was done while the women were coking and gossiping one another in their household yard i took part with them at one stage of gossiping they shared with me different ideas about sickness and health care this interview is called as unstructured or openended interview key informant interview method was followed to conduct this study a young man of 27 years old and young women of 19 years old were main key informants of this study who introduced me with other participants the primary data of this study come from fieldwork experiences and the secondary data come from various books articles journal and literary works some sensitive and important data about biomedicine and women health are analyzing this study with case studies narrative analysis and life history analysis of participants life history is essential for data collection and it is called as the descriptions of personal life that emerges through observation and interviews the practice of biomedicine in bangladesh study area the expansion of biomedicine in the indian subcontinent can be traced back to the colonial period to protect the health of colonial ruler as a developing country bangladesh is not free from the influence of biomedical treatment system or biomedicine in the postindependence period many hospitals and clinics were established in this country for the development of health sector where the institutionalization of biomedicine had begun the doctors and the nurses had practiced biomedicine and treated the patients at clinics and hospitals professional physicians and surgeons get their dignity today biomedicine has formed so wellorganized and institutionalized that it is dominating the herbal medicine ethnomedicine homeopath and alternative medicine the western hegemonic knowledge and biopower of biomedicine and the exclusive adaptation of it by the socalled privileged class of society which led to a widespread belief that there is no pair of biomedicines in the field of health care however the ideas that the biomedicine always ensures health protection the universal validity of it and the efficacy or competency of it to cure all types of diseases and sickness are not always valid and suitable to all rather the principle of mindbody dualism of biomedicine that separates body from mind and the disease study system based on physiology also contain some inconsistency on patients body from timetotime not only in urban area but also in rural area of bangladesh the use and practice of biomedicine are found the environment of rural households of bangladesh does not exist above disease and illness these are not free from the use and the impact of biomedicine now biomedicine has taught us all to believe that if we have a disease we have to go to doctor seek medical care and to take medicine when a member of household feels sick the first thing is to think about what kinds of health services have to provide to the person that he or she might be recover very quickly biomedicine is an immediate disease preventive although the people of rural area know that the cost of biomedicine is huge yet they accept it to relief from the outbreak of the disease the women of rural bengal also take biomedicine when they face various health related complexities today biomedicine has become more dominative and prestigious health remedy rather than other health care systems like traditional medicine homeopath ayurveda ethnomedicine etc biomedicine and biomedical practices are related to power hierarchies which occupy both in public and private health care sectors in bangladesh zaman shows three types of public health care system in bangladesh where different hierarchy belong on the basis on specialization of knowledge and power medical college and hospitals belong to tertiary level whereas district or urban hospital belongs to secondary level and the third level of hierarchy exists in the upazilla health complex although health policy is organized and developed but these are less effective to ensure good and equal health care to all people faruk shah has shown qualified doctors are available in urban areas and the number of skilled doctors is proportionately less in rural areas rural people face some social economic and political challenges to take health care services from a skilled doctor the inhabitants of kaiba village practice both of biomedicine and alternative medicine as they are cheaper than biomedicine as biomedicine is directly related to high economic factors and mens decision sometimes they are depriving of it rural practice of biomedicine the appearance of biomedicine is scientific and technocratic the modern feature of biomedicine is shaped and reshaped in rural area of bangladesh the global view of biomedicine is localized in rural area according to its situational nature there is lack of qualified and registered doctor rather than city areas zaman shows professional and qualified doctors are engaging themselves in private practice in city areas in observable areas there is a public hospital where the registered doctors have presence but the numbers of doctors are much less than the huge numbers of patients needs yet they are receiving healthcare from there and facing multifarious socioeconomic cultural and political complexities in the public hospital the people can take service from a professional doctor only paying 10 tk for per ticket professional surgeons give services at their private clinics which are far away from the local bazaar where they receive better remuneration for giving better treatment economically wellof patients take service from them besides these there are one village doctor who provides health service from one household to another household the other 5 quacks who are not registered but also familiar as village doctors on the basis on their quackery experience have their personal chamber in baganchara bazaar though they have no medical training but they pretend they are skilled on health and medicine they play a vital role in rural health care as the villagers can easily receive treatment from them nature of local biomedicine the study area has developed by one government hospital two private clinics private chambers and some pharmacy where the allopathy medicines are sold respondents claim that in public hospital there are lacks of healthy healthcare 35 years old majeda begum said that the environment of local hospital and clinics are substandard it is observed that the outside of the buildings is classy but the inside is damp the observed government hospital consists of 1 fourstoried and 2 twostoried buildings one of my informants zamila said there is a large women ward in upazila health complex that covers a fusty smell i also observed that there is dirty cotton full of red blood covering the basin of womens ward though there are 32 beds but only 2 bathrooms that are full of gatherings and a long line of patients there are some internal complexities of hospital when anyone wants to take treatment from a skillful doctor surgeon and to take a seat in the ward and cabin sumaiya who was a university student told me baksheesh is essential if you want to take service from a doctor baksheesh varies on 100tk to 500tk or more than these depending on various cases and complexities otherwise you will wait for hour after hour standing in a long line and it will be fruitless because the doctor will go when it will be 2 pm or at least 5 pm they will go their private practice chamber at due time the severe diseased patients are enforced to give baksheesh to the doctors assistant in the one hand the welloff women enrolled themselves very carefully in the existing economic and salient political structure in the local hospital one the other hand the sick and less wellof patients suffer more spending plenty of time in a large line many of times the sufferers back home and they search for alternative treatment like kabiraji homeopath herbal etc those are existing in the local area case study zamila begum who was 48 years old and she was a housewife suffering from severe back pain for 8 years she went to a govt hospital but there was a long line after spending two hours she observed a rich woman paying some extra money to the assistant of doctor then she easily entered into the chamber zamila begum had shown an interest for paying a tip or baksheesh to him but her husband ignores it as the money was limited for themselves after spending 4 hours she felt severe pain attacked in her spine and she cannot stand any more she backs towards her home with a heavy flow of sweat and pain after 3 days she took medicine from a village doctor who suggests some pain killer that removes her pain but faces severe gastric problem thus the unequal management structure of hospital and the inter political perspective of biomedicine directly or indirectly effects womens health apprehension about doctors presence in hospital and clinic the rural people face some tension and hesitation if the doctor presence or not in the local hospital and clinic i also observed that the doctors are not always present in local clinic and hospital if one goes to the hospital after a certain time the doctor will be absent it has become like a statutory rule in the local biomedical treatment system though the patients physical complexities increase and these go to a critical level they have to wait for the doctors arrival there are hospital clinics and huge number of patients but the proportion of doctors nurses and qualified surgeons are less compared to the patients it is very difficult to reach them after a certain period of time that holds some serious risk factors on rural womens health sometimes they embrace with the death but they never see the face of a doctor during the fieldwork the health seekers of kaiba mostly felt uncertain whether the clinics were open or closed most of the cases the clinics were open but the doctors were absent and busy their private dispensaries to provide service ayesha begum suffering from a serious itching in her whole body and went to the nearest clinic at 10 am but the doctors arrive there at 1130 am there was a big gathering and long line of patients about 1 pm she gets the opportunity to visit the expected doctor she told me to visit an expected doctor is time consuming here standing about 2 and 40 minutes i would able to face him she had to endure big sufferings heat and crowd which aggravated her itching and allergies she starts a heavy sweating and its increased her inflammation after a lot of trouble when she returned home at around 300 pm she had to listen to various harsh wards from the senior members of her family husbands and her mother in laws for coming home late from the clinic and did not getting the household works properly case study her name was selina khatun who was 23 years old belonging to a middleclass family she was a housewife and lives in my study area during my fieldwork i suddenly heard she had been felt severe pain in her abdomen in the middle of the night she was taken to the nearest clinic about 2 am as it was late night the doctor was absent her condition was critical in the meantime the relatives of selina made emergency phone call to the doctors but he could not receive his phone this time the assistant of doctor though he is not trained or educated in health and medicine he pretended that he is the main figure and all in all in the absence of doctor in the clinic i was curious about his educational background and after someday of that incident i got to know after completing honors degree on management he had joined at this great profession it brings a quite surprise to me however after sometimes he pushed two injections to selina simultaneously without any testing the next day i was curious about selinas condition and visited her home unfortunately this case turned into a great misery selina begums relative explain after pushing the injection selina slowly felt asleep in the morning the whole body of her become cold gradually her relatives realize she was no more they belief she had died due to absence of doctor and the lack of appropriate medical care the health services and patients expectation there are three heath care centers near the study area one is the govt hospital located beside the union parisad office and another two are the private clinics the rich middle class and the poor people take service from it the service is cheaper than the private clinics though the outside and inside environments are less clean the treatment is properly given the respondent said they felt obsessed if the hospital remained closed for any occasion then they were compelling to go and search for private clinics private chamber of doctors or the alternative medical care another female informant was suffering from menstrual problem and felt pain for 6 months she went to a private clinic the doctor suggested her to take different tests from a particular diagnosis center which were more costly she went there and spending about 4000tk she took all of her physical tests and went to the doctor to show the report the doctor prescribed to her some medicine and after taking it about 3 month her condition was irritated then she went to the govt hospital following the advice of her family members she told me that doctor apa was very good i spend only 450tk for buying medicine now i feel better but the cost of treatment in a private clinic is much expensive the cost of biomedicine in rural area and the complication of its management system the cost of biomedicine varies region to region and area to area if it is oneway to developed country it is different in developing and less development country in bangladesh this difference exits in very parts of country and even in rural to urban areas in the observed area there are two private clinics and a governmental hospital where the lack of healthy health care facilities exits according to informants opinion there are some complications of management systems that have emerged through deep observation it creates some risk factors on womens health there are some differentiations of outward and inward environment of govt hospital and private clinics i realized a sultry environment in the women ward of public hospital at the time of interviewing informant i was informed about the fusty smell there was some bloody cotton in the bathroom two basins were filled with dirty water the women ward had 32 bed and only two bathrooms the patients of csection wait long line for bathrooms which increases their physical and mental pains one of the patients of csection told me that i am waiting here about 20 minutes today is the 5 th day since i have done my surgery i have a lot of pain in my groin and lower abdomen i feel difficult to stand like this sometimes my new born baby also cries a lot without me in the bed private clinics provide relief from such discomfort situation but those are very expensive doctors are highly educated most of the patients like them to save money it is cheap and they want to get good treatment the respondents of this study claim although there is a rule to give half of the medicine free in the government hospital the patients have to pay some money to the ward staff to get the necessary medicine expensive medicine has to be collected from the pharmacy bearing by the own cost of patients due to the increase of the cost of biomedicine and biomedical service the rural women cannot accept it though they have good will to receive it biomedicine is treated as the immediate curative care according to hans baer it spends much more money in the clinic hospital drugs and miracle cure critical medical anthropology claims biomedicine must be seen in the context of the capitalist world system and the profitmaking orientation the cost of medical services in government doctorpatients relationship using cma this study emphasizes on doctorpatient relationship analysis it from social political and economic power relation hospital has become a primary area of different social relations biomedical physicians enjoy and occupy their professional dominance of power according to friedson the professional dominance of biomedicine is strengthened and maintained by the political and economic dominance of elite where the others are to be subordinated to this profession doctors have the monopoly of power for their lucrative medical skills the physicians perform the key function of controlling the sick role of patients in this sense they are superior and the patients are subordinate to them this is the main point of analysis of this study i observed doctors are superior for their strong position in rural hospital whereas the rural patients especially the women have less dignity to the doctors obviously they maintain good relation to patients on the basis on class status and their personal relationship sometimes the unequal relationship of doctor and patients impacted on health of observed women respondent claim they cannot talk about their health problem openly with doctors because they exert their deprecation to their patients according to nimmon stenforshayas the power of biomedicine indicating an unequal relationship of doctor and patients in biomedical system women children old people are less prestigious and the doctors get their dignity according to kleinman et al it is an important for a doctor to take a full concentration on patients experiences but most of the cases they do not take attention on patients need realization and knowledge ember ember shows the unequal relationship of doctor and patients in the observed hospital and clinics the doctors and the surgeons are more prestigious for their exclusive knowledge and somehow they used to less concentration on hearing the sickness explanation from the patients sometimes they admonish to their patients the observed women patients claimed that they cannot explain their health problem to the doctor that affected their mental and physical heath equally amena begum experiences given a proper understanding about the helplessness of the sick women of observed area 50 years old amena begum has done her surgical operation in her left leg i observed when the doctor take a round and after seeing her amena begum said that doctor shaheb though i have taken medicine and injection properly the pain and anguish in my leg have not dispelled the doctor answered with a rebuked and neglected that you have broken your legs at this old age how the pain will be vanished so easily she told me we cannot ask anything to the doctor anytime if we do he scolds us as he was a very busy man it is observed the doctor also scolds the other women like amena begum as she asked doctor how long she would have to be admitted there due to the high status of biomedicine and the biomedical professional makes a behavior to portray himself in a highly respectable manner this picture is not only found in the urban are but also in rural area of bangladesh that has become a very common matter in public and private health care sector the mechanical defects in unlicensed clinic women in the study area seek medical care from clinic and hospital for various ailments when they do not get any benefit they find out their condition are worsened due to the defective medical care from my informants i am informed and also observed in the study area there is a clinic that is built without legal authorization the doctors of the clinic have no certificates as they are not as registered doctor and none have proper medical education experience and qualification rather these doctors are quacks have political financial relation with local police administration and political leaders of these areas with their help they have established this clinic in the initial time the villagers did not know about this and they used to take medical care from them some of them were facing various health problems case study salma begum was 32 years old who had her abdominal tumor operation about 3 weeks ago in that clinic she told me about some strange experience of that clinic she told me after the surgery severe burning pain started in her wound area in the next day around the 10 am salma begum and others who were admitted to the clinic were told to leave the place at that time and requested to go to the roof of the clinic when the patients and their relatives asked to the authorities about the reason they said there was a little problem so they might leave that place the surgery patients went up to the stairs of the roof with the help of their relatives with great difficulty very slowly and much carefully later they learned that the doctors at this clinic were allowed to see patients but not the authorized legislation to admit them allowed to do medical surgery and operation at that time the senior police officer came to visit the clinic and soon they are asked to leave the place salma begums eyes filled with tears and she sobbing and said to me i have claimed the stairs on the roof with my wounded abdomen very difficult my surgery was not done with experienced hand i have a problem on my forehead if i had known it before i would not go there done my operation by this unskilled hand though it was 25 days have passed since the surgery was taking and she had taken medicine properly but no changed was observed she was broken hurt mentally biomedical error and technical mistakes biomedicine is greatly relied on science and modern technology at the time of diagnosis error may occur all kinds of care process from diagnosis to administration of medicine medication error also found in clinical environments that may lead unnecessary diagnosis various test prolonged hospitalization and even death it is often observed that biomedicine gives some false report that affects women health in the studied area rural women sometimes face health risks due to the mechanical failure of biomedicine i have a female informant who is 48 years old she was a direct victim of the mechanical failure of biomedicine she is a patient of high blood pressure and diabetes that is why she often goes to the doctors chamber to check her diabetes and blood pressure because her diabetes and blood pressure are not under control one day after measuring her diabetes the doctor gave her antidiabetic medication because it has risen again she felt physically weak for 3 days after taking that medicine later when she went to the doctor again the doctor said that since the machine was technically error yesterday so the diabetes point was not measured correctly then the doctor asked to take new medicine after measuring diabetes with a new machine after taking that medicine she felt better another informant of mine who is 40 years old told me that during an operation in a clinic in baganchra bazar the patient regained consciousness at one point the patient started screaming it happened because the doctor could not give the anesthetic medicine to the patient properly i spoke to a nurse at the clinic to find out more about this the patient was not properly anesthetized that day because the anesthetist was not present on the operation table she told me withholding her name and identity as a result the woman regained consciousness during the tumor operation mistakes in ultrasound report hastened the killing of fetus very intrinsically women in our country are eager to know whether the baby in the womb is a baby boy or a baby girl ultrasound is a blessing of modern science and widely accepted accurate medical technique to access pregnancy it also identifies various specific conditions such as age of fetus possible miscarriage number of fetuses baby movement fetal growth sex identification etc the observed village women who are pregnant know about their unborn children taking the blessings of biomedicine that introduced themselves to the new technology called as ultrasound which informs about their desired subject case study the women 41 years old rahima sultana have 4 daughters and she had also pregnant for the fifth time then she was much anxious about her unborn baby and went to a private clinic in the nearest bazaar to identify the sex quality of fetus receiving the ultrasound technology of biomedicine observing the report the physician assumed that she would not have a baby boy but a girl rahimas husband said her if she had a daughter this time he would divorce her finally she consulted with the physician and decided to have an abortion very secretly then she convinced doctor very difficult and finally received an injection of abortion from the local health care the next day she gave birth to a stillborn son it was a great tragedy for herself when she realized that it was a baby boy she told me i cannot tolerate my pain and sorrow as i am a mother whether it was a boy or a girl i got itself in my womb but my family urged me to do this abortion only because of her socioeconomic facts and her family condition aroused herself to do it also due to technical error in ultrasound report her life was at stake she felt very weak due to heavy flow of blood for abortion besides she could not accept the grief the losing of her child besides due to the terrible mistakes of biomedical treatment her family members told many bad comments to her biomedicine is preventive less curative according to alison gray biomedicine has failed to effectively control some disease like tuberculosis cancer and also unable to deals with social problem that causes the disease doctors prescribe different medicine but ultimately the ailments of patients are not cured a young girl ashura khatun the key informant of this research had been suffering from chronic cough and sour throat for long time she went to the government hospital and receiving treatment from biomedical doctor and her condition was not changed then she goes to a private clinic of local market and got a checkup after costing about 1200tk but she did not get cure after that on the advice of her father she took medicine from a homeopathy doctor and about 20 days later she recovered completely she told me that homeopathy treatment and its medicine kill germ forever but the in the cases of allopathy when the medicine is taken to be stopped the cough returns because it cannot exhaust the germ of cough forever this comment is simply similar to critical medical anthropological thought that claims that it is not always right that only the biomedicine is useful but alternative medicine and ethnomedicine are also beneficial as the efficacy are multidimensional generational differences of taking biomedicine a generational gap and some differences are observed in women of the researched area for the practice and acceptance of biomedicine to them while biomedicine has become more acceptable to the younger generation of women it has not become much popularity to the older women perhaps the elder people do not like to seek treatment from biomedical doctors unless the disease is serious they realize if one goes to the allopathy doctor heshe must have to go but the disease is cured before repeated visit to the homeopathy specialist there are effective treatments available at low cost but the costs of biomedicine are so high the older women consider the caesarean delivery of a young woman is an unnecessary waste of money the local hospital and clinics are full of male doctors and they dominate the knowledge of biomedicine there are only one two and some fewer female doctors so the elder women express their reluctance to hospital treatment system they are afraid of lost their veil and worry about sacred and sin as they motivated their life style according to islam purda has not only an aspect of muslim life but it has become an essential acceptable part of social and cultural life the nonmuslim older women also show aversion to take treatment from male doctors the social and religious practices of purda are more observable among the elders rather than youngers they do not like the intervention of technologies and male doctors on their body again and again in this regard the critical medical anthropologist m lock properly said medicalization is a patriarchal process in which the intervention of technologies and trained male doctors are observed over the female body the exercise of political power in hospital and clinics the internal environment of the hospital and clinics are not free from the influence of external political power the political leader and the economically powerful individuals enjoy especial privilege in local hospital and clinics for their power on the other hand the politically and economically disadvantages patients struggle to get a seat even in emergency in local hospital and clinics other time giving some money or baksheesh to hospital staff one can get a seat as a result the sick women face health risk at the time of emergency three beds were occupied by politically and economically powerful male though he had one patient but he occupied more because he will stay there with his family members on the other hand the sick young girl who belonged to middle class family broken her leg in a sudden accident did not get any seat though she was writhing in pain later she was laid on a mat in the floor this case is similar to critical medical anthropological perspective that depicts how spacious political relationship affecting individual health case study 22 years old woman had a tumor surgery about 5 days ago and she needed 8 stitches in her abdomen the assistant doctor was dressing her wounded area and she was mourning loudly two nurses were standing herself hold her two hands and she could not move the professor doctor kept scolding to her because she was crying she had a lot of pain due to infection in wound in the bed she had completed her natural work most of the time she was in tensed that when she will be able to recover to walk normally and there were many questions in her head when the women body undergoes biomedical treatment for a disease they are subjugated to biomedical knowledge technology not once but repeatedly drugging in womens body injecting them and undergoing surgery are the expression of biopower of biomedicine conclusion biomedicine is an effective treatment system as it immediately protects human health from acute manifestation of disease most of the cases it is considered as lifesaving medical care the observed women in researched area face various problems and challenges to take this lifesaving active medicine and medical care beside the local nature of biomedicine and biomedical care have some rigid and inflexible aspects those are impacted on women health if it were possible to reduce the additional cost of biomedicine unequal relationship between doctors and patients the absence of doctors in hospital clinics and other complication like the baksheesh sociopolitical aspect etc then the women did not have to face the health risk they could properly enter the practice of biomedicine even it is also important for biomedical practitioners to full concentrate on patients experiences of sickness that will improve doctorpatients relationship at the time of diagnosis doctors should emphasis not only on biology pathology science medical knowledge and technology but also on patients mind it will bear more fruitful result in biomedicine and biomedical treatment system

medical anthropology an interdisciplinary subfield of mainstream anthropology has become the most popular and potential knowledge that receiving its brawny figure at present world biomedicine a strong concept of medical anthropology includes the scientific medicine allopathy medicine modern medicine and the regular medicine that basically focuses on human biology pathophysiology western knowledge and modern technology it has become globally dominant during this century and wellpracticed in developed developing and less developed countries this study has explored what are the local nature practice and perception of western biomedicine in rural area of bangladesh this research paper systematically searches what type of challenges have to face by the rural women to get access to biomedicine or modern medical service in local hospital and clinics what a modern technology and scientific knowledgebased treatment system impacted on rural womens biological and mental health this paper explores that applying critical medical anthropology cma perspective this paper has sorted out to identify the sociocultural and politicaleconomic aspects of biomedicine and what are the impacts of biomedicine on rural women health what kinds of health problems rural women are facing and what are the ultimate result of it as practicing biomedicine that will be analyzed here using critical medical anthropology cma this study has analyzed the power relation that is found in biomedicine and biomedical health seeking in local hospital and clinics that has become the primary area of social control this article is a written interpretation of an anthropological fieldwork that was done in 2017 in kaiba village at sharsha upazilla of jashore district of bangladesh

introduction places of worship broadly refer to locations where people gather to practice some type of religion such as christianity hinduism islam and judaism to name a few in addition to religious socialization research has shown that pow are important because they tend to facilitate social ties mutual cohesion and trust and a willingness to intervene for the common good 1 2 3 4 5 which in turn can be used instrumentally to achieve a collective goal namely minimizing crime in neighborhoods the key implication is that social capital that originates within pow extends to other settings in the larger community 6 7 8 9 ultimately strengthening informal social control mechanisms such as the dissemination of information mobilization of resources or an informal system of monitoring public spaces this suggests that places of worship should have a crimereducing association in neighborhoods 67910 even after controlling for a range of factors known to be associated with aggregate crime outcomes although there are many reasons to expect places of worship will reduce the amount of crime in neighborhoods 679 there is a dearth of empirical work to assess this proposition 711 a principal reason for this mismatch between theory and data is that geospatial information on churches is generally lacking 711 because pow have taxexempt status they are not compelled to report to the internal revenue service or most municipalities thereby it is a bedeviling challenge for researchers to accurately capture pow aggregated to microgeographic units for example even the national center for charitable statistics does not have a directory or listing of all pow located across the united states 11 data issues aside the few studies to have analyzed the effects of pow have provided weak evidence of their crimereducing behavior 67912 this raises the possibility that pow might signify an unintended consequence for neighborhood crime control the crime and place literature has established the crime tends to spatially concentrate at or near risky facilities including bars liquor stores checkcashing stores retail outlets restaurants schools and more 13 14 15 16 17 this is because such facilities generally provide an opportunity structure for crime that is there is a tendency for motivated offenders and suitable targets to converge in space and time alongside weak guardianship 18 19 20 more specifically these facilities have deleterious effects because they operate as crime generators 1921 the latter is a foundational concept of environmental criminology and refers to the following particular areas to which large number of people are attracted for reasons unrelated to any particular level of criminal motivation they might have or to any particular crime they might end up committing 197 thus the concept of a crime generator is predicated on high foot traffic operating alongside emerging criminal opportunities the implication is that potential offenders are not traveling to these areas with the specific intent to commit crime 1819 rather potential offenders will recognize situations in which there is a weakly guarded target while going about their routine activities and seize these opportunities to commit crime 131920 analogous to how schools restaurants and retail stores have been linked to more crime in place 13172223 we propose that pow might unintentionally lead to neighborhood crime problems mainly because of their ability to induce high foot traffic which offers an abundance of targets while at the same time undermining guardianship and social control capabilities 2425 there are competing expectations for how places of worship might impact crime in place on the one hand the literature rooted in social capital suggests that pow are crimereducing because they engender social ties common values and goals and a responsibility for the collective good 134 conversely pow might unintentionally be associated with more crime because they produce high foot traffic and undermine guardianship and social control capabilities consistent with the environmental criminology literature 1819 despite these competing expectations there are few studies to empirically assess the powcrime nexus in neighborhoods therefore for the present study we conduct a block group analysis of crime places of worship wellestablished criminogenic facilities and sociodemographic characteristics in washington dc pow and social capital a voluminous body of literature highlights how local institutions facilitate networks of effective social action in terms of crime control 711 26 27 28 places of worship specifically have been argued to strengthen dimensions of social capital such as social ties mutual cohesion and trust and a willingness to intervene for the common good because of sponsored events and activities 2 3 4 consequently pow can produce two types of social capital 1 bonding social capital builds intraneighborhood cohesion and social ties among adherents and residents while 2 bridging social capital establishes interneighborhood cohesion and social ties among local institutions municipal agencies and other groups of people 48 both bonding and bridging social capital are theorized to strengthen neighborhoods capacity for collective action against crime problems so when neighborhoods exhibit relatively higher levels of social capital there is a greater likelihood that residents and adherents will acknowledge crime problems will achieve consensus on how to address these problems and will solve the problems in a more collective fashion 248 this leads to our first proposition p1 places of worship will be associated with lower counts of both violent and property crime controlling for a range of factors known to be associated with crime in neighborhoods the seminal work of robert putnam 429 posits that successful outcomes are more likely in communities with high social capital with local institutions like churches being the catalyst for the latter putnams 4 analysis indeed reveals a negative effect of local institutions on crime in us counties similarly lee constructs an index of civic engagement which includes an indicator of congregations and finds that this index is negatively associated with crime in rural us counties in one of the more comprehensive examinations linking pow to crime in place beyerlein and hipp determine that three pow measures are largely associated with lower levels of murder burglary assault and robbery in us counties yet despite this evidence in support of proposition 1 there is also evidence to the contrary for instance one study failed to determine that pow are related to lower violent and property crime in new york block groups 7 this study also failed to detect any conditional effects of their pow measure also another study found that three church measures had nonsignificant effects on informal social control in louisville and lexington block groups 9 pow and criminal opportunities environmental criminology has argued and shown that crime is spatially concentrated in neighborhoods with a high density of nonresidential activities 30 31 32 more specifically activity nodes refer to locations where people spend a significant amount of time conducting nonresidential routine activities while pathways are features of the planned physical environment that connect activity nodes with one another neighborhoods with a higher concentration of nodes and pathways have indeed been shown to have a disproportionate amount of crime 131631 and this is because nodes and pathways yield overlapping activity and awareness spaces of large numbers of peoplea recipe for crime problems 18 19 20 environmental criminologists have increasingly used the term crime generator an extension of the activity node concept to denote physical structural qualities of neighborhoods that breed crime as a result of foot traffic and anonymity specifically 131633 stores restaurants and schools commonly operate as crime generators because of their ability to increase the volume of targets and undermine guardianship capabilities that is the ability to informally monitor and regulate public spaces 16 17 2224 34 35 offenders do not travel to these locations with the specific intent to commit crime 19 rather the key implication is that amid high foot traffic a potential offender will notice a weakly guarded target and seize the opportunity to commit crime given that foot traffic is a defining characteristic of crime generators we argue that pow might operate in the latter capacity in addition to religious meetings and services that occur on a weekly basis many pow have a mission statement that involves the provision of needbased social services to its members as well as less fortunate people in the larger community these services include shelter and housing foodsoup kitchens therapy and counseling and job procurement and training 7912 when pow are effective in improving the social circumstances of people these people may be less inclined to resort to criminal behavior 711 yet this remains an open question on the other hand high foot traffic because of the provision of needbased services will almost certainly induce criminal opportunities 6 analogous to how a shopping mall not only provides positive services and economic benefits but also provides criminal opportunities by increasing the presence of both potential offenders and targets 22 a place of worship has the ability to increase the number of potential offenders and targets in a neighborhood simply through the increased foot traffic that results we therefore evaluate a second proposition p2 places of worship will be associated with higher counts of both violent and property crime controlling for a range of factors known to be associated with crime in neighborhoods two studies reveal that places of worship might unintentionally lead to crime problems in neighborhoods triplett white determine that neighborhood variation in street crimes and domestic assaults respectively are positively associated with the number of churches in norfolk block groups desmond kikuchi examine how different types of religious congregations are linked to crime in indianapolis block groups the authors determine that their congregation measures mainly have nonsignificant effects on violence whereas for property crime most of these measures yield significant positive effects conversely there are no instances in which the density of congregations shows a crimereducing association however both these studies do not control for the presence of wellestablished criminogenic facilities and therefore the observed criminogenic effects of pow might be attributed to the latter facilities in the sections that follow we explain our data and analytic strategy used to test our propositions after reporting the findings we provide a discussion of the implications for criminological theory urban studies public policy and future research data and methods study area the study area is washington dc the capital of the united states dc is an urban area with 670050 persons according to the most recent estimate by the united states census bureau it follows that dc is one of the most populous areas within the united states specifically ranking 23 rd among us cities dc also has an ethnically diverse population 373 of residents selfidentify as white 458 as black 115 as latino and 45 as asian although the median household income is significantly more than the national average such disparity is explained by dcs high cost of living and therefore it is not surprising to observe that dcs poverty rate exceeds that of the national average washington dc offers a favorable setting for examining the effects of places of worship on crime in place for several reasons first dc has recently exhibited rather high levels of both violent and property crime among the 100 most populous us cities in 2019 for example dc ranked 24 th and 29 th in violent and property crime rates respectively therefore there is a need to determine the factors that affect the spatial distribution of crime problems in dc this leads to a second reason washington dc has a large presence of facilities which have been theorized or shown to be associated with more crime in place 131619 the presence of various criminogenic facilities has been provided through dcs open data portal and therefore this provides the necessary means to minimize the possibility of obtaining spurious effects of our key independent variable on crime furthermore dc has a large presence of pow with the corresponding longitude latitude data made publicly available through the portal notably previous researchers have documented the many challenges of collecting geospatial data on pow 7112636 most notably there is not a census of pow in the us because most of them are taxexempt and therefore they are not accurately captured by data provided by the national center for charitable statistics by using dc data on pow in combination with their large presence it affords us the flexibility to test for a multitude of main and moderating effects units of analysis and sample the us census bureau provides data on various geographicspatial units we draw on block groups specifically to link places of worship to crime in place primarily because block groups have been designed to be homogenous on a range of sociodemographic characteristics including income and poverty educational attainment household structure age and length of residence 3738 thus our selection of block groups as our units of analysis is consistent with previous empirical work that has examined neighborhood effects on a range of outcomes such as ethnic and racial segregation eg 39 social networks eg 40 walkability and health 41 gentrification eg 42 and crime 43 to name a few the present study involves secondary data analysis of block groups from publicly existing data and therefore did not require institutional review board approval for our analysis we estimate crime models using a sample of 449 block groups one block group has been dropped because it is missing necessary information from the us census american community survey we cannot use constituent tract information as a substitute for missing block group information because for this block group the tract and block group boundaries are exactly the same we suspect missing data for some variables is attributed to the fact that this area largely encompasses georgetown university and its affiliated facilities dependent variables crime counts we have collected crime data from dcs open data portal these are official crime data coded and reported by the district of columbia metropolitan police department mpd has provided crucial information on each crime incident from 2021 including the longitudelatitude coordinates of the crime the date in which the crime occurred and the type of part 1 crime committed according to the uniform crime reporting program in the united states accordingly we aggregated these data to their constituent block group and computed the number of incidents for the following crime types murders robberies aggravated assaults with a gun burglaries larcenies and motor vehicle thefts furthermore we created an index of violent crimes along with an index of property crimes notably our main models utilize the latter two indices as outcome measures whereas some of the ancillary models assess each of the crime types that comprise both indices independent variables places of worship criminogenic facilities and sociodemographic characteristics dcs open data portal provides information on places of worship in 2019 most notably the longitudelatitude coordinates of each pow we identified 742 pow in the dataset after eliminating 32 cases with coordinates outside of the study area or with duplicate coordinates although some prior studies have theorized that the effects of pow differ by the religion or denomination of pow 8944 dc only classifies its pow by seven religions of which 97 of them are determined to be christian denomination information was not provided for places of worship we also determined that the name of pow was not sufficient for accurately classifying pow into denominations thus we have created an index of the number of all places of worship aggregated to block groups one of the most enduring correlates of spatial crime patterns is the presence of facilities that provide an opportunity structure for offenders targets and weak guardianship to converge in space and time 1819 accordingly we constructed several variables to capture such facilities these facilities include the number of onsite alcohol outlets offsite alcohol outlets checkcashing stores and retail districtscenters we also include a dichotomous variable for the presence of a dc metro station it is also necessary to control for sociodemographic characteristics that have been linked to the spatial distribution of crime 25 45 46 47 drawing on data from the us census bureau we create measures of various sociodemographic characteristics in particular we utilize the american community survey fiveyear estimates from 2015 to 2019 aggregated to block groups to capture differences in economic hardship we account for poverty in block groups we computed a herfindahl index of five ethnic groups to account for the ethnic heterogeneity of block groups the concentration of both black and latino residents are also included to account for populations that have been historically marginalized by the political economy of place 48 furthermore we employ a variable of homeowners as a proxy for residential stability and we control for two types of housing characteristics the number of housing units and occupied units finally we created a variable of the population along with a variable that specifically captures the age group with the highest rate of offending and victimization that is persons aged 15 to 29 descriptive statistics for all measures are shown in table 1 analytic strategy the dependent variables of crime counts are significantly skewed and overdispersed thus we analyze the spatial distribution of crime using negative binomial regression in stata 17 a poissonbased regression that effectively accounts for overdispersion via its alpha parameter 4950 while the poisson distribution can be appropriately used to model certain count variables for the present study we find that statas likelihoodratio test which tests the null hypothesis that the dispersion parameter is equal to zero is significant for all our models negative binomial regression is therefore needed to account for overdispersion 4950 yet at the same time we acknowledge that ordinary least squares regression is a viable alternative for modeling the spatial distribution of crime especially given that a large majority of block groups do not have zero crime incidents and therefore we have estimated ancillary models using ols to be clear we are concerned with using the appropriate model to analyze the spatial distribution of crime however it should be noted that negative binomial and ols regression models are not representative of spatial regression therefore we estimate ancillary spatial error models as a final robustness check geographic units such as block groups are not islands unto themselves 51 in fact the conditions of spatially contiguousadjacent units can very well shape what occurs in the focal unit what is often referred to as a spillover effect what this means for the current study is that crime in the focal block group is likely impacted by the amount of crime in nearby block groups 52 53 54 to account for this spatial dependence we constructed a spatially lagged measure for each crime outcome using geoda software with firstorder queen contiguity such a measure captures the average number of crime incidents among contiguous block groups in relation to the focal block group we include a spatially lagged measure of crime in our full models a general expression of the negative binomial regression models that we estimate is as follows y ¼ b 1 pow þ b 2 sd þ b 3 cf þ b 4 sly þ að1þ where y is the number of crime incidents pow is the number of places of worship sd is a matrix of the sociodemographic characteristic measures cf is a matrix of the criminogenic facility measures sly is the average number of crime incidents in block groups adjacent to the focal block group and α is an intercept while one approach for modeling crime across geographic units is to specify the population count as an exposure term we have instead modeled crime counts by including the population count as a predictor given growing concerns over population count being the denominator of a calculated crime rate eg see 18 55 56 57 58 as anticipated we detected minimal evidence of spatial autocorrelation in our full models as a result of including the spatially lagged measure of crime although the morans i value was statistically significant in all instances the maximum value was 08 furthermore we assessed and found no evidence of multicollinearity issues based on variance inflation factors the maximum vif was 468 which does not exceed the commonly used cutoff of 10 5960 in the results section we present two models for both the violent and property crime outcomes we first estimate a baseline model that features our places of worship measure along with the sociodemographic characteristic measures consistent with the modeling approach undertaken by certain prior studies for example see 6812 we then estimate a full model that additionally includes the measures of wellestablished criminogenic facilities and the spatially lagged measure of crime in order to determine the extent to which places of worship maintains a significant effect on crime crime and place researchers have called for analyses to integrate measures associated with social disorganization and routine activities theories simultaneously for example see 3361 therefore our full model is consistent with this call in addition to discussing the observed effects in terms of their direction and statistical significance we highlight the magnitude of these effects in relation to one another we draw on an approach that determines the percent change in the expected crime count for a one standard deviation increase in the variable of interest using the following formula 1 � 100 this is a preferred approach because some of our independent variables drastically differ in terms of their scales 49 492493 514516 most notably the pow and facility measures are counts whereas the sociodemographic characteristic measures are percentages similar to previous crime and place studies 62 63 64 65 we utilize this approach to effectively compare the effect sizes of variables with substantively different scales on the other hand we recognize that another common approach is to assess the magnitude of the effects using incident rate ratios specifically an irr denotes the percent increase or decrease for every oneunit increase in a predictor by multiplying the difference between the irr and one by 100 where positive values yield a percent increase and negative values yield a percent decrease 49 in table 3 we compute the effect sizes using both approaches although we base our inferences on the first approach because for the second approach a oneunit increase may represent a very large increase for one predictor and a very small increase for another predictor results violent crimes model 1 a baseline model shows that places of worship is significantly and positively associated with violent crime counts controlling for sociodemographic characteristics that are commonly accounted for by crime and place researchers 45 a 1 standard deviation increase in places of worship implies a 276 increase in the expected number of violent crimes based on the following formula 1 � 100 we also find that ethnic heterogeneity is positively associated with violent crime albeit at the marginally significant threshold while the percentage of black residents also shows a positive association with the outcome the percentage of homeowners is significantly and negatively associated with violent crime whereas the number of housing units exhibits the opposite relationship this baseline model suggests that pow might have an unintended consequence consistent with proposition 2 to minimize the possibility of obtaining spurious effects of pow it is necessary to account for physical structural qualities of neighborhoods that have been linked to crime in model 2 we therefore include measures of various facilities as well as the spatially lagged measure of violent crime counts although ethnic heterogeneity is found to be no longer related to violent crime the positive relationship between the percentage of black residents and violent crime persists moreover the negative relationship between homeownership and violent crime remains as well on the other hand the positive effect of housing units becomes nonsignificant whereas population is now related to more violent crime most of the facility measures indicate significant relationships with violent crime in the hypothesized direction that is violent crime in block groups is positively linked to the presence of alcohol outlets checkcashing stores and the presence of dc metro stations respectively we also determine a positive relationship between the spatially lagged measure and the outcome what this means is that violent crime in nearby block groups is related to higher numbers of violent crime in the focal block group similar to model 1 we observe that pow maintains its significant and criminogenic effect in block groups yet the size of the coefficient from model 1 to model 2 has decreased by more than half thus the effect of pow on violent crime is much weaker as well there is a 126 increase in the number of violent crimes for a 1 sd increase in pow although the inclusion of the facility and spatial lag measures naturally reduces the pow effect in terms of magnitude the latter has one of the strongest effects among the variables in the full model the magnitude of the effect of pow specifically rivals or even outpaces those of onpremise alcohol outlets offpremise alcohol outlets checkcashing stores and the presence of a dc metro station all of this is to say is that the full model of violent crime reinforces the notion that pow appear to operate as crime generators property crimes model 3 a baseline model reveals that places of worship is significantly and positively related to higher numbers of property crime in block groups controlling for sociodemographic characteristics that have been linked to crime in place the magnitude of this effect is quite strong notes sd effect size refers to the percent change in the expected crime count using the formula exp1 100 on an all other things equal basis irr refers to the incident rate ratio effect size empty cells denote nonsignificant effects a 1 sd increase in places of worship implies a 314 increase in the expected number of property crimes consistent with proposition 2 while most of the sociodemographic characteristic measures have nonsignificant effects we do find some instances in which they do indeed affect the spatial distribution of property crimes for instance we detect positive effects for ethnic heterogeneity number of housing units and the percent aged 15 to 29 on the other hand percent homeowners exhibits a negative effect on property crime in model 4 we additionally include the facility measures along with the spatially lagged measure of property crime this provides a conservative test of the effect of pow on property crime in block groups we find that the effects of ethnic heterogeneity the percent homeowners and the percent aged 15 to 29 are no longer significant in the full model conversely the number of housing units maintains its positive effect while the population measure now shows a marginally positive association with the outcome consistent with environmental criminology 1819 each of the facility measures have a positive effect on property crime we also find evidence of property crime being spatially clustered as the spatially lagged measure indicates a positive effect the coefficient estimate for pow has decreased by more than half from the baseline to the full model which is similar to what we observed for violent crime nonetheless the criminogenic effect of pow remains strong there is a 142 increase in the number of property crimes for a 1 sd increase in pow moreover the magnitude of this effect is stronger than all the other predictors in the model with the exception of housing units and the spatially lagged measure of property crime because pow have strong positive effects on both violent and property crimes this suggests that pow may need to be reconceptualized as a crime generator rather than a source of social capital that is leveraged to reduce crime ancillary results an alternative analytic strategy is to model the violent and property outcomes using ordinary least squares regression instead of negative binomial regression thus we have estimated ols models of violent and property crimes using the same model specifications as those implemented for negative binomial regression table 4 shows the results of the ols models and it is apparent that the pattern of results is very similar to those produced by negative binomial regression although the criminogenic effect of pow weakens in magnitude between the baseline and full model for both violent and property crimes it nonetheless remains statistically significant and crimeproducing also the measures capturing sociodemographic characteristics and wellestablished criminogenic facilities yield effects that are virtually the same as those produced by negative binomial regression another line of inquiry that is necessary to investigate is whether pow affect certain crime types differently we therefore estimated separate models for each crime type that comprises the violent and property crime indices from table 5 we determine that pow is significantly and positively associated with the number of robberies burglaries larcenies and motor vehicle thefts while demonstrating a marginally significant association with murders in the same direction so aggravated assault is the lone instance by which pow fails to have a statistically significant relationship with a form of crime finally we did test for moderating effects between certain independent variables but in all instances these interaction terms were found to be nonsignificant a final consideration is to determine whether the pattern of results remains unchanged when estimating spatial regression models given that negative binomial regression and ols regression do not explicitly account for spatial autocorrelation we therefore estimate a spatial error model for both the violent and property outcomes thereby mimicking the full model specifications illustrated in table 2 specifically we draw on geoda software to conduct maximum likelihood estimation of spatial error models that include a spatial autoregressive error term table 6 shows the results of the two spatial error models and it is apparent that the pattern of results is very similar to those produced by negative binomial regression and ols regression not only is pow significantly and positively related to violent and property crimes but also the morans i of the spatial error residuals are very close to zero this means that including the spatially autoregressive error term has in effect removed all the spatial autocorrelation from these models discussion physical structural qualities of neighborhoods have been argued to have consequences for crime 21820 yet there is a dearth of research investigating how places of worship shape spatial crime patterns 69 whats more there are competing theoretical arguments for how pow would impact crime in neighborhoods with social capital and environmental criminology perspectives arguing that pow have negative and positive associations respectively accordingly we examined the spatial distribution of violent and property crime in washington block groups as a function of places of worship wellestablished criminogenic facilities and sociodemographic characteristics we highlight three key findings the first key finding was that we consistently found pow to be associated with more violent and property crime consistent with the results of two previous studies 612 this coupled with the fact we failed to detect a single instance of pow having a significant and crimereducing effect suggests that pow do in fact operate as crime generators in neighborhoods that is the presence of outsiders lessens familiarity and makes it more challenging for insiders to identify potential offenders and detect suspicious crimerelated activity 181924 for insiders there may be ambiguity concerning whom they should direct territorial behavior at but also the situational contexts by which it is acceptable to do so 246667 recent studies have drawn on social media cell phone and transportation data to measure various properties of the ambient population and have indeed determined that the size of the ambient population is associated with more crime in place 5658 68 69 70 thus we propose that a significant increase in the volume of potential offenders and targets is enough to disrupt a process whereby social capital is formed in pow and later used to instrumentally prevent and solve crime problems the second key finding was that places of worship exerted strong criminogenic effects even after controlling for wellestablished criminogenic facilities and sociodemographic characteristics we found that the effects of pow were stronger in magnitude than most of the other predictors in the violent and property crime models including alcohol outlets with onsite consumption checkcashing stores and the presence of a dc metro station moreover ethnic heterogeneity and poverty two predictors often equated with social disorganization 4546 were not significantly related to more crime because pow are important local institutions insofar as they promote education steady employment marriage drug and substance avoidance and friendships among members our findings should not be interpreted as an indictment on religion or pow rather it highlights pow as an ecological risk factor for neighborhood crime similar to how shopping malls central business districts restaurants and retail stores have been deemed to operate as crime generators 13162235 our results have implications for both researchers and policymakers when modeling crime across geographic units crime and place researchers importantly control for factors that induce criminal opportunities we suggest additionally controlling for pow to minimize the possibility of obtaining spurious effects with regards to the independent variables of interest relatedly for crime policy we encourage researchers and city officials to account for the presence of pow in determining the risk of crime across areas within a city this could be accomplished via two data driven approaches 1 combine regression analysis and the mapping of predicted outcome variables eg see 71 and 2 implement risk terrain modeling eg see 72 many policing strategies and intervention efforts are predicated on identifying areas with a disproportionate amount of crime therefore the incorporation of pow may provide more accurate profiles on which areas would benefit the most from increased policing or municipal resources services and partnerships limitations and directions for future research although the current study provides crucial insight into places of worship and crime in neighborhoods we acknowledge certain limitations and directions for future research first because of data limitations we were unable to test the theorized mechanisms that may link pow to violent and property crime in neighborhoods thus we encourage future research to collect neighborhood level data on social capital civic engagement foot traffic and anonymity in order to test whether these factors do in fact mediate the effects of pow on crime second our key independent variable captures the presence of places of worship and therefore it does not capture the differential capacity of pow to impact crime a natural extension is for future studies to assess variation in neighborhood crime as a function of more finegrained characteristics of pow such as the number of adherentsmembers employees incomedonations and years of operation a few studies have explored this line of inquiry 61127 yet it remains to be seen whether measures that account for the differential capacity of pow provide additional knowledge beyond what can be gained from the standard measurement approach also it is an open question the extent to which dcs data on pow is exhaustive and accurate though we have no reason to suspect that these data are any less valid than other pow sources and there is no reason to think that any missing data is not random or systematic third the analysis is crosssectional and therefore it is unable to test how changes in the number of pow influence changes in the number of crimes while this does not repudiate the findings of the present study as understanding the spatial distribution of crime at a single timepoint offers an important baseline future research may want to perform a longitudinal analysis using a fixedeffects approach finally the analysis and findings pertain to neighborhoods of a single city it is therefore possible that the observed effects might operate differently across us cities accordingly future work needs to examine potential relationships between places of worship and crime across a diversity of ecological settings including cities beyond the united states the data on crime places of worship and wellestablished criminogenic facilities can be found on open dc the data on sociodemographic characteristics can be found on the united states census bureau website

places of worship pow have traditionally been argued to have crimereducing effects in neighborhoods because of their ability to produce social capital yet the evidence for this proposition is surprisingly weak consequently an alternative proposition rooted in environmental criminology suggests that pow might unintentionally operate as crime generators in neighborhoods insofar as they induce foot traffic and undermine guardianship and social control capabilities because of these competing propositions in combination with the limited number of studies on this topic we conduct a block group analysis of crime places of worship wellestablished criminogenic facilities and sociodemographic characteristics in washington dc we estimate negative binomial regression models of both violent and property crime and find strong evidence for only one of the propositions with the effects of pow being relatively strong in comparison to other predictors in the models the implications of these findings for criminology urban studies and public policy are discussed

introduction epidemics are considered to be a prominent source of psychological and social disorders eg fear anxiety and reluctance to communicate with others 1 it is common during epidemics and pandemics for people to suffer from stress and anxiety including the fear of infection and death avoiding receiving medical treatment at health facilities fearing the loss of relatives and fearing isolation because of quarantine which causes boredom loneliness and depression 2 there is a psychoneurotic connection between acute inflammations of the respiratory system and psychological disorders as occurred with sars decades ago people in quarantine suffer from boredom anger and loneliness symptoms such as cough and fever can increase anxiety intrusive thoughts and the fear of covid19 infection 3 the world is currently experiencing the covid19 pandemic that spread to all countries in a short amount of time the who declared the novel coronavirus outbreak a pandemic in march 2020 and predicted it to spread to all countries urging countries to take the necessary steps to control it 4 the number of people who have had a coronavirus infection is in the millions it is therefore a threat that invokes anxiety depression and indignation in people to protect themselves people now adhere to social distancing so as to not catch the infection from close contact with others 5 being at home all the time can affect the mental health of both children and adults children and adolescents have therefore been advised to focus on home activities to forget about the negative effects of the coronavirus 6 middle eastern countries have also been affected by the pandemic by 7 july 2020 214000 confirmed coronavirus cases and 1968 deaths had occurred in saudi arabia in the united arab emirates 520068 infected cases and 324 deaths were reported in egypt 760222 infected cases and 30422 deaths were reported a total of 1167 infected cases and 10 deaths were reported in jordan 7 several studies have reported on the negative effects of epidemics and pandemics on the psychology of infected people and their caregivers 89 those studies reported a high level of psychological stress among people providing care to infected cases in many studies people with acute respiratory syndromes were reported to have psychological disorders such as anxiety depression and other forms of mental illness 10 11 12 in the saudi context in terms of the effect of mers on psychological stress female students had a higher level of psychological stress than that of male students 13 in the omani and bahraini contexts the coronavirusinduced anxiety among families was average and no significant differences were found by country however there was a significant difference in favor of females people aged over 40 years people with lower educational levels and unemployed people retired people were reported to experience the lowest level of anxiety 14 in terms of the psychological impact depression anxiety and stress at the beginning of the coronavirus pandemic in a sample of 1210 participants from 194 chinese cities 538 of the participants suffered an acute psychological impact because of the pandemic whereas about 288 of the participants were found to suffer from average to acute anxiety 15 in a study conducted in italy the percentage of people having high and severe coronavirusrelated anxiety ranged between 289 and 743 16 the who also asserted that some populations such as people working in health and security had infection fears and suffered from stress due to dealing with infected people work pressure and changed sleep and eating routines ministers and leaders in authorities confronting the pandemic suffer from similar psychological effects 17 two surveys were also conducted by the british academy of medical sciences via the internet the results of the first survey revealed that the majority of the sample suffered from problems with mental health participants reported fears about their health and access to support and services during the pandemic the second survey reported anxiety among participants about social isolation and economic difficulties resulting from the pandemic with expectations of the increased occurrence of anxiety and stress during the pandemic researchers expect an increase in the number of depressed people and people who are prone to commit suicide in 2003 during the sars epidemic the rate of suicide in people over 65 years witnessed a 30 increase researchers asserted that actions taken at that time to eliminate the spread of sars had serious effects on peoples mental health as unemployment rates and feelings of financial insecurity and poverty increased 18 research results concerning gender differences in epidemicrelated anxiety are inconsistent with some studies reporting higher levels of anxiety among females 15161920 and others reporting higher levels of anxiety among males 21 some studies have reported differences in anxiety about the future by gender in favor of females and by social status in favor of the unmarried no differences were found by profession 22 23 24 lowtoaverage anxiety levels were found between participants the frequency of mild average and severe anxiety among participants was 77788 56 and 2752 respectively the study did not find gender differences in depression and anxiety on the other hand it found differences in favor of the unmarried 25 the authors in 15 found higher levels of anxiety among students than those among employeesworking personnel the level of anxiety did not correlate with social status the size of the family or age similarly social status having no children and workplace did not significantly contribute to anxiety or depression 16 smartphone use has been globally widespread during the coronavirus pandemic which has induced feelings of isolation social distancing and a need for leisure recreation and shopping 26 with this intensive use smartphone addiction has become a universal concern 27 it is a recent phenomenon in human behavior that can adversely affect the mental health and social functioning of people who overuse smartphones 28 smartphone addiction is the overuse or compulsive use of smartphones resulting in negative consequences in social behavioral and emotional functioning 29 it is a form of behavioral addiction that makes the individual unable to control the strong desire to use the smartphone and its applications with the loss of productivity the denial of negative effects preoccupation and feelings of annoyance and even panic when deprived of the smartphone 30 some studies have shown a connection between smartphone addiction and psychological adjustment problems eg anxiety and depression a korean study found that smartphone addiction can be predicted by depression 31 a similar finding was also reached in a chinese study 32 where loneliness which relates to depression was found to be a strong predictor of smartphone addiction in an american study social interaction anxiety was found to predict smartphone addiction 33 another study found a positive correlation between anxiety and depression and smartphone overuse 34 smartphone addiction could be predicted by anxiety and depression anxiety as a major symptom of smartphone addiction emerges once the person is deprived of their smartphone 3536 this shows that the smartphone itself is a source of anxiety 37 smartphone overuse is a factor leading to mental health problems they also found that gender was the strongest predictor of depression symptoms of anxiety were more frequent in younger people 38 a positive correlation between smartphone addiction and psychological stress was also found research also revealed a weak relationship between age and hours of use on the one hand and smartphone addiction on the other 39 more than one study did not find a correlation between age and smartphone addiction 4041 meanwhile a positive correlation was found between daily use hours and the problematic use of smartphones 42 however differences in smartphone addiction in favor of individuals using a smartphone for more than four hours a day were found 43 this same finding was reported by haug who reported a correlation between smartphone addiction and daily use hours 44 facebook addiction and state anxiety could be predicted by an increased use rate the interaction of gender and trait anxiety predicted facebook addiction 45 as mentioned above and the increase in cases of covid19 infection around the world in general and in middle eastern countries in particular can lead to increased levels of anxiety with negative behavioral effects such as smartphone addiction the present study aimed to identify the level and frequency of anxiety about covid19 infection in some middle eastern countries and differences in this anxiety by country gender workplace and social status the study also aimed to identify the predictive power of anxiety about covid19 infection variables daily smartphone use hours and age in smartphone addiction method 21 participants this study comprised a total of 651 participants from four middle eastern countries jordan saudi arabia the united arab emirates and egypt their age ranged between 18 and 73 years of the 651 participants 246 were single 378 were married and 27 were divorced the number of participants working for the government the private sector and students were 242 243 and 166 respectively instruments 221 anxiety about covid19 infection scale the authors developed a scale to measure anxiety about covid19 infection to develop the scale the authors surveyed scales in the relevant literature eg the statetrait anxiety inventory 46 and scales of social anxiety and general anxiety 15 47 48 49 50 51 the authors also used anxiety indicators including the whos reports about prevention and the health guidelines for dealing with the virus the scale had 40 items with 5point likert scales ranging from 5to a very high degree to 1to a very low degree the preliminary version of the scale was facevalidated by five professors who specialized in psychology measurement and evaluation they were asked to judge if items represented the measured trait and if the wording of items was sound and clear this resulted in modifying some items but no deletions were made correlations among items and the total score were computed these ranged from 0628 to 0842 all of which were high and statistically significant the unilaterality of the scale was established by factor analysis the results revealed that all items were significantly loaded on the first factor the first eigenvalue was 22025 and the second eigenvalue was 2345 the explained variance of the first factor was 5563 this is consistent with rechases 52 suggestion that the unilaterality condition is met if the first factor can explain at least 20 of total variance the reliability of the scale was then checked by computing the alpha cronbach coefficient of participant scores the scale yielded an alpha coefficient of 0978 which indicates that the scale was highly reliable participant scores on the scale ranged between 40 and 200 scores were categorized by range into high anxiety with a weighed mean ranging from 367 to 5 average anxiety with a weighed mean ranging from 234 to 366 and low anxiety with a weighed mean ranging from 1 to 233 smartphone addiction inventory after surveying the literature on smartphone addiction and the instruments used in relevant studies we used the smartphone addiction inventory that was used in the studies of pavia cavani blasi and giordano 53 and lin et al 54 it is an inventory developed on the basis of the chinese internet addiction inventory 55 items of this inventory assess several dimensions of smartphone addiction compulsory use withdrawal tolerance and problems in relationships with others and time and health management the reliability examination of the inventory was originally performed on a chinese sample of 283 university students another examination of its psychometric characteristics and factor structure was performed in italy 53 the sample consisted of 485 male and female students whose ages ranged between 10 and 27 years exploratory and confirmatory factor analyses revealed that the items of the inventory were loaded on five factors time spent compulsivity daily life interference craving and sleep interference the alpha cronbach reliability coefficient of the whole inventory was 094 the english version of the inventory was translated into arabic by two bilingual researchers the accuracy of translation was verified by back translation which was performed by a third researcher the retranslated version was then compared with the original english version and differences were very few very few adaptations were made to make the inventory suitable to the arab environment as a result the version used in the study originally had 24 items measuring 5 dimensions with a 4point rating scale ranging from 4strongly agree to 1strongly disagree thus a respondents score on the inventory ranged from 24 to 96 the higher the score of a respondent was the higher their level of smartphone addiction the inventory was validated by having it refereed by specialists and by establishing its construct validity for construct validation correlations among items and the total score were computed and they ranged between 063 and 085 which were all statistically significant the unilaterality of the inventory was established by exploratory factor analysis the results revealed that all items significantly loaded on the first factor eigenvalues were 12632 for the first factor and 1460 for the second factor the explained variance of the first factor was 52635 and 31299 this indicates that the inventory was unilateral the reliability of the inventory was then checked by computing the alpha cronbach coefficient of the participants scores the inventory yielded an alpha coefficient of 0982 which indicates that it was highly reliable procedures the authors developed an electronic questionnaire including the scale on anxiety about covid19 infection the smartphone addiction inventory and demographic data the link to the questionnaire was then sent to participants via whatsapp and twitter with the help of authors who live in the four countries included in the study completion of the questionnaire took three weeks the application of the questionnaire coincided with the application of strict health procedures imposing social distancing and quarantining movement between cities was also prohibited in the four countries other procedures included the prohibition of gatherings distant learning school closures and restricted travel the aims of the study and instructions for completing the questionnaire were provided with the electronic questionnaire participants were told that the completion of the questionnaire was voluntary and that data collected from the completed questionnaires would only be used for research purposes for this reason they were not required to write their names or give any information about their identities they were also told that the honest completion of the questionnaire would be the key for the successful completion of the study following this the authors scored and codified the received completed questionnaires and categorized the data according to the study variables data analysis the obtained data were statistically analyzed using ibm spss statistics25 to answer the research question about the frequency of anxiety about covid19 infection descriptive measures were used the ttest for independent samples was used to identify gender differences in anxiety about covid19 infection and the anova test was used to identify differences in anxiety about covid19 infection by country social status and workplace pearsons correlation was used to explore relationships among variables lastly the multiple stepwise regression test was used to explore the predictive power of the anxiety about covid19 infection scale daily smartphone use hours and age in smartphone addiction results frequency of anxiety about covid19 infection among participants table 1 shows means standard deviations and percentages of anxiety about covid19 infection by country table 1 shows that the country with the highest anxiety about covid19 infection was egypt followed by saudi arabia the united arab emirates and jordan differences among countries in anxiety about covid19 infection to identify differences among the four countries in anxiety about covid19 infection the anova test was performed these results are listed in table 2 the data in table 2 reveal that there were significant differences among countries in anxiety about covid19 infection the effect size was partial eta squared 013 the country variable explained 13 of variance in anxiety about covid19 infection after performing post hoc analysis using the scheffe test differences were found to be significant only between jordan and egypt in favor of egypt of which the mean was higher gender differences in anxiety about covid19 infection the ttest was performed to explore gender differences in anxiety about covid19 infection in the four countries table 3 presents these results table 3 shows that there were no statistically significant gender differences in anxiety about covid19 infection in saudi arabia however there were significant differences in jordan and egypt in favor of females and in the united arab emirates in favor of males the effect size according to cohen was small in the jordan sample and average in the egyptian and emirati samples at the level of the whole sample there were significant differences in favor of females with a low effect size differences in anxiety about covid19 infection by social status differences in anxiety about covid19 infection by social status were explored by performing the anova test with three categories single married and divorced these results are presented in table 4 table 4 shows that there were no significant differences in anxiety about covid19 infection by social status differences in anxiety about covid19 infection by workplace differences in anxiety about covid19 infection by workplace were explored by performing the anova test with three categories governmental job privatesector job and student these results are presented in table 5 table 5 shows that there were no significant differences in anxiety about covid19 infection by workplace predicting smartphone addiction by anxiety about covid19 infection daily smartphone use hours and age pearson correlations among study variables were computed a statistically significant negative relationship was found between age and smartphone addiction a statistically significant negative relationship was found between age and anxiety about covid19 infection a statistically significant negative relationship was found between age and daily smartphone use hours lastly a statistically significant positive relationship was found between smartphone addiction and anxiety about covid19 infection and between smartphone addiction and daily smartphone use hours to identify the predictive power of anxiety about covid19 infection daily smartphone use hours and age in smartphone addiction stepwise multiple regression was used table 6 shows these results collinearity was checked using the variance inflation factor and the value was less than 10 which indicated that the problem of multicollinearity was not present anxiety about covid19 infection was the best predictor of smartphone addiction as it could explain 0181 of the variance in smartphone addiction the interaction of anxiety about covid19 infection and daily smartphone use hours explained 0273 of the variance in anxiety about covid19 infection thus the daily use hours variable could predict an additional amount of smartphone addiction of 0090 which was significant at the 001 level the prediction equation can be stated as follows smartphone addiction 31160 0168 × anxiety about covid19 infection 1127 × daily use hours discussion the results of the study revealed that the percentages of participants who had high average and low anxiety about covid19 infection were 103 373 and 524 respectively this refers to an average level of anxiety at the level of the whole sample regarding the frequency of anxiety in the four target countries all frequencies were at the average level with egypt being in first place with a mean of 2655 followed by saudi arabia the united arab emirates and jordan this finding largely concurs with the findings of previous studies conducted in some gulf states during the outbreak of the pandemic those studies reported average anxiety and stress resulting from the pandemic 1314 the percentages here were also close to their counterparts in the chinese study 15 and slightly higher in high anxiety than the percentages in the italian study 16 the current percentages showing average and high anxiety exceeded their counterparts in the australian study 25 data collection in the present study coincided with the application of strict health procedures in all countries globally eg the prohibition of gatherings and curfews regarding differences in the frequency of anxiety about covid19 infection in the four arab countries the results revealed significant differences between egypt and jordan in favor of egypt this finding seems logical given that egypt in comparison with jordan was late in imposing health restrictions and giving the real numbers of infected cases unlike egypt jordan took actions with the appearance of the first infected case jordan imposed a curfew and closed schools governmental institutions mosques and airports such procedures largely reduced the number of infected cases accordingly the number of infected cases in jordan up to 7 july was 1167 with a recovery rate of 82 and a death rate of 008 on the other hand the number of infected cases in egypt up to 7 july was 76222 with a recovery rate of 28 and death rate of 45 this may refer to a deficiency in health procedures and the provision of health support to critical cases that required special and costly treatment protocols egypts population is also more than 100 million the frequency of high anxiety in egypt exceeded its counterparts in a number of arab and asian countries that were covered in previous studies 13 14 15 16 25 the finding of insignificant differences in the level of anxiety about covid19 infection between saudi arabia and the united arab emirates is in line with the study conducted on omani and bahraini samples 14 in which no significant differences were found between the two countries in anxiety about covid19 infection the saudi environment is largely similar to the omani and bahraini environments analysis of the data collected from the whole sample revealed gender differences in anxiety about covid19 infection in favor of females gender differences were also found in three of the four countries the differences were in favor of females in the egyptian and jordanian samples and in favor of males in the emirati samples no gender differences were found in the saudi sample this general finding about females having higher anxiety about covid19 infection than males concurs with several previous studies 13151656 this finding is also consistent with previous studies exploring gender differences in general psychological anxiety 1920 22 23 24 57 the finding about gender differences in covid19 infection anxiety in favor of males in the emirati sample can be explained by the fact that most respondents in the sample were nonemirati who represent about 89 of the total population in the united arab emirates those respondents live with their families and work in various sectors in the country male residents in the united arab emirates may have higher levels of anxiety than females do because of fears about their jobs with the economic damages resulting from the pandemic some sectors there made some employees redundant or reduced their salaries for this reason nonemirati male employees may fear the loss of their jobs and becoming unable to sustain their families women on the other hand do not have these fears because women in eastern societies are not required to work and sustain their families furthermore women stay at home most of the time which makes them less anxious about catching the infection this finding is consistent with 14 in which residents had higher levels of anxiety because of the lack of occupational security and being in countries other than their own this finding is also consistent with studies investigating general anxiety and anxiety about the future in which males were reported to have higher levels of anxiety than females 2158 males and females in the saudi sample had comparable levels of anxiety about infection a possible explanation for this finding is that they live in the same environment and face the same threats this finding is in line with the australian study in which no significant difference in infection anxiety was found 25 regarding the effect of social status on anxiety about infection no significant differences were found among single married and divorced participants this means that anxiety about infection is not affected by ones social status or being single married or divorced this same finding was reached in 1516 it is however inconsistent with 25 in which the unmarried had a more significant level of anxiety this finding also concurs with studies conducted before the coronavirus pandemic in which the unmarried had higher levels of general anxiety 22 23 24 as with social status no gender differences were found in infection anxiety by workplace participants working for the government and the private sector and students had comparable levels of anxiety about infection this finding is consistent with 16 and with studies that did not find differences in general anxiety by workplace 22 23 24 however it is inconsistent with 15 in which students outnumbered employees in terms of anxiety and with 14 in which unemployed respondents outnumbered employees in terms of infection anxiety overall social status and workplace need to be further studied with other variables such as educational level income and age because of the inconsistent results about the latter two variables in the few studies conducted so far regarding the predictive power of infection anxiety daily smartphone use hours and age in smartphone addiction stepwise multiple regression analysis revealed that smartphone addiction can be predicted by infection anxiety and daily smartphone use hours age on the other hand did not contribute to the prediction of smartphone addiction infection anxiety was the strongest predictor of smartphone addiction followed by daily use hours this means that people who are more anxious about infection tend to excessively use their smartphone the authors did not find studies exploring the relationship between infection anxiety and smartphone addiction however the current studys findings are in line with previous studies that reported a positive correlation between general anxiety depression stress and loneliness on the one hand and smartphone addiction on the other 9 27 28 29 30 31 32 33 34 3739 this finding seems logical and concurs with the mainstream views from previous research with the outbreak of the coronavirus and restrictions such as social distancing and staying at home most of the time the smartphone can be the only resort for people in order to vent pass time and search for information about the virus the smartphone is also used for distant learning due to the closure of schools people may therefore excessively use the smartphone to the degree that they cannot control the time spent in its use this in turn can lead to compulsivity sleep interference and excessive attachment to the smartphone which are all symptoms of addiction this concurs with 3536 reporting anxiety as a major symptom of smartphone addiction it also concurs with the assertion of 59 that overdependence on smartphones and the use of social media to know about current events can result in the fear of missing events known as fear of missing out the finding that daily use hours contribute to smartphone addiction is consistent with some studies 42 43 44 45 and is inconsistent with 39 in which a weak relationship was found between smartphone use hours and addiction the finding that age did not contribute to the prediction of smartphone addiction despite the presence of a significant negative relationship between them indicates that age is not a factor contributing to smartphone addiction during the coronavirus pandemic this is in line with most studies that have examined the relationship between age and smartphone addiction 39 40 41 lastly pearsons correlation revealed a significant weak relationship between age and infection anxiety this finding is partly in line with studies in which anxiety was found to be more frequent among young people 162556 it also concurs with the contention that young people are more prone to anxiety because of their quick access to information via social media 60 this finding is inconsistent with 14 in which people aged over 40 years were found to be more anxious about infection and with 15 in which age did not correlate with anxiety conclusions this study explored anxiety about covid19 infection and its relationship with some psychological and demographic variables it revealed that this anxiety exists in some middle east countries regardless of their social status workplace and age participants in the study suffered averagetohigh infection anxiety some sort of intervention is therefore required so this anxiety does not become morbid the study also revealed that infection anxiety can lead to smartphone addiction with all its negative psychological and physical effects as well as the disorder known as nomophobia women were found to be more anxious about infection anxiety about infection and daily use hours were found to significantly contribute to smartphone addiction it is therefore necessary to develop preventive programs to eliminate this phenomenon awareness must also be raised about the judicious use of smartphones people should be advised on how to find alternative ways to fruitfully spend time control their desire to use smartphones and sterilize their phones which can be a source of infection it is also recommended that social media should be used to support people during the pandemic and instruct them on how to keep safe and manage their anxiety they should be told not to show fear and anxiety in front of their children as this can leave negative effects on their development people especially mothers should be advised not to spend too much time on social media as this can make them anxious this can adversely affect childcare which might cause insecure attachment during quarantine people should telecommunicate with relatives to alleviate the impact of social isolation on children and adolescents people can make an opportunity out of the crisis to practice activities and hobbies for which they previously had no time adults should distract children and adolescents from bad news by providing them with daily home activities and events the use of smartphones and electronic games by children should be monitored so that they do not become addicted to them it is a good idea to develop electronic programs to enhance peoples psychological hardiness and to teach them how to face crises there should also be programs of interest for old people to help them safely pass the time it is also necessary to use social media to spread awareness about the virus and preventive healthcare in this respect medical sites do not make good use of social media study results show that further research is required to explore anxiety about infection on larger samples and different populations future research is expected to focus on the negative effects of infection anxiety research endeavors are also required to develop and test the effectiveness of counseling and preventive programs in eliminating pandemicrelated anxiety researchers can also examine the relationship between anxiety about infection and other variablessuch as depression burnout anxiety about the future and death psychological security hardiness optimism and pessimism healthy behavior selfefficacy and achievementand attitudes to the vaccination process even though the results of the study documented the relationship between smartphone addiction and gender the application of the instruments to a limited sample from four middle eastern countries whose ages ranged between 18 and 73 limits the generalizability of the results to age groups and populations in different contexts furthermore the study was limited to an electronic questionnaire distributed via social media during the period of restrictions on movement and social distancing the authors used the available data in the four countries about the numbers of infected cases and deaths up to 7 july 2020 cautious interpretation of results is important due to the use of a selfreported questionnaire the results of selfreported questionnaires are prone to be affected by social desirability lastly in this study we used the descriptivecomparative method further experimental and longitudinal studies using quantitative and qualitative data collection tools are required informed consent statement informed consent was obtained from all subjects involved in the study all the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the helsinki declaration of 1975 as revised in 2000 informed consent was obtained from all the patients for being included in the study data availability statement data of this research will be available on demand

this study explores the level and frequency of anxiety about covid19 infection in some middle eastern countries and differences in this anxiety by country gender workplace and social status another aim was to identify the predictive power of anxiety about covid19 infection daily smartphone use hours and age in smartphone addiction the participants were 651 males and females from jordan saudi arabia the united arab emirates and egypt the participants ages ranged between 18 and 73 years m 3336 sd 1069 a questionnaire developed by the authors was used to examine anxiety about covid19 infection furthermore the italian smartphone addiction inventory was used after being translated adapted and validated for the purposes of the present study the results revealed that the percentages of participants with high average and low anxiety about covid19 infection were 103 373 and 524 respectively the mean scores of anxiety about covid19 infection in the four countries were average egypt m 2655 saudi arabia m 2458 the united arab emirates m 2413 and jordan m 2336 significant differences in anxiety about covid19 infection were found between egypt and jordan in favor of egypt significant gender differences were found in favor of females in the jordanian and egyptian samples and in favor of males in the emirati sample no significant differences were found regarding workplace and social status the results also revealed a significant positive relationship between anxiety about covid19 infection daily smartphone use hours and age on the one hand and smartphone addiction on the other the strongest predictor of smartphone addiction was anxiety about covid19 infection followed by daily use hours age did not significantly contribute to the prediction of smartphone addiction the study findings shed light on the psychological health and cognitive aspects of anxiety about covid19 infection and its relation to smartphone addiction