Datasets:

mimiklee

/

masterthesis_data

like 0

520617c508c2711fa18b8aad09c340540b3215e8

Modeling and Simulating Student Protests Through Agent-Based Framework

This paper presents an agent-based model to study the effect of grievance, net risk, social, sympathy, and political influence on the likelihood of student protests emerging in South Africa universities. Studies of student protests in several fields have been conducted, but no ABM has been used to explore factors contributing to student protests. Student protests have proved to be disorderly, frequently leading to property damage, academic program cancellations, and injuries. Simulation experiments demonstrated that inequality level, number of activists, activist's influential size, number of friendship ties, suspend delay, and sympathy are elements that determine the model of social conflicts, since there are statistically significant in the logistic regression. For university administration to effectively handle disruptive student protest actions, risk management policies should focus on understanding network structures that integrate students' interactions to monitor the spread of opinions that initiate protest mobilization.

INTRodUCTIoN Student protests at Public Higher Education Institutions (PHEI) in South Africa continue to be prevalent, even after more than two decades of democracy, for example, #FeesMustFall protest (Luescher, Loader, & Mugume, 2017). Students are becoming impatient when faced with current high tuition fees, decreased funding opportunities, inadequate student residence, and significant academic and financial exclusions, given the current political and socio-economical landscapes fueled by the promise presented by the National Plan for Higher Education (2001) document (Dominguez-Whitehead, 2011), hence we are currently witnessing high volume of state-directed protests in our institutions. Recent student protest actions have proven to be unruly and frequently leading to property damage, academic program cancellations, intimidation of non-protesting students, and injuries (Peté, 2015). Several studies of student protest have been conducted in a variety of fields, including social and political studies (Oxlund (2010); Dominguez-Whitehead (2011)), but no agent-based model (ABM) has been suggested to predict student protests at higher education institutions. The construction of such a model will aid in the forecasting of student protests. Studying how social conflicts emerges from social context and how they lead into a protest remains a central important topic in political studies, history, social psychology, and sociology (Lemos, Lopes, & Coelho, 2014a). However, several studies that seek to evaluate communities through the framework of complex adaptive systems have increased in the last decade. The most adopted approach in modelling complex system is bottom-up technique, which represent a fundamental characteristic of ABM (Ormazábal, Borotto, & Astudillo, 2017). A number of studies based on conflict or violent collective behavior have shown how ABM through crowd simulation can support the development of a useful techniques to examine protests (Bhat & Maciejewski, 2006;Epstein, 2002;Lacko et al., 2013). In the early-2002, Epstein developed a widely adopted classical agent-based computational model of civil violence, and since then, crowd simulation has evolved. For example, the Epstein's model was adopted by among other, Lemos, Lopes, and Coelho (2014b), Kim and Hanneman (2011). Agent-Based Modeling Simulation (ABMS) approach is ideal when modeling a complex scenario, for example, studying the behavior of actual protest participants which involves the interaction of heterogeneous agents (Pires, 2014). This study aims to design, implement, and simulate a theoretically grounded Agent-Based Model (ABM) that predicts the emergence of student protests in order to gain insight understanding of macro-level behavioral dynamics of a complex student protest system at Public Higher Education Institutions (PHEI) in South Africa. The proposed model will assist in identifying micro-level behavioral patterns which may result into a protest action. The understanding of this emergent behavior will assist university management in several ways, such as identifying behavioral patterns that may result into a protest and subsequently prevent damage to property, intimidation of staff and non-protesting students and possible injuries (Peté, 2015). The structure of this article is as follows: In the second section, an overview of the agentbased modeling method is provided. Then, the article presents an investigation of ABMs of social conflicts proposed by other scholars. Hypotheses and a conceptual model are then introduced with the description and implementation of the model. The article is concluded by the findings of the simulation experiment and followed by conclusion. --- AGeNT-BASed ModeL ABM is an early majority modelling paradigm that is gaining its popularity in several fields that leads to modelling of complex dynamic systems such as student protests, artificial financial markets, pedestrian movement, and population dynamics (Macal & North, 2008). Agent based model is normally used as a bottom up individual-based approach to simulate heterogeneous and autonomous decisionmaking agents that uses behavioral rules to interact with their artificial world (Kiesling, Günther, Stummer, & Wakolbinger, 2012). ABM can be utilized as a methodology to simulate behavioral patterns which are challenging to be modelled using mathematical equations (Dada & Mendes, 2011). In addition, interactions of the agents within an ABM are represented by a set of behavioral rules and the emerged behavioral actions or patterns are observed at the macro level. Agents social interactions may have non-linear influence which can be a challenge to represent using analytical mathematical equations (Lu, 2017). In ABM, social interactions can be categorized as micro-level, meso-level and macro-level. Micro-level represent agent to agent or agent to environment interactions at a local level (Démare, Bertelle, Dutot, & Lévêque, 2017). At micro-level, students can exchange their discrepancies in resources allocation (levels of inequalities) to formulate their dissatisfaction or grievances. Meso-level represents interactions between agents and their group of conformity (Kiesling et al., 2012). For instance, at meso-level, student activists can influence a group of students that are linked to their political group, or a student can influence friends that are linked to their social group as well as neighbors during protest recruitment. Macro-level represents the emergence of overall patterns of the system at a global level (Démare et al., 2017). For instance, macro-level represents the overall emerged behavioral pattern used to provide model users with insights about students' protest under conditions which are systematically represented within an environment. Co-evolution and emergence of social structures are the outcomes of agent-based model simulation (ABMS) which are mostly used in predicting human behaviour. System patterns accumulated from a series of changing behavioral rules by heterogeneous agents can lead to coevolving or emergent phenomena (Narasimhan, Roberts, Xenitidou, & Gilbert, 2017). Emergence represent the overall system behavioral patterns that are simulated, as well as resulting from the continuous interactions of agents at individual level over a set of time (Narasimhan et al., 2017). Co-evolving social structure are caused by peer-to-peer agent's behavioral influence. Agent Based Modelling approach represents a process that changes over a period of time (Dulac-Arnold et al., 2020). ABM contribute to the development of knowledge and understanding of significant processes and methods that enables complex adaptive systems to be solved. ABMs are used to formulate theories instead of regenerating the exact occurrence of events nor provide accurate predictive model (Dulac-Arnold et al., 2020). ABM aids in exploring the significance of several parameters under certain artificial world settings and various agents rule set (Dulac-Arnold et al., 2020). Agent-based models of social conflicts, such as student protests, can help researchers get a better understanding of how social gatherings aimed at addressing social inequities mobilize a large number of people (Lemos 2018). Furthermore, the social conflict model may show how individuals choose to organize a collective group based on their perceived grievances (Kim & Hanneman, 2011;Lemos 2018). The social network aspect of ABM, in particular, may be utilized to better understand the function of newly emerging technologies like social media as a valuable protest mobilization tool (Filippov, Yureskul, & Petrov, 2020;Waldherr & Wijermans, 2017). Furthermore, protest simulation models may show how a network of social and political groups in deprived communities can be used to mobilize people in order to address accumulated grievance (Akhremenko, Yureskul, & Petrov, 2019). --- SoCIAL CoNFLICTS Social conflict is an appropriate theory to investigate causes of protests within societies. Social conflict studies present how conflicts emerge, and their variations, as well as their societal effects. In the study of Lemos , Coelho, and Lopes (2017), social conflict is defined as confrontation or social dynamic of imposing will to produce desire end. For example, conflict can be in the form of a protest, disagreement between few individuals, or goes as far as an international conflict, such as World war (Pires, 2014). Inequality in the distribution of resources and power have been identified as main sources of existence of conflicts between population groups (Pedersen, 2004). Furthermore, Social conflict generates beliefs, unity and sympathy among interacting individuals or groups within the society (Marx, 2020). Weber suggested two classifications of social actions, which are instrumental rationality, in which objectives are attained through rationally chosen actions, as well as value-oriented rationality whereby values are attained by conscious believe (such as religious, ethnicity, political, and so on) (Fukuda, 2018). Three social stratification dimensions-economic class, status group, and political party-were provided in other researchers (Protsch & Solga, 2016). These stratification dimensions show significant variations in how people behave or think. When it comes to protests, status groups offer chances for compassion and the mobilization of others who share the same grievance, while political parties offer forums that encourage the action of those who feel wronged (Bischof, 2012). To conceptually study the interaction between class and race, as well as further examining the patterns of protest waves, Kim and Hanneman (2011) suggested an ABM to model crowd dynamics of workers' protests. According to Kim and Hanneman (2011), the motivation to protest is driven by a grievance, which is symbolized by relative deprivation brought on by wage disparities, a perception of an increased risk of being detained, and group affiliations, which is shown by ethnic and cultural identities. The simulation experiment results in Kim and Hanneman (2011) show that wage disparities (or grievances) have a significant impact on how frequently protests occur. However, Kim and Hanneman (2011) analysis only considers the neighborhood social contacts of agents without integration of influences from network structures and activists. Similarly, the study of Ormazábal et al. (2017) developed an ABM to explore the dynamics of social conflicts on Epstein (2002)'s ABM of revolution when money distribution is incorporated to condition each individual's level of grievance. The study of Ormazábal et al. (2017) is aimed at evaluating the effect of inequalities in the distribution of resources on social mobilizations. Furthermore, Ormazábal et al. (2017) ascertained that protest outbursts and strength are significantly reduced when the level of dispersion of resources are even. However, unlike workers' protest model of Kim and Hanneman (2011), Ormazábal et al. (2017)'s ABM lacks factors that seeks to explore ethnic and cultural identities as well social and political network structures. Furthermore, the study of Fonoberova, Mezić, Mezić, Hogg, and Gravel (2019) presented an ABM of civil violence to explore the effect of non-neighbourhood links on protest dynamics when varying cop agents' density and network degree. The ABM proposed by Fonoberova et al. (2019) does not integrate the effect of friendship links, political ties and the influence of empathy towards aggrieved neighbors. Pires and Crooks (2017) adopted a geosimulation approach by proposing an ABM that incorporate social interaction over a spatial environment. The model proposed by Pires and Crooks (2017) seeks to explore the effect of local interactions of heterogeneous individuals, their environmental characteristics, constructed from on empirical data of an actual geospatial landscape, population and daily activities of Kibera residence in to the emergence of riots. Rumor was utilized as an external factor to trigger the riots. The simulation results in Pires and Crooks (2017) indicate that youth are more attracted to rioting behaviour, which is evident that their model captures the right dynamics, and further provide support to existing empirical evidence and theories of riots. Although this model captures adequate social interactions of protesting civilians, and simulates more realistic dynamics of crowd patterns, it does not explore effect of risks as participation cost. In addition, their model does not incorporate network structures to explore the effect of social influence, political influence, and sympathy. The goal of this research was to construct an ABM of student protests that builds on Epstein's ideas. The model incorporates the hardship resulting from resource distribution disparities which is computed as function of RD. Furthermore, the model investigates the impact of integrating sympathetic effect which arise from Moore's neighborhood network graph, political effect which was denoted by directed activist links, and social influence indicated by undirected friendship ties. --- HyPoTHeSeS The conceptual framework of the model that predict student protest is demonstrated in Figure 1. In the social conflict context, the first latent variable proposed is the grievance factor that can influence the willingness of students to participate in protest action (Epstein, 2002;Raphiri, Lall, & Chiyangwa, 2022). Klandermans, Roefs, and Olivier (2001) applied theory of relative deprivation to investigate grievance development in the South African context, where grievance was defined as the effect of objective conditions (such as perceived living conditions) and subjective conditions (in relation to others over time). Number of policies have been implemented to address inequalities caused by apartheid policies in South Africa, but these inequalities are still prevalent. Ortiz and Burke (2016) argued that, for government to be legitimized, they need to address the grievances of protesters, such as reducing inequalities within the society. Lemieux, Kearns, Asal, and Walsh (2017) theorized that high grievance will (a) increase the probability of any form of participation in political activities in general (b) increase interest of participating in protest action (c) increase participation in conflicts activities. Thus, the first hypothesis considering the conceptual model in Figure 1 reads as follows: H1: Grievances resulting from discrepancies in living conditions have positive influence on students' decision to participate in protest action. At a personal-level, perceived risk of punishment has been identified to influence people's decision to engage in protest. Other scholars have identified operationalized risk as consequences rather than the probability that a potential punishment will be imposed on the individual (Lemieux et al., 2017). The study of Lemieux et al. (2017) further theorize that when risk is high: (a) it reduces the probability of any form of participation in political activities in general (b) it reduces interest of participating in protest (c) reduce participation in conflicts activities. Therefore, H2: Perceived net risk resulting from risk aversion and probability of being suspend negatively influence students' decision to participate in protest activities. When an individual is integrated into network structure, the likelihood that one will be targeted with messages during social movement mobilization process increases. For instance, van Stekelenburg and Klandermans (2013) emphasized that individuals with friendship links or acquaintances that are actively involved in a protest action are more likely to participate in social movement actions than others. Therefore, Historically, activists heavily relied on mass media to stay connected to a larger public, but nowadays they have established their own platforms on Twitter and Facebook for protest mobilization and interactions with their (Poell & Van Dijck, 2015). For example, the Arab Spring revolutions, Occupation protests and #FeesMustFall protests managed to attract a larger number of people because activists' influential sizes were higher as a result of social media. Therefore, H4: Student activists with larger influential size develops high level of political influence which positively contribute to protest occurrence. van Stekelenburg and Klandermans (2013) argued that individual's first step in protest participation is guided by consensus mobilization, whereby the general society is distinguished into people who sympathize with the cause and others who do not. The more effective consensus mobilization has been, the bigger the number of sympathizers a protest can attract. Therefore, H5: Sympathetic students who are exposed to other active students develops sympathy influence which positively contributes toward decision to participant in protest action. --- deSCRIPTIoN oF STUdeNT PRoTeST ModeL The "Overview, Design concepts, and Details" (ODD) (Grimm et al., 2010) protocol is used for the proposed simulating student protest model. The ODD protocol provides mechanisms to standardized model description, and to make it more understandable and repeatable. --- Purpose The model presented in this study was to simulate the effects of grievance on the possibility of student protests. It used the factors of relative deprivation (RD), net risk, social influence, political influence, and sympathy influence on the likelihood of student to engage in protests action. To achieve this purpose, the classical model of civil violence proposed by Epstein (2002) was extended to incorporate the new decision parameters. For the proposed model to be simulated and analyzed, several equations are assumed to integrate state variables, behaviour and scale of model entities. --- entities, State Variables and Scales The 2 presents an abstract flow diagram that outline the behavioural states of the student agents. The go submodel repeatedly executes: 1) the action rules for both student and officer breeds, 2) then run the move procedure, 3) decrement the suspend term of laid off students and suspend delay for rested officers, 4) increment the time step, and 5) display and update the macro or behavioural state of model entities using plots or interface controls provided by NetLogo. --- Model details --- Initialization The setup procedure initializes fixed parameters and properties of each entity used in the model. The development environment allows model observers to use sliders and switches to adjust global scales and categorical parameter input. The hypothetical environment simulated in this study does not denote any particular terrain, as there is no integration of spatial data to feature mountains, buildings, or forests that guide agents' movement. Lattice only portrays an abstract virtual environment focusing on the interaction of students. Table I provides the attributes of the student and officer breeds used in parameter sweeping when conducting simulation experiment. --- Submodels In this study, five main submodels are implemented in the model to compute relative deprivation (grievance), net risk as well as network influences classified as social, political and sympathy. This fundamental submodels presented in this section forms decision variables in predicting the likelihood of protest occurrence. --- a. Grievance The ABM of student protest represent grievance as a function of a person's intuitive relative deprivation (RD). This model looked at consumable resources as a proxy for relative deprivation: consumable resources were viewed as a measure of a person's ability to access resources; whereby each unit of consumable resource reflected a distinct set of goods that were consumed. Each student's possible range of RD in relation to certain reference group (neighbors, social links, political groups) within the society is [ 0 , x * ], whereby x * denote the maximum resource available in the society. For each student i, 0, xi       represent range of resources accessible to i , whereas [ xi , x * ] denote ) can be computed by 1 -F x ( ) , whereby F x f y dy k ( ) = ( ) ∫ 0 is the cumulative resource distribution, and 1 -( ) F x is the related frequency of students with resource accessibility above x . Grievance as a feeling of RD of student i at time t is defined in (1): RD x F y dy i t x x i * ( ) = -( )       ∫ , 1(1) b. Perceived net risk Students decide to participate in protest action if the grievance outweighs the cost or consequences. For student i at time t , cost of participation was quantified by perceived net risk ( NR i t , ) of being suspended from academic activities. The NR i t , is denoted by a function of layoff probability estimate, risk aversion (RA), and maximum layoff term (J). The layoff probability estimate ( P i t , ) of student i at time t , is calculated based on (2): P i t , = - -                  1 exp k V V O t AS t . , ,(2) Where constant k = 2.3, V AS t , and V O t , represent the local ratio of the number of active students and law enforcement officers at time t in the vision radius, respectively. Vision radius is determined by the number of patches, based on Moore (or indirect) neighborhood network (Klancnik, Ficko, Balic, & Pahole, 2015), which each student can see, that can host other students and officers. Risk aversion (RA) represent a uniformly distributed value ranging from 0 to 1 which is heterogeneous and remained fixed for each student during simulation experiment. Whereas the maximum layoff term (J) was a fixed and homogenous value across all students. The net risk ( NR i t , ) of student i at time t is represented by the (3): (4) NR RA P J i t i i t , , . . =(3) The propagated opinions among aggrieved individuals in the integrated social friendship network was quantified as the different between relative deprivation ( RD x i t ( ) , ) and net risk ( NR i t , ) at time t . Where Î ASN t represent the number of active students over time within the friendship network structure of student i and w 1 denote global social influence weight which was constant. --- d. Political Influence The political network structure in the ABM of student protest is modelled in the form of a directed graph G A A A E E E num activists ∈ … ∈       … 1 1 , , , , , _ _ political influenc ce size _       { } , whereby A and E represent set of activist nodes ranging from one to NUM_ACTIVISTS and set of directed edges ranging from one to POLITICAL_INFLUENCE_SIZE, respectively. Each edge represented an ordered pair node a n , ( ) from a n ® (whereby influential opinion is directed from activist (a) to normal student (n)). The constructed political network graph incorporated activists that have a positive out-degree denoted by deg a + ( ) which was defined by POLITICAL_INFLUENCE_SIZE in this model and zero in-degree (deg a -( ) ). Each activist act as a source with directed links pointing to a proportion of randomly selected student population whose internal property of POLITICAL_PARTICIPATION? is equivalent to TRUE. Activists still maintain their individual undirected friendship ties. A student can be linked to multiple activists. Equation ( 5) was used to represent the form of political influence ( PInf i t , ) in this model: PInf RD x NR i t NAP i t i t i , , , . = ( ) - ∈ ∑ w 2 (5) Whereby, Î NAP i represent number of incoming opinions (quantified as RD x i t --- ( ) , minus NR i t , ) from political sources which are activist directional links for student i and w 2 denote global political influence weight which was constant. --- e. Sympathy Influence In the constructed ABM of student protest, students can be sympathetic towards other active neighboring students located in their vision radius. For student i , Moore neighbourhood graph G x y x x r y y r =       - ≤ -≤ { } , : , 0 0 , where x y ) . Sympathy influence ( SyInf i t , ) of student i was calculated using ( 6): SyInf RD x NR i t AV i t i t i t , , , , . = ( ) - ∈ ∑ w 3 (6) Similar to the other network structures, propagated opinions between protesting neighbors were calculated as the difference of relative deprivation ( RD x i t ( ) , ) and net risk ( NR i t , ) at time t . Where Î AV i t , denote set of active students in the neighbourhood graph of student i over time t , and w 3 denote global sympathy influence weight which was constant. --- ModeL IMPLeMeNTATIoN The model constructed in this study was coded using Netlogo 6.1 which is an ABM integrated development environment (IDE) (Wilensky, 1999). Simulation experiments were carried out on Netlogo BehaviorSpace. In Netlogo, a model is implemented by simply drag-and-dropping components into the IDE's graphical user interface, and by writing source code through Netlogo programming language which represent a simplified English like syntax. Netlogo IDE further include a model documentation tab. The IDE allows developers to implement, simulate, and observe the model. In addition, the IDE provide helpful and easy to follow tutorials and documentation materials. BehaviorSpace aid in execution of the model in the background and provide model users with platform to run several scenarios, while conducting parameter sweeping and store simulated data into a comma separated values (.csv) file. Figure 3 shows the user interface of an agent-based model of student protest that was implemented in this study. --- experiments The model presented in this study uses several combinations of parameters to simulate various conditions that led to the emergent of student protest behavior. The fixed global parameters values used in the model during simulation experiments that in this study, were adopted from social conflict research (Epstein, 2002;Kim & Hanneman, 2011;Moro, 2016;Ormazábal et al., 2017;Raphiri et al., 2022). Quick runs of the model were done using Netlogo's graphical user interface platform for debugging and testing the code, as well as instant visualization of simple system dynamics. Systematic simulation experiments were carried out using Netlogo BehaviorSpace, to enable parameter sweeping while storing model output into csv file for further in-depth analysis. This systematic simulation performed by BehaviorSpace also aided in improving model execution time. Each experimental scenarios of certain combined parameters were repeated 10 times for 250-time steps. Table 2 shows frequencies of variated parameters used during simulation experiments. The effect of grievance as a function of relative deprivation was computed through varying INEQUALITY_LEVEL parameter, while SUSPEND_DELAY was utilized to reduce the risk of active students being suspended by law enforcement officers. The variation of MAXFRIENDS was used to calculate the social influence, whereas political influence was based on the variation of NUM_OF_ACTIVISTS and POLITICAL_ INFLUENCE_SIZE. Sympathy influence was activated using SYMPATHY_ACTIVATION? parameter. Table 2 contains factors used in the experiment design. When other parameters were kept constant, the main focus was to evaluate how the degree of inequality level, number of activists, activist's influential size, number of friendship ties, suspend delay and sympathy affect the dynamics of student protests. Running simulation experiments was challenging and time consuming due to resource constraints, such as high-performance computing desktop. A desktop computer with eight core processor was used to run the model. As illustrated by Netlogo' BehaviorSpace tool in Figure 4, simulation of ten experiments with similar combination of parameters took an average time ranging between 25 and 60 hours. Simulation experiments that took more time to complete were encountered when running scenarios with network structure that contains larger average degrees. --- Model Calibration Model calibration techniques were performed in verification, validation, and sensitivity analysis stages. Firstly, iterative programmatic testing is conducted throughout the model implementation phase to make sure that the code is free from syntax and logical errors, and that it behaves as expected (Anderson & Titler, 2014). Model-to-model validation is carried out to ensure that the dynamical patterns of the implemented model correspond to theories presented by Kim and Hanneman (2011)'s ABM of worker protest and other similar computational models when similar parameter values are used. Sensitivity analysis is carried out to explore the dependencies of model output to parameters variations and evaluate the influence degree of each input parameter toward the observed output (Iooss & Saltelli, 2017). Going through sensitivity analysis assisted in gaining insights understanding of various dynamics represented in the implemented model and the robustness of output towards parameter uncertainty. --- Results As illustrated in Figure 5 and Figure 6, in each simulation run, a line graph indicating the average grievance (shown in red) and net risk (drawn in green) which were both calculated from inequality level, and suspend delay are plotted in each time interval. The dynamics of grievance and net risk over time in the social conflict scenario are recorded when system decision parameters are set to low, medium, and high. High inequalities rapidly increased grievances and reduced the risks of protesting because the grievance was always above the net risk in most time step. An increase of decision factors (i.e., number of activists, maximum activist's influential size, and number of social friendships links) result in rapid increase of network influential values (which are political, social, and sympathy values) as shown Figure 7. An increase in the number of activists as well as maximizing their influential size, which may be regarded as optimizing mobilization resources, resulted in an increased in the political influence value, more especially when students are sympathetic towards one another. As mentioned earlier, the focus in this research was to evaluate how various factors presented in the proposed conceptual model significantly assist in the prediction of student protest emerging. Therefore, the logistic regression model to evaluate the effect of each parameter on the probability of protest emerging was conducted using Python. As demonstrated in Table 3, all predictor variables in the model were statistically significant with p-value less than 0.01. The accuracy of logistic regression classifier on test set is 0.949. The precision of 0.96 for false positive prediction and 0.95 for true positive predictions and the recall of 0.98 for false positive prediction and 0.89 for true positive predictions can be observed from Figure 8. --- Grievance from Inequality Level The findings of this study show that growing levels of inequality have an impact on students' grievances; as was shown in the statistically significant in predicting the likelihood that students would take part in a protest action (Coef. =3.4779; p value < 0.05). This is consistent with the research of Lemieux et al. (2017) who claimed that a certain degree of resentment tends to enhance the likelihood of an individual participating in political activities like protest actions. This result thus supports hypothesis (H1) from section IV. --- Perceived Net Risk Based on Suspend delay The research's findings also highlighted the significant of the contribution of perceived suspension delay, which is used to compute net risk (Coef. =-0.8446; p < 0.05), that indicates the likelihood of students engaging in protest behavior. This is in line with the findings of a study by Lemieux et al. (2017), who claimed that when risk reaches a certain level, (1) it reduces the likelihood of engaging in any political activity, (2) it decreases interest in taking part in protest, and (3) it reduces engagement in conflict-related activities. Therefore, this finding supports (H2). --- Social Influence as Function of Friendship Ties: According to the study's findings, bidirectional friendship networks are a statistically significant factor in the likelihood that a student will engage in protest behavior (Coef. =-0.2933; p < 0.05). This finding is further supported by a research by van Stekelenburg and Klandermans (2013), which found that people (participants) are more likely to take part in social movement activities if they have friends or acquaintances who are actively engaging in a demonstration. As a consequence, the outcome supports the hypothesis (H3) ----------------------------------------------------------------- ----------------------------------------------------------------- --- Political Influence Based on Number of Activists and Activist's Influential Size The simulation findings show that both of the political impact calculation components were statistically significant determinants of the likelihood that a student would engage in protest behavior (=-0.2121; p 0.05) and (=-0.1953; p 0.05). These results are consistent with earlier work. Political discourses like protest, according to Singh , Kahlon, and Chandel (2019), are largely articulated via several levels of concerns including the spread of political influence and political mobilization. According to Poell and Van Dijck (2015), the widespread use of social media platforms has made it possible for activists to mobilize huge numbers of people for protests, which has increased protest participation. Consequently, this outcome supports (H4). --- Sympathy Influence The findings of this study imply that sympathetic impact contributes statistically significantly to the likelihood that students would engage in protest behavior (=3.3129; p 0.05). According to a research by van Stekelenburg and Klandermans (2013), the initial stage in a person's protest involvement is determined by consensus mobilization, in which the general public is divided into those who support the cause and those who do not. The more supporters a demonstration may gather, the more successful consensus mobilization has been. As a result, the conclusion supported by this finding (H5). --- CoNCLUSIoN The literature review showed that recent student protests have been disruptive, leading in property destruction, academic program cancellations, intimidation of non-protesting students, and injuries, to name a few outcomes. In this study, we adapted Epstein's (2002) AB of civil violence in the context of students' protests. Simulation experiments demonstrate that inequality level, number of activists, activist's influential size, number of friendship ties, suspend delay and sympathy are elements that determines the model of civil violence proofed by the statistically significant in the logistic regression model. We discovered that when these independent variables have increased in various scenario's studied, both the volume of outbursts and strength of protests increases. The results of this research imply that university administration or policy-makers should design their risk management strategies and policies to concentrate on understanding the network structures that integrate student interactions that seek to support the spread of students' grievances. The interception of such channels by policymakers will aid in reduction of the disparities in resource distribution, and subsequently lessen grievances that causes frustrations among students. --- FUTURe ReSeARCH dIReCTIoNS The model created in this study offers a general tool to explore some processes that influence the genesis of protest activities, although it is yet unclear if the model can be applied to actual events. Future research may thus use actual empirical data to confirm the model assumptions to build more plausible models that can also be used to forecast student protest events. Additionally, the model developed included endogenous decision-making factors that influence students whether to protest or not. As was shown during the #FeesMustFall and #RhodesMustFall social movements, using exogenous mechanisms to launch messaging, such as tweets about active protest activities, would have a huge influence on student participation in protests. --- Joey Jansen van Vuuren (PhD) heads the research in the Department of Computer Science, Faculty of Information and Communications Technology at Tshwane University of Technology and is the Vice Chair of IFIP (Federation for Information Processing) Working Group 9.10. She is also one of the coordinators of SA for the BRICS Integrated Thematic Group Computer Science and Information Security (ITG-CSIS). Her research focus on cybersecurity, education, government, policy and culture. She was the coordinator of the South African Cybersecurity Centre of Innovation for the Council for Scientific and Industrial Research (CSIR) that initiated several cybersecurity government initiatives in South Africa. The centre also focused on the promotion of research collaboration, cybersecurity education and the exchange of cyber threats. She was also involved in the development of cybercrime strategies for the South African Police Services. Previously as the Research Group Leader for Cyber Defence at CSIR, she gave the strategic research direction for the research conducted for the South African National Defence Force and Government sectors on Cyber Defence. She has spent over 25 years in academia and research, and she has published various journal papers, conference papers, and book chapters on cyber security governance. She has presented on numerous forums, such as national conferences, and also international conferences, some of which she has been invited to as the key note speaker. Bertie Buitendag is a passionate researcher, in ICT education, knowledge management systems and organizational knowledge sharing and collaborative practices. His research interests also include Living Labs, knowledge networking, data exchange technologies and the semantic web.

987b7cda5f2e5428bb598bc44816901aaf5195d3

Female Genital Mutilation/Cutting: The Secret World of Women as Seen by Men

Efforts aimed at the abandonment of Female Genital Mutilation/Cutting (FGM/C) in the communities where it is deeply rooted have extensively considered and addressed women's perceptions on the issue, leaving those of men barely acknowledged. Although the practice is generally confined to the secret world of women, it does not mean that men cannot be influential. Indeed, men can play an important role in prevention. In order to address this gap, and having as background an extensive ethnographic field work, a transversal descriptive study was designed to explore Gambian men's knowledge and attitudes towards FGM/C, as well as related practices in their family/household. Results show ethnic identity, more than religion, as the decisive shaping factor on how men conceive and value FGM/C. The greater support towards the practice is found among traditionally practicing groups. A substantial proportion of men intend to have it performed on their daughters, although reporting a low involvement in the decision making process, with very few taking alone the final decision. Only a minority is aware of FGM/C health consequences, but those who understand its negative impact on the health and well-being of girls and women are quite willing to play a role in its prevention.

Introduction Female Genital Mutilation/Cutting (FGM/C) is defined by the World Health Organization (WHO) [1] as all procedures involving partial or total removal of the external female genitalia, or injury to the female genital organs, for nontherapeutic reasons. The WHO classifies the practice into four types: type I (clitoridectomy), type II (excision), and type III (infibulation) are ordered according to a growing level of severity, while type IV comprises all other harmful procedures performed on the female genitalia for nonmedical purposes (e.g., pricking, piercing, incising, scraping, and cauterization). According to the WHO latest data, 140 million women and girls in the whole world are thought to have been subjected to the practice, and 3 million girls are at risk of having it performed every year. FGM/C constitutes an extreme form of discrimination and violation of the human rights of girls and women, with health consequences now acknowledged and documented. In the short term, the practice can result in shock, haemorrhage, infections, and psychological consequences, while in the long term it can lead to chronic pain, infections, keloids, fibrosis, primary infertility, increase in delivery complications, and psychological sequela/trauma [2][3][4][5][6][7]. FGM/C has been practiced for centuries, having acquired a deep cultural meaning. Under a shared vision of the world where life is understood in cycles, FGM/C had been linked with the moment in which a girl becomes a woman in many societies. During the rite of passage to adulthood, within a ceremony secretly kept from outsiders, especially men, initiates were taught about the cultural and social wealth of their community, as well as their roles and responsibilities as women, mothers and wives, establishing gender power relationships [8]. The physical cutting would be the proof that a girl was granted with all necessary teachings that make her worthy to belong to her community. FGM/C had become a synonym of cleanliness, femininity, beauty, and purity, a way to protect virginity, guarantee "family's honour, " and ensure marriageability [9,10]. In The Gambia, the overall prevalence is estimated at 76.3% [11], meaning that it affects approximately 3 out of 4 women. However, this global figure obviates important discrepancies within regions and ethnic groups, as shown in Tables 1 and2. Its impact for health has been assessed in two clinical studies conducted in-country by the first author of the present paper, which revealed that 1 out of 3 girls and women presented injuries as a consequence of the practice [12] and the risk of complications during delivery and for the newborn increased 4.5 times for women with FGM/C [13]. Whilst these girls and women will need specific medical care for decades to come, prevention is an urgent step. However, strategies need to be carefully designed in order to respect the deep cultural value of the practice within the communities where it is performed. Although traditionally the practice was part of the rite of passage to womanhood among certain ethnic groups, as extensively described in an ethnographic research conducted by the first author of this paper [8], over the past generation several changes have been occurring. In a recent study, Shell-Duncan et al. [14] found that the physical cutting is increasingly becoming divorced from the traditional ritual. FGM/C is not a condition to ensure marriageability, but mainly a way to facilitate entry into a social network and have access to social support and resources, with peer pressure playing a major role in its perpetuation. In order to gather evidence to inform prevention strategies, many studies have focused in women's perception regarding the practice, but much is still unknown about the role played by men on its perpetuation. However, their perception of the "secret world of women" might bring important elements to understand the context in which the practice occurs, as well as enlighten effective ways to involve them in prevention. What lies under their support towards the practice? Do they establish a parallelism with male circumcision, the cutting-off of the penis' foreskin prepuce? Indeed, in all the societies where FGM/C is found, male circumcision is also performed [15], sometimes linked to the rite of passage to adulthood as a keystone component of the socialization process. It has a similar hygienic and aesthetic meaning and an analogous power to preserve ethnic and gender identities [2,3,8,16]. A deep situation analysis on FGM/C conducted in The Gambia in 1999 [17] revealed that some respondents established a parallelism between the two practices. Since Islam endorses male circumcision as an acceptable practice and makes no distinction between genders, some would argue that female circumcision is also prescribed. Acknowledging this gap, a new line of research is now emerging, interested in exploring how men position themselves on the matter, with the objective of assessing their potential inclusion in preventive actions and programmes. The results obtained so far have showed different-and sometimes contradictory-levels of involvement and support towards FGM/C that seem to be influenced by sociodemographic variables, such as ethnicity and religion [18][19][20]. Others have highlighted that both men and women blame each other for the continuation of the practice and position themselves as victims [21]. In a recent study conducted in The Gambia with health care professionals [22], it was discovered that FGM/C found higher support among men. While women would give more strength to the deep cultural roots of the tradition, men seemed to privilege a moral perspective, prioritizing the fact that the practice is mandatory by religion and attenuates women's sexual feelings, contributing to family honour. This study intends to contribute towards this field of research, by exploring the knowledge and attitudes of Gambian men towards FGM/C, as well as practices in their family and household. It expects to help to increase the understanding of the social environment embedding the practice, in order to inform prevention strategies that might successfully accelerate its abandonment. --- Materials and Methods --- Design of the Study. A transversal descriptive study was designed with the main objective of assessing the knowledge and attitudes of Gambian men on FGM/C, as well as related practices in their family/household, exploring eventual associations with sociodemographic characteristics. A secondary objective was to empower and promote knowledge's ownership of the native population, through a strategy designed to build capacities on FGM/C and social research skills. For this reason, the study was integrated in the Practicum of Community Medicine of the School for Enrolled Community Health Nurses and Midwives (ECHN/M) at Mansakonko, Lower River Region. Students were given the responsibility for data collection, under the supervision of their tutors and trainers from Wassu Gambia Kafo (WGK), the non-governmental organization that supported the study. To ensure the accuracy of this process, students received specific training on social research skills, by a team consisting of a medical anthropologist and ECHN/M tutors. Furthermore, prior to their involvement on this study, students had already been trained on FGM/C identification, management and prevention, as their school is one of the health schools that integrated FGM/C in its Academic Curriculum-an initiative of WGK. The survey was implemented through questionnaires administered face to face. Taking into consideration the sensitivity of the topic, it was considered that the best strategy to avoid resistance was to administer the questionnaires in the communities where these students were doing their practicum, and in their home villages. In this way, it was ensured that (1) they were known and respected; (2) shared the same cultural background of the interviewees; and (3) were able to speak their local language, what contributed to create an environment of trust conducive to conduct the interviews. The selection of the communities where the practicum was conducted was a responsibility of ECHN/M tutors. As a consequence of this strategy, the survey was implemented in three regions of the country: Lower River Region, North Bank Region, and West Coast Region. According to Census 2003, the population in the first two regions is predominantly rural (80% approximately), while in West Coast Region is mainly urban (60%) [23]. As stated in Table 1, FGM/C prevalence rates in these regions are 90.6%, 49.2%, and 84.5%, respectively [11]. --- Research Population. The overall sample is composed of 993 men. The study intended to capture men with heterogeneous profiles in terms of occupation, age, ethnicity, religion, and marital status, both from rural and urban areas. Due to the fact that this study was integrated on a strategy to build students and tutors capacities on social research, it was considered that a quota sampling method was the most feasible method to apply. Each student was requested to administrate the questionnaire to 30 men. --- KAP Questionnaire. The data collection tool was a questionnaire with nineteen close-ended questions, designed to gather information on men's knowledge and attitudes with regard to FGM/C, related practices in their families/households, and sociodemographic data. The questionnaire was developed by a researcher and medical anthropologist, having as background former ethnographic studies conducted in the country since 1989 [8]. Although the questionnaire was drawn up in English, the official language of The Gambia, students were carefully instructed to know how to administer it in local languages whenever needed, in order to ensure an accurate understanding of the questions and of what was meant by "FGM/C. " In The Gambia, the practice is generally conceived as the equivalent to types I and II as established by WHO, which are the most prevalent in the country (66.2% and 26.3%, resp., [12]). Each ethnic group has specific words to distinguish the "cutting" and the "sealing" formed during the healing process after cutting and repositioning the labia. --- Variables. The five socio-demographic variables comprised occupation (agriculture, livestock, and fishery sector; services sector; health professionals; education professionals; students), age, ethnic group (Mandinka, Wolof, Fula, Djola, Serahule, and Serer), religion (Muslim, Christian), and marital status (married, single). The variables analyzed, chosen from the questionnaire, are presented below. Among them, Q1, Q5, Q8, Q13, and Q15 were selected as active variables for the Cluster Analysis. --- Ethical Aspects. The study was submitted and approved by The Gambia Government/Medical Research Council Laboratories Joint Ethics Committee (Ref: R08002). The purpose of the research was carefully explained and clarified by the students to the interviewees. The administration of the questionnaires only took place after respondents' signature or thumb print on an informed consent that was kept under the custody of WGK. The identity of the participants was maintained through rigorous confidentiality. Obstetrics and Gynecology International 2.6. Statistical Analysis. A descriptive analysis was carried out of the main variables, and prevalence proportions (%) and 95% confidence intervals (95% CI) were calculated for the overall sample and, in order to detect differences, for each of the socio-demographic variables (occupation, age, ethnic group, religion, and marital status). Prevalence proportions were compared with Chi-squared test or Fisher's exact test when appropriate. Unspecified data ("other religion" and "other ethnic group") were not taken into account in the analysis. Statistically significant differences were considered at 𝑃 < 0.05. A multiple correspondence analysis (MCA) and a cluster analysis were conducted to detect underlying groups of individuals according to their knowledge and attitudes regarding FGM/C, as well as related practices in their families/households, as defined by the active variables. The five socio-demographic variables were included as supplementary information, allowing the identification of opposite profiles of men towards the practice. The information was computerized via EpiData. Descriptive univariate and bivariate analyses were conducted through SPSS Version 19, while MCA and cluster analysis through SPAD version 5.6. --- Methodological Issues. The main methodological issue regarding this study has to do with the sensitivity of the topic itself, as it is common to find resistance to talk openly about FGM/C, especially to an outsider. This was addressed by giving Gambian students the responsibility for interviewing people in communities where they were known and respected. Another methodological issue is related to the fact that Serahule's sample size was quite small (only 12 individuals). --- Results The socio-demographic characteristics of the respondents are shown in Table 5. The sample was composed predominantly of young men, their mean age being 36.5 years old, with Muslim affiliation (96.2%). The majority were married (74.4%) and worked in agriculture, livestock, and fishery (51.3%) or in services sector (20.6%). However, the sample also included education and health care professionals (7.8% and 7.0%, resp.) and a few students (7.6%). With regard to ethnicity, 41.2% were Mandinka, 19.9% Wolof, 17.6% Fula, 9.7% Djola, and 1.2% Serahule. The prevalence proportions and 95% CI of knowledge, attitudes, and practices, according to socio-demographic variables, are presented in Table 3. FGM/C appears in this study as a widespread practice, with a prevalence rate (70.0%) not far from the most recent official data (76.3%). A total of 61.8% men embrace its continuation and 60.7% intend to have it performed on their daughters in the future. Although FGM/C is mainly performed by families affiliated with Islam (72.5% versus 27.3% Christians, 𝑃 < 0.05), prevalence proportions disagree amongst Muslims with different ethnic backgrounds. With statistically significant differences, traditionally practicing groups (Mandinka, Djola, Fula, and Serahule) are the ones reporting the highest prevalence rates in their families/households, expressing the highest support towards the continuation of the practice and the strongest willingness to have it performed on their daughters. Also with statistically significant differences, almost 60% of Mandinka consider FGM/C as equivalent to men's circumcision, a parallelism that is established by 47.3% Djola, 43.8% Fula and 33.3% Serahule. Whilst 75% Serahule and 72.8% Mandinka believe that the practice is mandatory by Islam, only 56.0% Fula, and 36.4% Djola do so. Serer and Wolof, which are also Muslims but traditionally nonpracticing groups, do not establish a connection between the practice and Islam neither acknowledge a parallelism between FGM/C and male circumcision-indeed, around 95% of Wolof and 90% of Serer deny it (𝑃 < 0.05). Interesting but not statis-tically significant, men over 60 years old establish the relation between FGM/C and Islam and its equivalence with male circumcision in a higher percentage than other age groups. In the overall sample, almost 72.0% of men do not know that FGM/C has a negative impact on the health and wellbeing of girls and women. The highest awareness is found among Wolof men (47.9%, 𝑃 < 0.05), health and education professionals (48.0% and 46.3%, 𝑃 < 0.05). Although not being a statistically significant trend, it is found that awareness of FGM/C health consequences decreases with age, with the lower levels being found among men over 60 years old (15.4%). Also interesting but not statistically significant is to find that the group of men between 31 and 45, who have the highest awareness of FGM/C health consequences, are also the less supportive of the practice, with a lower intention to have it performed on their daughters and the highest willingness of seeing men intervening in its prevention. The negative impact that the practice has on the health and welfare of girls and women is, indeed, the major reason given by 72.9% of those who, on the overall sample, are against its perpetuation. This study also reveals that over 39.8% of girls are subjected to FGM/C before completing their fourth anniversary. This is mainly reported by men between 31 and 45, whilst men above 60 report the practice to occur when the girl child has already completed 4 years old (67.4%, 𝑃 < 0.05). A minority of men take part in this decision-making process, especially if they are not married (married 39.3%, single 21.1%, 𝑃 < 0.05). Only 8.0% take the final decision towards subjecting their daughters to the practice, and 6.2% join the wives in this decision (Table 4). FGM/C appears mainly as a women's choice (75.8%) or a decision of other relatives and community members (10.0%). Since there is no statistically significant association with the socio-demographic variables, this information is not shown in Table 4. Cluster Analysis. The cluster analysis revealed statistically significant differences for ethnicity and religious affiliation, allowing the identification of two profiles of respondents which are identified in Clusters 1 and 2 (Tables 5 and6, and Figure 1). Cluster 1 is composed of those men who declare, on a rate statistically significant and higher than the overall sample, that FGM/C is practiced in their families/households (99.7% versus 67.4%); that they are involved in the decision making process (37.0% versus 25.6%); intend to have it performed on their own daughters (92.5% versus 60.9%); are not aware of the practice having health consequences (82.9% versus 71.7%); and do not think that men have a role to play in its prevention (68.8% versus 48.4%). This cluster comprises almost two-thirds of the overall sample (65.1%) and is overrepresented by men from Mandinka, Fula, Serahule, and Djola ethnic origins, with Muslim affiliation. Cluster 2 comprises the remaining one-third of the total sample and is composed of those men whose knowledge, Obstetrics and Gynecology International attitudes, and practices are opposite to the ones expressed by men in Cluster 1. This group gathers those who report, on a rate statistically significant and lower than the overall sample, that FGM/C is not practiced in their family/households (80.7% versus 30.0%); that they are not involved in the decision making process (87.2% versus 74.4%); do not intent to have it performed on their daughters (96.0% versus 39.1%); are aware that the practice has health consequences (47.0% versus 28.3%); and believe that men have a role to play in its prevention (86.1% versus 51.6%). In this group, Wolof and Serer ethnic origins are overrepresented, together with the Christian religion (7.5% versus 3.5%). --- Discussion Seen through men's eyes, the secret world of women remains embedded in cloudy concepts shaped by culture in ethnic tradition, also influenced by religion. All ethnicities included in this study follow Islam, but each one of them establishes a different relation between FGM/C and religion. While those from traditionally practicing groups tend to consider the practice as a religious injunction or as "Sunna, " finding justification for its continuation, almost all those from traditionally nonpracticing groups deny that the practice is an obligation in Islam. FGM/C is, in fact, a pre-Islamic practice. Even within traditionally practicing groups, perceptions diverge substantially. Mandinka found FGM/C on its mandatory character by Islam and are eager to consider it as equivalent to male circumcision. Serahule share the same religious conviction but do not establish the equivalence with the male practice, in opposition to Djola, for whom religion does not seem to be significant but the parallelism with male circumcision is more evident. Although sharing the same nationality and religion, ethnic identities are built up on different cultural values and social norms, which are the decisive shaping factors of men's concept of the practice. Ethnicity's power to influence the knowledge, attitudes, and practices with regard to FGM/C had already been shown in a previous study conducted with Gambian health care professionals, by the same authors of this paper [22]. Amongst older men, FGM/C is seen as a mandatory practice by religion, equivalent to male circumcision, with no health consequences. But a window of opportunity for change is found among younger generations. Men between 31 and 45 are the less supportive towards the practice, have the lowest intention to have it performed on their daughters and the highest willingness to play a role in its prevention, and are also the group more aware of FGM/C health consequences. Can this increased knowledge and less supportive attitudes be linked, and on this foundation built on a strategy for prevention? This and other findings from this study suggest that it can. Indeed, among the group of men who are against the continuation of the practice, health consequences are presented as the major reason to stop its continuation. Health and education professionals, who are the ones more aware of FGM/C health consequences, show more willingness to participate in prevention. The fact that the majority of men are not active in the decision making process concerning the practice does not mean that they do not have the power to influence it. The finding that 60.7% of men intend to have FGM/C performed on their daughters in the future, but only 34.8% actually participate in the decision-making process and a few 14.2% take the final decision, alone (8.0%) or with their wives (6.2%), suggests that decision-making is not a simple oneway process. Indeed, field work evidence reveals that women who decide that their daughters will not undergo the practice face, not only peer pressure, but also feelings of helplessness when not actively supported by their husbands, as well as other influential male leaders from their communities. In a patriarchal society, although men might not be actively participating in FGM/C decision making process, they are still decision-makers. The finding that decisions concerning FGM/C can be made by multiple actors including women, men, relatives, and community members corroborates the results achieved by Shell-Duncan et al. in a study recently conducted in The Gambia and Senegal [14]. These authors explain that the multiplicity of decision makers and peer pressure among women makes individuals less able to act upon intentions to carry on with the practice or not. In the secret world of women, avoiding discrimination is a powerful motif to perpetuate FGM/C, and this social force must be acknowledged. However, men's power to influence it should also not be disregarded. Over the past generation, FGM/C practices have changed in many ways in Gambian societies. The group ritual in the "bush" is giving place to individual ceremonies behind doors [14]. Field experience reveals that the traditional knife, used to perform FGM/C on a number of girls without being sterilized, is being replaced with individual razor blades, as a result of HIV/AIDS awareness campaigns. Similarly, traditional herbs and charms, used to manage bleeding, relief pain and accelerate the healing process, are being complemented with modern drugs. Nowadays some babies and girls are taken to health facilities when health complications cannot be managed at community level, in opposition to the secrecy that characterized the seclusion period in the past. Sometimes, FGM/C is even performed by health professionals themselves: medicalization is already a reality in the country [22]. Finally, the age at which the practice Obstetrics and Gynecology International is performed is declining-our study reveals that over 40% of Gambian girls are subjected to FGM/C before celebrating their fourth anniversary. This reduction may be explained by the belief that wounds heal faster and pain is lower for babies than for grown-up girls. This paper suggests that new actors can be called on stage to play an important role in FGM/C prevention. May knowledge be shared and synergies be built up, in order to promote positive changes that lead to the abandonment of the practice. --- Conclusions Although sharing the same religious beliefs, men from traditionally and nontraditionally practicing groups see the relation between the practice and Islam in different ways and have diverse perceptions of its parallelism with male circumcision. Differences are also significant within traditionally practicing groups, showing how ethnic identities are the decisive shaping factors on how men conceive and value FGM/C. The decision to subject or not a girl to the practice appears as the result of a complex process involving multiple actors. Although few men are active participants in this process, their intention to have FGM/C performed on their daughters is likely to influence it. The support towards the practice is highly dependent on ethnic identity, being much higher among men from traditionally practicing groups. However, awareness on FGM/C health complications is prone to positively influence men's willingness to play a role in its prevention. In this line of thought, a strategy of acknowledging men's ethnic background and focusing on increasing their understanding of FGM/C negative impact on health might well be an effective way to influence and promote a positive change to the secret world of women.

fd03441c06b5168fdaaa9d3ba7f7e6a7d3faaa6f

The Analysis of the Phenomena of Obedience and Conformity in the Society

Social Psychology is a branch belonging to the sphere of Psychology, preliminarily studying humans' behaviors in society. Conformity and obedience, two significant terminologies in social psychology, are frequently manifested in real-life situations, such as the case that emerged during COVID-19, which firmly illustrates the above phenomena, and currently, people experience these two situations, or phenomena, often. Starting from their definitions and experiments, this paper mainly studies the phenomena of these two situations, and this aims to investigate the causes of conformity and obedience. The methodology of this paper is literature review and theoretical analysis. This paper finds that such phenomena (obedience and social conformity) could be attributed to some reasons: culture impact, internet impact, pressure impact, education impact, and the existence of authority.

Introduction This paper mainly focuses on obedience and conformity, which are two classical psychology terms. Obedience refers to the behavior that people, to avoid being punished or blamed, tend to obey others' instructions and thoughts. Conformity refers to the behavior that, living in a group and society, people are inclined to change or even forgo their thoughts to cater to others and the group. Obviously, people could not always have their own thinking patterns and could not always express their ideas. Many have lost the ability to think individually and critically on account of conformity and obedience, which could be seen in many examples: during the period of COVID-19, many were credulous about experts' ideas, thus losing the way to think by themselves; on the internet, it is seen that people are susceptible when seeing new arguments. Therefore, driven by numerous cases, this paper aims to analyze the reasons why people are extremely credulous and why they have lacked the ability to think independently instead of easily believing the opinions of others. In other words, this paper is written to find the causes of conformity and obedience in the society. The main methodology used in this article is literature review. At the end of the paper, several ways to ameliorate the situations, and hopefully, this could be of help to the relevant individuals. --- 2. --- Conformity and Obedience --- Case During COVID-19 in Chinese Societies During COVID-19, it was palpable that people were outstandingly susceptible to others' opinions. Hearing many and many news and learning about COVID via other information sources, they lived in fear of getting infected by it. Therefore, they would expect others, especially the so-called experts, to offer them solutions and ideas, and they would be very credulous, thus never distinguishing between various arguments given by experts. This was typical on social media. To be more specific, when social media, like TikTok, posted some new news and information about COVID, it was seen that below each video, there were thousands of proponents who praised the ideas. For instance, at the end of 2022, when COVID was prevalent and influential throughout Chinese societies, many socalled specialists contended that COVID would not carry any symptoms when people would be infected. However, such an argument could hardly bear further verification--evidently, most Chinese people felt uncomfortable as their bodies became troublesome, and most people caught colds, coughs, fevers, and many other derived illnesses. Accordingly, people's previous propositions collapsed naturally, and then they complained that the problems should be ascribed to those experts as they misled the Chinese individuals. Although some of the individuals had once cast doubt on these experts' arguments, finally it turned out that almost everyone believed in them. --- Conformity and Asch Effect Conformity is the tendency for an individual to get their attitudes, beliefs, and behaviors along the others within a group [1][2]. Conformity can take the form of overt social pressure or subtler, unconscious influence. It is powerful irrespective of its forms, and it could alter a person's thoughts, change the person's behaviors, and even resolve conflicts in the group. Conformity renders individuals comfort and dignity when an individual form is subdued by the collective form. Asch Effect illustrates conformity. In Asch Experiment, subjects were instructed that they were participating in a study of perceptual judgment, during which, they were asked which of the three lines shown was the longest [3]. The answers were outstandingly obvious, and the judgement should have been made without too much thinking; nevertheless, all other participants, who were asked by the experimenter to give incorrect answers, all indicated that the longest line was the one that ranked second in length, which was highly evident. Therefore, being influenced by other "participants," the real participant, who had already decided to make the correct choice, eventually made the same answer in a bid to go along with other participants. In this situation, the subject knew the uniform and incorrect of the other members of the group before he makes his own response. As a result, he might give the same answer as the others to cater to the group. This is defined as Asch Effect. --- Obedience and Milgram's Obedience Experiment Obedience refers to changing one's behavior on account of the command of an authority figure, with sometimes the case being that people are under supervision of others. Stanley Milgram, an American social psychologist, conducted the famous Milgram Obedience Experiment in the 1960s in Yale University, the purpose of which was to test people's obedience under the command of authority [4]. The experiment was simple. Two individuals came to the lab to participate in a "memory experiment." One of the individuals, unknown to the other, was the experimenter's confederate and, through a rigged drawing, became the so-called victim. The other person, assigned the role of "teacher," watched while a set of electrodes was attached to the learner. Then, Milgram gave the unsuspecting teacher a small 45-volt shock to demonstrate what it would feel like and to enhance the experiment's credibility. To this end, the "teachers" were told that such a transient hit would not lead to a permanent hurt to the experiment subject. "Teachers" were then asked to test those individuals' ability to recollect of previously learnt things. If the learner made an error in answering the questions asked, the teachers needed to shock the learners. The purpose of the experiment was to assess the effects of punishment on retention and learningwould the teachers stop shocking the learners as the voltage increased gradually. The teacher was placed before the shock generator, which had a series of switches, each labeled to indicate a voltage, arranged from 15 to 450 volts, in 15-volt increments per each time [5][6]. Before the experiment, some professors in Yale University had once made some estimations. Yale University psychiatrists predicted that teachers' most common reaction would ultimately reject to click on the button of electric shock as the numerical value of voltage increased; plus, they predicted that the majority of teachers, approximately 68%, would not go beyond 150V, 4% would reach 300 V, and only one in a million would press 450 V. Nevertheless, the result was dramatically astonishing. Over 60% of participants ("teachers") continued to obey the authority's persistent instructions to press the last button of an electric shock generator. Experts in human behavior and laypersons alike underestimated the teachers' degree of obedience. --- Reason Analysis Though the above concepts are different-conformity and obedience are observed under different circumstances-two concepts to one phenomenon-people would lose some of their own thoughts or hide them and could not express them overly, gradually losing some ability of individual thinking. --- Culture Impact Cultural differences may affect people's thinking patterns. Individualistic culture, referred to as the culture like most Western countries, will be more likely to accommodate people who could think more individually. Such culture underlines intrapersonal values, morality, political philosophy, and their own thinking patterns. Thus, people's own thoughts and actions will be more accepted, valued, and propagated, and people in those countries will advocate that person's interest is more important than that of a society or a country. Individuals tend to reject authority figures from other groups, societies, or governments. Consequently, those individuals would be less likely to experience conformity and obedience. On the contrary, collectivist culture, referred to as the country like China and Cuba, tends to emphasize collective interest, in which a person's value should be consistent with societies' values, group thinking therefore being more important. In such a culture, individuals' rights and thinking are restricted by groups, and therefore, people might lose some ability to think and embody their own thoughts. Collectivism holds that individuals belong to society, individual rights are subject to group power, and individual interests are subordinated to collective, national, class and national interests. The more collectivist the society, the more likely it is to work together. In the previous Asch effect, people with higher collectivism have higher conformity behavior. Also, when asked to do something, in collectivist cultures, people are more likely to obey the rules, whereas, in individualistic cultures, breaches of social rules could be seen as drastically frequent, being a troublesome phenomenon. --- Internet Impact When a certain event arises, netizens collide with each other thanks to different motives, positions, and interest demands, forming a turbulent public opinion pattern. The formation of public opinion is a process of mutual actions; notwithstanding the members of the group are independent individuals with perplexing and variable psychology, which brings challenges to the command of authority [7]. --- Overall network Public opinion reversal events, behind which, group consciousness is existing to promote the development of public opinion. When the Internet gets more frequently used, more netizens see different arguments online, during which, conformity would happen as a result. Netizens might cause doubt about group morality, which means a totality of conscious response of various classes or strata or interest communities to social and economic conditions, political system and cultural life. Congruence in idea is the feature of group thinking on the internet, and thus, individuals seem to agree with one, only idea which, probably, is proposed by some so-called expert, like the case mentioned before during COVID-19 about the issue of symptoms of infection. Hence, as long as the strength that is strong enough is not embodied in a clear form, it is generally accepted by many, and those minority who have different ideas might not share their ideas in front of others on the internet. Members will get the illusion that everyone is in agreement, being also a kind of conformity. For example, many emergences of rumors could be attributed to the conformity on the internet: although some possess different ideas, they tend to believe the thought of the majority, and sometimes the majority would blurt out some unattributable, unreasonable rumors. --- Working Pressure The existence of working pressure in concurrent society is everywhere, owing to which, compared with last generations, people in current society are more confined to the workplace [7]. In working place, the tendency that nowadays people are getting more critical, thoughtful, and individual would increase the likelihood that employers expel the employees. Therefore, although, in comparison with past generations, people nowadays begin to have more individual thinking and self-awareness, making them think more in the workplace, the tendency discussed above could still result in conformity: for example, during the process of decision-making in a company, most employees would still withhold their ideas and avoid sharing them if someone having greater rights and reputation holds a different one. Also, most of the workers in the workplace are mandated to obey their managers' or leaders' instructions to eschew any possible conflicts from occurring. --- Cognitive Patterns in Childhood The pattern of education shapes children's life and future. Education also determines the ways individuals think enormously. Due to the relative lack of social experience and the ability to identify, judge and choose, it is easy to produce a blind herd mentality, especially among teenagers, which is then produced. Blind conformity will cause teenagers to blindly imitate the words and behaviors of others, which leads to weak self-awareness, poor independence and deficiency of creativity. Teenagers are in a period of growth and ability development, and therefore, in such period, they are likely to experience conformity. This may be due to the following reasons [8]. First of all, teenagers lack a deeper and well-rounded understanding of the world; hence, they do not possess the capability to think deeply, individually, and profoundly, so rather than do something wrong and get criticized, they tend to believe others' words and thoughts. Cognitive dissonance would arise during childhood. Secondly, teenagers, even Human beings, are social, so their life, study, work, and so on need to be in the collective. In the process of development, growing teenagers will feel involuntarily fearful when deviating from groups. Palpably, it can be seen that the fear of deviating from the group is also why teenagers choose to conform to others. --- The Figure of Authority The existence of authority could also explicate obedience. It is extremely reasonable that people will conform to authority. The authority could be an entity, for example, the government. It is known that people are obliged to obey the laws, rules, and other legislations enforced by the government, regardless of their rationality. Authority could also be virtual. Knowledge, especially the one that is written in books, is considered undoubted; at least, most people would not spontaneously cast doubt on some authorized knowledge overtly, irrespective of their own thoughts. Another explanation could demonstrate this. When obeying authority, people usually get benefits. In other words, they would not be punished at least. On the contrary, when repelling the authority, people are possibly punished: consider the punishment and fine on account of breach of the social rules and legislations. Therefore, we can consider that people are experiencing positive punishment: the bad things, the punishment, are avoided when people obey the rules, and vice versa. --- Approaches to Be More Creative and Critical Here are a few suggestions and approaches the paper proposes that could make individuals more critical and reduce the behavior of conformity and obedience: As starters, people should be encouraged to think of different ideas, and this is dependent on culture. Living in a culture that promotes individual thinking, people could be more creative. Secondly, teenagers should be bolstered to think more individually. Being a test taker is not a good solution; instead, it is essential that kids are equipped with the ability of critical thinking. Additionally, they should be brave enough to do so, Thirdly, the government should be more accommodating to accept, at least not reject, different but reasonable ideas. It could create some channels that allow citizens to offer distinct ideas and thoughts, therefore promoting the whole society to have a better atmosphere and make more progress. --- Conclusion This paper focuses on the causes of conformity and obedience, with definitions of them analyzed for starters. The reasons leading to the two situations could be ascribed as culture, internet, concurrent pressure, cognitive patterns in childhood, and authority figure. The paper vests new ideas and discussions for social psychology. Nevertheless, there are some limitations and flaws in the overall content and methodology in this paper. secondly, the article might lack some investigation, such as reviews and questionnaires of individuals. In light of endless and promising progress made in social psychology by extraordinary and preeminent researchers in relevant spheres, it is speculated that, in the future, more studies could focus on the comparison of obedience and conformity.

93be1a5f37b3e8caa3910bdc890c65c57c60cf9f

Building a Narrative of Equity: Weaving Indigenous Approaches into Community-Engaged Research

In 2020, global injustice has taken center stage during the uprising of the Black Lives Matter movement and other social movements. Activists are calling attention to longstanding disparities in health outcomes and an urgent need for justice. Given the global socio-political moment, how can health researchers draw on current critical theory and social movements to create structures for equitable outcomes in health research and practice? Here, we demonstrate principles for effective health research and social justice work that builds on community-engaged approaches by weaving critical Indigenous approaches into structural project designs. Our project, "Health Resilience among American Indians in Arizona", brought new and seasoned researchers together to collect and analyze data on the knowledge of healthcare providers concerning American Indian health and well-being. Four years after the conclusion of the project, the team developed and created a post-project self-assessment to investigate lasting impacts of project participation. In this communication, we discuss the principles of defining and measuring the capacity to build together. This work responds to the call from Indigenous scholars and community leaders to build an internal narrative of change. While we will not present the full instrument, we will discuss building a strong foundation using the principles of engagement for planning and implementing justice and change.

Introduction The complexity of global and local crises is immense. There is not a single solution that can solve urgent, health-related problems. The 2020 uprising of social movements like Black Lives Matter, which began after Minneapolis police officer Derek Chauvin murdered George Floyd, brings to light many years of longstanding inequalities in life and health. Indigenous peoples have also faced health disparities and threats to their well-being and life at higher rates than their nonindigenous counterparts. The relationships between social justice and health are not new for people who live with these threats, nor are relationships that have been unexplored by social scientists and public health researchers. Public health researchers and social scientists have turned to community-engaged approaches to address unequal health outcomes. These approaches provide well documented success in advancing health through multiple forms of knowledge [1,2]. Engaged approaches are strongest when they incorporate methods for collapsing divides between communities and institutions, specifically when including people who have more or less economic and political power. Indigenous leaders suggest a need for research designs that are developed "with" instead of "on" people in ways that provide opportunities for "counter-storytelling" [3]. It is in this confluence of approaches that new narratives of impact emerge. This communication presents the principles behind the development of an internal measure of capacity building to discuss a foundation for justice in engaged research that can contribute to narratives of change. --- Community-Engaged and Indigenous Approaches Community-based participatory research (CBPR) and other engaged approaches share goals of collapsing divides between researchers and the researched by equally incorporating different skills and forms of knowledge. These approaches differ from those that exclusively center professional research skills [4][5][6][7]. However, underlying principles of engagement, do not always result in equitable outcomes of project research and practice. Even when working toward justice, benefits of health-focused projects are sometimes unequally weighted. For example, people who already have leadership positions in hospitals, health clinics, schools, and academic researchers, may obtain more measurable benefits from grant-funded projects than community researchers who bring valuable insider knowledge and skills [8,9]. For instance, the evaluation of a project may only measure the impact on people who are considered to be "beneficiaries" instead of collaborators. A more inclusive look at capacity might reveal that tenure-track university researchers have gained additional grant experience, which is advanced in scholarships, promotions, publications, and other benefits. The short-sightedness of measuring only one type of capacity building leaves equity in benefits from funding unexplored. Developing a more inclusive narrative of how all partners benefit from the project allows groups to understand if benefits are equally weighted [10]. One way of capturing a more inclusive look at how multiple communities benefit from engagement is to involve all project partners in the evaluative process that incorporates multiple perspectives and reflects on the long-term impact that aligns with and draws on Indigenous approaches to research [11,12]. This shift also places trust in the building and the skill development at the center of project goals rather than considering them to be a side effect of partnership projects. Our goal in developing a collaborative process for capacity building was in part to create and understand more fully what capacity building looked like for all members of the team instead of focusing only on members of a "community" outside of leadership. We defined the layered definition of capacity building that our group developed together in the results section. The authors of this article include members of original research and post-project evaluation teams. Here, we share principles and strategies to continue the conversation of how to measure and interpret capacity building through a process of narrative creation and expand our discussion of the principles used to create a process fully engaged with a research team and community-based and Indigenous theories of change. --- Context The parent project for the development of the evaluation was called "Health Resilience among American Indians in Arizona", (hereafter "Health Resilience"), which is funded by the National Institutes of Health (NIH) and National Institute on Minority Health and Health Disparities (NIMHD), under the Center for American Indian Resilience (CAIR). "Health Resilience" built on prior engaged studies to investigate health and patient-provider perceptions. Project leads (a health scholar and medical anthropologist) developed a strategy to identify and hire community members to join the team as researchers. Past employment and degree status were not considered in the hiring process intentionally to reflect a community-engaged strategy [13]. Community researchers became paid employees beginning with a multiday intensive training session and continuing into data collection, analysis, implementation, and dissemination. The "Health Resilience" project team included community and academic researchers of different tribal affiliations, ages, genders, and life experiences. Data collection included semi-structured interviews, focus groups, and Wellness Mapping activities [14]. Researchers obtained permissions through the American Indian led local organizations and a university institutional review board (IRB). The team gained permission from the Navajo Nation Human Research and Review Board, Hopi Tribe, and Indian Health Service. Once the multiyear project concluded, the team analyzed data and wrote about, presented, and continued "Health Resilience" in different ways. --- Building a New Instrument Together Researchers built capacity by creating their own instrument based on experiences with the project and questions they had about lasting change after the conclusion of "Health Resilience". This emergent model reflected a process similar to "counter storytelling" [3] as an epistemological approach to building knowledge. Indigenous researchers have discussed how to make research and evaluation "culturally responsive", being called culturally responsive indigenous evaluation (CRIE) [15]. This varies from a research strategy that uses a vetted evaluation instrument in a local site. In the case of "Health Resilience", we specifically created the process to define and understand capacity and relationship building while developing an internal narrative. We did not use a CRIE-specific research design, though we did develop our instrument through a similarly emergent process that focused on capacity and relationship building, which is in line with Indigenous approaches to research. Understanding why the group chose to develop a narrative requires replacing a traditional research focus with one that is steeped in community engagement and the values of Indigenous focused research. Findings from a recent systematic review found that CBPR projects in Indigenous contexts yielded improved research and capacity and, at the same time, there was a need for projects that improved rigor by defining research questions in partnership [16]. Over half of the projects reviewed relied exclusively on researcher-defined questions that had not been developed with community member involvement. Research with Indigenous peoples has been identified as an area where existing evaluation tools are lacking, and where there are opportunities for using principles of engagement to create a new narrative rather than relying on an existing one [12]. Community-, culture-, and language-focused programs tend to show improvements in health, relationship building, and sustainability of change [17]. In one example, a community-engaged approach was used to develop a "healing model of care" for Indigenous people by building crucial partnerships [18]. These partnerships led to the development of dynamic partnerships that contributed methodologically and in practice to evidence-based models of care. In another example, a research partnership with a Native American community developed procedures for measuring CBPR, which included a focus on measuring "level of participant involvement" and "community voice" to be used in the measure trust and "trustworthiness" of an engaged and participatory project [5]. Indigenous researchers highlight the importance of building a narrative for evaluation together [5]. The development of the assessment allowed for an organic structure of openness to emergent narratives of change [19,20]. The team positioned "community" as a series of overlapping groups including academic researchers and highlighted the need to "integrate knowledge and action for all partners", as suggested for use of community engagement in tribal contexts [21]. In our team, there was no definitive line between community and academic partners in that some community members had or have since obtained positions affiliated with the only university in the region, while others had full time appointments there. Over half of the researchers were Indigenous or American Indian with different tribal affiliations. This framework of a broad understanding of community beyond academia and non-academia allowed team members to re-think how people work together to challenge and shift power structures in campus-community partnerships. --- Defining "Communities" in Engaged Research A collaboration that crosses institutional, tribal, social, and other boundaries relies on trust, transparency, and tangible reciprocity to function well. Achieving these principles requires project designs and measures that include different communities as both targets of health programming and recipients of the benefits of community-engaged work [3,22]. Community-engaged and Indigenous-focused approaches to research attempt to decolonize research and methods by reducing the traditional categories of researchers and the researched and positioning people who may not have academic degrees as "cultural experts" over their neighborhoods and social spaces [23][24][25]. These approaches recognize the benefits of including people from outside institutional settings. For instance, noninstitutional team members learn new skills like team-building and institutional team members learn how to collaborate and learn from the people in the communities of study. In limiting a definition of "community" to people outside of academia and clinical settings, researchers can fail to incorporate a full understanding of how researchers themselves constitute a community, or series of overlapping communities. Project leadership at health clinics, hospitals, universities, or other entities constitute a set of communities in the same way that neighborhoods encompass a set of overlapping communities. Community-engaged research offers an opportunity to examine benefits and capacity changes over time in multiple communities, including those who already occupy positions of power. Ongoing collaborative evaluation helps to ensure that outcomes are reaching through barriers to support equity where it is needed most. The development of evaluation in this setting rests on current challenges to empirical models of data collection and analysis discussed by Indigenous researchers and by drawing on foundations that shift the researcher-researched roles to develop new narratives [24,26]. Decolonizing implicit bias of power in definitions of "community" in research is necessary for the health and justice of those communities involved in research activities [26]. --- Project Assessment in Relation to Parent Project Methods for the parent project were designed collaboratively with a group of researchers. The parent project grew out of a series of community-engaged projects. Those prior projects resulted in questions about patient-provider communication and American Indian resilience. Upon funding, project leads developed a hiring strategy to recruit and select researchers from communities of study who were skilled at listening and critical thinking regardless of education or work experience. Once the team came together, there was intensive multiday, collaborative training. Intensive research for the parent project lasted 6-8 weeks, with additional weeks for transcriptions and ongoing analysis. This post-project activity happened long after the conclusion of the parent project. At the conclusion of the project, members of the team continued to stay in contact and work with one another in different capacities. We were curious about how the project impacted all of us, and wanted to ask ourselves and each other about impacts that stayed with us. Evaluation models that exist help groups to explore and understand community coalition functioning and capacity building [10,27]. In addition, the creation of the process presented an opportunity for group members to continue their work together in the development of an instrument and the dissemination of results. Engaged project approaches and designs include ongoing, iterative evaluation embedded within processes of research and implementation [10]. Development of evaluation was part of the primary collaborative training that the team led and participated in together. Leadership was provided by one of the project principal investigators (PIs). This PI is not an American Indian person, although the other two PIs are. She designed and developed the project based on learnings from Indigenous scholars and practitioners, and on experience from developing best practices for community engagement with partners outside of academia. This detailed description of the process of development and evaluation occurred on the foundation of a project structure in a communicative environment. --- 1. During research and analysis, team members discussed doing a post-project evaluation together. No one person prioritized this process. Instead, it was part of the ongoing discussions during analysis meetings. 2. After the project ended, several members of the group stayed in touch through professional and friendship connections. One project lead and the person who had served as a research specialist discussed checking in with the group to determine the remaining interest in evaluating the long-term impacts of the project. --- 3. A project lead had sent an inquiry via email to the team. All but one team member responded that they would be interested in participating. The team was unable to locate the remaining member of the team. Everyone was invited to participate in the discussion, which was possible because of trust established during the parent project. 4. The group circulated an inquiry asking people to create questions they would like to have answered about lasting impacts of the project and post-project reflections. All team members responded to the email with ideas. 5. An outside researcher organized the questions into an online survey and analyzed results. This decision was intentional so that the organization of the questions would occur by someone who was not involved in the original project, and therefore did not have a heavy investment in project outcomes. Only the outside researcher had access to the raw data to analyze results and to share the results with team members. 6. All members of the team with the exclusion of two people, who were not available, participated in the development and writing of the manuscript. --- Materials and Methods Methods specific to the assessment include project partners reconnecting to create an evaluation instrument to assess capacity at an individual level and to evaluate lasting impacts. The project fostered ongoing engagement and capacity building for team members outside of and within university settings. These relationships provide opportunities for employment, raises or promotion, entrance into graduate programs, new partnerships, new funding proposals, and other tangible opportunities. Working together on equal ground to develop the evaluation instrument demonstrated our ability to work together professionally in the years after the completion of the research. Final questions and answers reflected our ability to quickly pick up where we left off at the end of the project, and reflected use of our relationships and skills to complete the evaluation. This process was evaluative in practice and in outcomes. --- Results The most salient outcome of this process was the development of our own way of thinking through and defining lasting capacity building. Capacity building has been defined elsewhere as community-level outcomes resulting from leveraging a community's individual and organizational resources toward addressing collective problems and resources, relationships, and leadership [28]. Approaches to community engagement can add skills, knowledge, experiences, new partnerships, and a breadth of experience to deepen individual and community level knowledge and experience. Once a community builds on existing skills to increase capacity, there can be many outcomes that go beyond a project and transform into new partnerships, projects, grants, relationships, and wellness [29]. We drew on these definitions to develop an operationalized concept of capacity building that reflects increases in skills, knowledge, and ability to design and perform related projects; new and/or improved skills that lead to different employment and educational opportunities; new generative relationships of trust; and new knowledge that leads to other outcomes beyond the stated project goals. Capacity building includes human relations skills within a collaborative working team, recognition of project timeline and priorities, and a respectful communication style. Our view of capacity building began with the understanding that it can impact people on an individual level (e.g., a person obtaining a higher paying job) as well as on a community level (a community leveraging partnerships to bring resources to a neighborhood), and even a larger, policy level (new partnerships that lead to local, state, and federal policy change). Capacity building through engagement can add to a skill set and opportunity landscape for community members who may not hold positions of power or have degrees, as well as people who already hold leadership and research positions, by providing a learning experience that leads to better and more holistic relationships between individuals and organizations as the trust and experience grows. Our perspective on capacity building reaches beyond the idea that capacity is owned, and distributed by people in positions of power. Certainly, people in positions of power can provide training opportunities and access to resources; however, equally important is the ability for project leads and researchers to learn how to engage with communities outside of these entities to challenge inequality. In light of the focus on power and position in engaged work, scholars and partners critique the public health programming that begins with an assumption that researchers hold knowledge and community partners can (and should) learn from them [30,31]. A layered read of capacity building assumes differently positioned groups can learn from one another for a common goal. Researchers and healthcare providers can learn from communities, just as community groups may learn from investigators [30]. --- Discussion In the burgeoning area of community-engaged work, project teams develop plans based on collaborations between researchers and the researched; however, the relationships between researchers and community partners are not always central to the functioning of these projects. There are numerous reasons for the breakdown of equitable and productive relationships between individuals who already have access to resources before a project begins, including policies that result in unequal pay, structures that only involve community members as recruiters, and other system level issues. Indeed, in our own work, we have witnessed projects where inequality between researchers is borne out through unequal employment advancement, lack of transparency in authorship roles in publications, and the weight of ongoing project success falling on people who are already in positions of power. Partnerships and relationships between people working together in a community-engaged project are central to the ability of projects to positively impact health and well-being [29,32]. Scholars and researchers who work in health knowledge and implementation must consider how engaged practice impacts project team members and communities in multiple ways, and how benefits of research and practice are distributed. Highlighting capacity building as a focus of research and practice is one way to measure and understand what works, and to identify possible improvements [30]. This is a multifaceted alternative to more popular approaches that assess programs, typically dealing with a hierarchical set of dichotomies such as patient/provider or client/provider, and cogently answers many critical concerns coming from Indigenous researchers [15,24,26]. In our engaged assessment, we implemented a communal-reflective contingent of community building [24]. The inclusion of multiple team members demystified the barriers usually constructed between academic cultures, students, and community members and opened a space for exploring intersectionality and challenges assumed boundaries of power. This established a balance between flexibility and commitment through collaboration efforts bridging professional and social gaps among different community spheres of influence, which brought about a sense of equitable distribution of knowledge and power. Team members developed relationships that continue on through collaborative work. These relationships reflect a greater ability to engage in ongoing work based on the relational aspects of the research, which are the qualities that Indigenous researchers define as key principles in understanding and conducting research [31,32]. --- Conclusions We recommend that projects with the goal of engaging multiple communities reducing unexplored boundaries of power create a group process of instrument development and analysis. This activity could be implemented annually for multiyear projects and again after the conclusion of the project to explore and measure who benefits from research. It would enable groups to adjust structures to meet the needs of different and overlapping communities participating in research and practice and help to integrate a framework into practice to erode an assumed barrier between a community of need and others. This would be a summative process that could cause community engagement practices to become more deeply woven into present and future project benefits and keep partnerships accountable for areas where benefits could be equitably distributed. --- Conflicts of Interest: The authors declare no conflict of interest.

ebfc3f8f3cad7d466893835b6e99739b25df9455

Youth in India Ready for Sex Education? Emerging Evidence from National Surveys

Context: Sex education/family life education (FLE) has been one of the highly controversial issues in Indian society. Due to increasing incidences of HIV/AIDS, RTIs/STIs and teenage pregnancies, there is a rising need to impart sex education. However, introducing sex education at school level always received mixed response from various segments of Indian society.We attempt to understand the expectations and experiences of youth regarding family life education in India by analysing the data from District Level Household and Facility Survey (DLHS-3: 2007-08) and Youth Study in India . We used descriptive methods to analyse the extent of access to FLE and socio demographic patterning among Indian youth.We found substantial gap between the proportion of youth who perceived sex education to be important and those who actually received it, revealing considerable unmet need for FLE. Youth who received FLE were relatively more aware about reproductive health issues than their counterparts. Majority among Indian youth, irrespective of their age and sex, favoured introduction of FLE at school level, preferably from standard 8 th onwards. The challenge now is to develop a culturally-sensitive FLE curriculum acceptable to all sections of society.

Introduction Sex is a very sensitive subject and public discussion on sexual matters is considered as a taboo in Indian society. Given this context, introducing sex education at school level always attracted objections and apprehensions from many quarters. Family life education (FLE) or Sex education refers to a broad programme designed to impart knowledge/training regarding values, attitudes and practices affecting family relationships [1,2,3,4,5,6]. It aims to develop the qualities and attitudes on which successful family life depends. The real purpose behind family life/sex education is the transfiguration of a male child into manhood and of a female child into womanhood. The education that provides knowledge on physical, social, moral, behavioural, and psychological changes and developments during puberty is termed as Adolescent Family Life Education. It teaches the adolescents about the role of boys and girls in family and society, responsibility and attitude of boys and girls towards each other, etc. within social context. Many psychologists believe that sex education begins at an early age and continues throughout the life of an individual. The purpose of sex education should be to facilitate the best possible integration between the physical, emotional and mental aspects of the personality, and the best possible assimilation between the individuals and the groups. Sex education also instils the essential information about conception, contraception and sexually trans-mitted diseases. It is a continuous process of developing attitudes, values and understanding regarding all situations and relationships in which people play roles as males or females [7]. The major objectives of Family Life/Sex Education (FLE) can be broadly described as follows: 1) To develop emotionally stable children and adolescents who feel sufficiently secure and adequate to make decisions regarding their conduct without being carried away by their emotions. 2) To provide sound knowledge not only of the physical aspects of sex behaviour but also its psychological and sociological aspects, so that sexual experience will be viewed as a part of the total personality of the individual. 3)To develop attitudes and standards of conduct which will ensure that young people and adults will determine their sexual and other behaviour by considering its long range effects on their own personal development, the good of other individuals, and welfare of society as a whole [7]. More than biological specifics, sex education should also include social and moral behaviour, proper attitudes and values towards sex, love, family life and interpersonal relations in the society. Due to growing incidences of HIV/AIDS, RTIs/STIs and teenage pregnancies, there is a need to impart sex education among youth. The problem of over-population also demands family life education, including family planning as a priority, as many of the young people are about to be married and should be aware of the responsibilities they have. A study on child abuse in India, conducted by the Ministry of Women and Child Development, reports that 53 percent of boys and 47 percent of girls surveyed faced some form of sexual abuse [8]. Therefore, family life education might help the vulnerable young population to be aware about their sexual rights and empower them to protect themselves from any undesired act of violence, sexual abuse and molestation. India's National Population Policy also reiterates the need for educating adolescents about the risks of unprotected sex [9]. Furthermore, the provision of family life education might result into multiple benefits to the adolescent boys and girls. This might include delayed initiation of sexual activity, reduction in unplanned and early pregnancies and their associated complications, fewer unwanted children, reduced risks of sexual abuse, greater completion of education and later marriages, reduced recourse to abortion and the consequences of unsafe abortion, curb the spread of sexually transmitted diseases including HIV [10]. Adolescence (10-19 years) is an age of opportunity for children marked with a time of transition from childhood to adulthood; wherein young people experience substantial changes in their physiology after puberty, but do not instantaneously imbibe the various associated roles, privileges and responsibilities of adulthood. This crucial period in the lives of young people presents prospect to promote their development and equip them with appropriate knowledge, attitudes, beliefs and skills (KABS) to help them successfully navigate through various nuisance and vulnerabilities of life, and realize the full development potential [11]. Current statistics indicate that almost one in every fifth person on the globe is an adolescent, as they comprise 18 percent (1.2 billion) of world's population in 2009, with 88 percent living in developing countries, particularly in the South Asia, the East Asia and the Pacific region [11]. India has the largest adolescent population (243 million), followed by China (207 million), United States of America (44 million), Indonesia and Pakistan (41 million each). Interestingly, more than 50 percent of the adolescent population lives in urban areas, which is expected to further reach 70 percent mark by 2050, with the largest increase likely to occur in the developing world. This entire scenario indicate the considerable demographic and socioeconomic challenges, particularly for the developing countries like India, in terms of meeting the specific needs for improving the survival and general health conditions, nutritional status, and sexual and reproductive health of the adolescents. Recent literature on adolescents have documented that irrespective of being relatively healthy period of life, adolescents often engage in the range of risky and adventurous behaviours that might influence their quality of health and probability of survival in both short and long term over the life course [12]. These includes early pregnancy, unsafe abortions, sexually transmitted infections (STIs) including HIV, and sexual abuse and violence. Pregnancy related problems comprise a leading cause of death among adolescents aged 15-19 years, mainly due to unsafe abortions and pregnancy complications [13]. However, the sexual and reproductive health needs of adolescents and youth are poorly understood and grossly underappreciated owing to limitation of scientific evidence compounded with the unpreparedness of public health system, which may jeopardize the initiatives to advance the health and well-being of adolescents. Adolescents and youth in India experience several negative sexual and reproductive health outcomes such as early and closely spaced pregnancy, unsafe abortions, STI, HIV/AIDS, and sexual violence at alarming scale. One in every five woman aged 15-19 years experience childbearing before 17 years of age that are often closely spaced; risk of maternal mortality among adolescent mothers was twice as high as compared to mothers aged 25-39 years [14,15]. Importantly, adolescents and youth comprise 31 percent of AIDS burden in India [16]. Furthermore, multiple socioeconomic deprivations further increase the magnitude of health problems for adolescents. This limits their opportunity to learn and access the appropriate health care services. This inadvertent scenario calls for a serious and comprehensive public health initiative to provide Indian adolescents and youth with accurate and age-appropriate essential information and skills for a responsible lifestyle, that might help in reduction of risky sexual behaviour, early pregnancy, HIV/AIDS and STI, etc. Recently, recognizing the need of the time, Government of India has experimented with the provision of Adolescent Education Programme (AEP) to lay the foundation for a responsible lifestyle, including healthy relationships and safe sex habits among adolescents and youth. However, this initiative attracted mixed reactions from different sections of the Indian society. There is scanty scientific literature which throws light on the level of knowledge, perceptions and viewpoints on issues related to family life education among Indian adolescents and youth. Are adolescents and youth in India really prepared to understand and benefit from this new experiment? Hence there is a need for studies that scrutinize and critically evaluate the knowledge, attitude, perceptions, skills and experiences of family life education among Indian adolescents. --- Controversy Over Introducing Sex Education in Schools With the view to generate awareness and inculcate necessary skills among adolescents and youth, a scheme for adolescent education programme in the school curriculum was promoted by the National AIDS Control Organization (NACO) and the Ministry of Human Resource Development (MHRD), Government of India, which led to a major controversy in 2007. The ardent opponents argued for a ban on starting sex education in schools on the ground that it corrupts the youth and offends 'Indian values' [17,18]. They contended that it may lead to promiscuity, experimentation and irresponsible sexual behaviour [19]. The critics also suggested that sex education may be indispensable in western countries, but not in India which has a rich cultural traditions and ethos. On the contrary, the proponents argued that conservative ideas have little place in a fast modernizing society like India, where attitudes towards sex education are changing rapidly. As fallout of this controversy, several Indian states including Gujarat, Madhya Pradesh, Maharashtra, Karnataka, Kerala, Rajasthan, Chhattisgarh and Goa declared that the course content as suggested by MHRD was unacceptable and thus banned the programme [1]. At the same time, attempt towards the introduction of sex education at school level in India met with opposition from the fundamentalists arguing that it may degrade the tender minds and destroy the rich family systems in India. Furthermore, some teachers and principals were threatened that, ''if you don't stop sex education, neither will you remain in the jobs, nor will your schools survive''. However, the other side of the coin (pro for sex education) reflects supportive campaign towards introduction of sex education that may help to reserve the rich heritage and culture of India. Adolescents should be scientifically educated about the facts and myths related to sexual activities that may lead to number of health related risks. Being vulnerable to various changes associated with physical, emotional and psychological transitions, adolescents/youth must have proper knowledge of sex education that may empower them into healthy, productive and responsible adults [20]. Though few politicians and religious leaders have opposed the introduction of sex education in schools, studies have shown that Indian adolescents and youth do not have sufficient information about sexual matters, thereby increasing the possibility of falling prey to various forms of sexual violence. TARSHI (Talking about Reproductive and Sexual Health Issues), a non-governmental organization running a helpline on sexual information, received over 59,000 calls from men, seeking information on sexual anatomy and physiology [1]. An analysis of this data showed that, 70 percent of the callers were below 30 years of age, while 33 percent were in the age group of 15 to 24 years, which indicates that young people do have the need, but lack adequate authentic source to receive appropriate and correct information in a positive manner. The WHO report (2003) on family life, reproductive health and population education documented that promotion of family life/sex education has resulted in delayed age of entering into sexual relationship, reduced number of partners, increased use of safer sex and contraception, and other positive behaviour [10]. It was further noted that sex education in schools did not encourage young people to have sex at earlier age; rather it delays the start of sexual activity and encourages young people to have safer sex. However, both the critiques and proponents of introducing family life/sex education in Indian schools propagate the analogous ideology of 'sexual restraint' i.e., delaying the initiation of sexual activity among adolescents before marriage, which may also help to curtail the menace of HIV/AIDS, sexually transmitted diseases and restrict the pace of population growth [21]. India has become the second largest hub of HIV/AIDS pandemic in the world. The proponents of sex education stressed the need for providing knowledge about HIV/AIDS, teenage pregnancies and information about sexual health. In a survey of college students conducted by the All India Educational and Vocational Guidance Association, it was reported that 54 percent of males and 42 percent of females did not have adequate knowledge regarding matters of sex [7]. About 30 percent of males and upto 10 percent of females are sexually active during adolescence before marriage, though social attitudes clearly favour cultural norms of premarital chastity [14]. We need to accept the fact that we are living in a complex world leading complicated lives. Preventing access to pornographic movies or erratic contents on television shows is not prudent, but adding a single chapter to the school curriculum is relatively simple and practical [22]. Mass media being highly influential has been part of both solution and of the problem in the area of sex and youth. It has been part of the solution because it has helped to bring sexual topics into discussions. Radio and television has been the medium in opening doors to the deliberations of several topics which were previously considered as taboo. A survey conducted in Mumbai found that 88 per cent of the boys and 58 per cent of the girls among college students had received no sex education from parents and their source of information were books, magazines, and youth counsellors [7]. Internet is the greatest culprit which makes pornography easily accessible in recent times. Studies have shown that vast majority of parents do not accept the responsibility for providing sex education to their sons or daughters [23]. However, another study states that 68 percent of the parents believe that they should be the primary sex educators of their children, followed by schools [24].The apparent stigma attached to any discussion on sex in India is due to the fact that people tend to view sex education in a narrow sense, that is, the mere explanation of anatomical and biological differences. Ideally home is the best place for sex education and the attitudes of parents are of vital importance. When a child feels the subject as forbidden, he/she feels more curious to know about it which can lead to misleading information, if parents feel embarrassed in talking about sex with their children. --- Available Evidences The recent emerging scientific evidence across globe documents substantial confirmatory positive influence of sex education towards promoting overall health and well-being of adolescent and youth. A recent study from Nigeria presents paramount significance of providing sexual education to youth that helped them to develop critical thinking and insights on range of family life/sexual issues like premarital sex and pregnancy, abortion, teacher-student relationships and lesbianism [25]. Another study in Indonesia suggests the mixed viewpoint on the pros and cons of sex education among youth [26]. Proper information about sexuality should be provided to youth to help them grow healthy and responsible. A study conducted in Venezuela highlighted the importance of imparting sex education to youth, as it helped to prevent adolescent pregnancy, abortion, HIV/AIDS and sexual abuse [27]. A study in India revealed that majority of school teachers was in favour of imparting sex education to school children [28]. Fourteen years of age was considered to be the most appropriate for imparting sex education by 28.6 percent of school teachers. School teachers and doctors were considered to be the most appropriate persons for providing sex education. Another study from India attempted to assess the impact of sex education on the students noted that doctors were the first choice to impart sex education followed by school teachers; the preferred mean age to start sex education was 15-16 years [29]. A study conducted in seven private co-educational schools to understand the adolescent attitudes towards issues of sex and sexuality in India showed wide lacuna in the knowledge on sex and sexuality matters among adolescents [30]. Majority of mothers believed that discouraging pre-marital intercourse should be the most important objective of sex education, and those who felt that their own sex education was inadequate were in support of providing sex education for their children [31]. Parents should provide sex education to their children in a friendly and informal atmosphere so that children may get rid of the idea that sex is dirty and be aware of their responsibilities [32]. A survey conducted in Hyderabad and Secunderabad cities of India found that the major sources of information on sexual matters among adolescents were books and films, followed by friends [33]. An important observation emerging from this study is that, in spite of exposure towards sex education, many adolescents did not have the correct knowledge regarding reproduction process. This further raises serious questions regarding the content, technique and format of the sex education being imparted in certain institutions which failed to have a desired impact on adolescents/youth. Family life education for boys and girls at the adolescent stage should be constructive enough so as to contribute to healthier emotional growth and it must prepare them to enter into a responsible adulthood [34]. Adolescent boys and girls need sound and correct knowledge about sexual matters. In general, the knowledge among boys regarding sexual issues is more than that of girls may be because boys try to satisfy their curiosity more readily [23]. It was also found that educated parents help their children to clarify their doubts and anxieties about sexual matters in a more realistic way. The findings of National Family Health Survey show that majority of men and women in India favour family life education [35]. More than two-thirds of adults approve of teaching school children about physical changes in their bodies that come with puberty, although there is somewhat less approval of children learning about puberty in the opposite sex. According to the Youth Study in India [36], 83 percent of young men and 81 percent of young women (aged 15-24 years) felt the need to impart family life education. However, there exists a substantial rural-urban differential in reporting of the need for family life/sex education. Those who received the family life education consisted of only 23 percent of unmarried women and 17 percent of unmarried men. --- Youth Ready for Sex Education? Though few micro-level studies have been conducted in India to examine the knowledge, attitude and perceptions of adolescents toward family life education, yet there exists huge gap in appropriate understanding regarding various issues of family life/sex education and its effective implementation. Since there are supporters and opponents towards introducing sex education in Indian schools, it is most important to understand the perception and attitudes of youth on this controversial issue. This study is an attempt in the same direction using evidence from two nationally representative sample surveys to analyse the perceptions and experiences of family life education among young women in India. These large-scale household surveys [36,37] conducted across India and various parts thereof, provide a unique opportunity for the first time to gauge the attitudes of younger generation. In this study, the terms sex education/family life education/adolescent life education were interchangeably used. The present study broadly attempts to gauge the views, perceptions, aspirations and experiences of adolescents and youth regarding family life education. The specific objectives are as follows: 1) To study the perception regarding family life education (FLE) among adolescents and youth. 2) To examine the experiences of youth who received family life education. 3) To evaluate the awareness on reproductive health (RH) issues among youth and the impact of FLE on their awareness. --- Ethics Statement The study was based on an anonymous public use data set with no identifiable information on the survey participants; therefore no ethics statement is required for this work. --- Data and Methods The data for the present analysis comes from two major household surveys in India. The District Level Household and Facility Survey (DLHS-3) [37] in 2007-08 is perhaps the largest ever demographic and health survey carried out in India with a sample size 7,20,320 households covering 601 districts of the country. The perception and knowledge about family life education, family planning, RTI/STI, HIV/AIDS and reproductive health issues were collected in this survey. About 1,60,550 unmarried women were interviewed in DLHS-3, using a structured interview schedule. The second survey is the ''Youth in India: Situation and Needs'' conducted in 2006-07 in six Indian states [36]. The main objective of this survey is to gather evidence on key transitions experienced by youth as well as their awareness, attitudes and life choices. The study was conducted in the following selected Indian states: Andhra Pradesh, Bihar, Jharkhand, Maharashtra, Rajasthan and Tamil Nadu. In all, 50,848 married and unmarried young women and men were successfully interviewed, from 1,74,037 sample households. Unmarried men and women as well as married women (15-24 years) were interviewed, whereas the age group for married men was extended to 15-29 years, in the first ever landmark survey on youth in India. Literature suggests that the attitudes and behaviour of youth are usually influenced by socio-economic, cultural and demographic characteristics. The pertinent socio-economic and demographic characteristics considered in this study includes age groups (15-19 and 20-24 years), type of residence (rural and urban), religion (Hindu, Muslim, Christian and others), caste (Scheduled Caste, Scheduled Tribe, Other Backward Classes and others), education (non-literate, 1-5 years of schooling, 6-9 years and 10 years or above), economic status of the household as presented by wealth index and employment status (not working, agriculture, manual, non-manual). Awareness about contraceptives has been computed based on modern methods (sterilization, pills, condom, IUD, etc.) and traditional methods (rhythm, withdrawal, abstinence, etc.). --- Findings Table 1 presents the composite picture concerning the perceived importance of family life education (FLE) and the perception regarding at what age and standard it should be introduced in India. Nearly four-fifths of unmarried women (15-24 years of age) perceived that FLE is important. DLHS-3 asked women about their opinion regarding-at what age and at what level in school does the FLE should be introduced? Majority of women reported that FLE should be provided in the age group 15-17 years (38 percent) and initiated from the 8 th to 10 th standards (55 percent). The information regarding major sources of FLE among unmarried women who perceived FLE to be important was also collected. Majority of the respondents reported that the main source for providing FLE should be parents (81 percent), followed by teacher/school/college (55 percent), sibling/ sister-in-law (50 percent), and friends/peers (30 percent) respectively. On the other hand, health care provider/experts (10 percent), husband/partner (4 percent), youth club/NGO worker (3 percent) were respectively chosen as other preferred sources of information on FLE among unmarried women in India. Table 2 indicates the proportion of women who actually received FLE and their experiences regarding the same. Around 50 percent of women actually received FLE, overwhelming majority from schools or colleges. The other sources were NGO programmes, youth clubs, government programmes, etc. Among the women who received FLE, majority reported that the teacher/ trainee explained it in a way that can be understood and FLE answered/clarified many of their questions. It is important to note that, around 40 percent of women felt embarrassed while attending family life/sex education classes. Table 3 presents the percentage of unmarried women 15-24 years who perceived FLE to be important, and those who actually received FLE by selected demographic and socioeconomic characteristics in India. The prevalence of perceived importance of FLE was relatively high among the youth (81 percent) in India. However, only 49 percent of women actually received FLE. The relatively mature unmarried women (20-24 years) residing in urban areas with more than ten years of education, engaged in non-manual occupation, and coming from better-off families had higher prevalence of perceived importance of FLE as well as that of receiving FLE than others. In general, the perceived importance of FLE among youth in India is relatively high with strong demographic and socioeconomic differentials. The actual experience of FLE among youth is extremely limited. The knowledge and awareness on reproductive health issues among unmarried women were also collected in the DLHS-3. On an average, the women who received FLE had much better awareness on various reproductive health issues like RTI/STI, possibility of finding out the sex of a baby before birth, and knowledge about reducing chances of infecting HIV as compared with women who did not receive any FLE (Table 4). In general, women who received the FLE were relatively more aware about methods of contraception as compared to their counterparts. For instance, among women who received FLE, nearly 98 and 27 percent of women were aware about any modern and traditional methods of contraception respectively. On the other hand, this figure declines to 89 and 12 percent respectively among women who do not receive FLE. Table 5 illustrates the young people's opinion on family life/ sex education across men and women, and married and unmarried. Around 83 percent of young men and 78 percent of young women felt that it is important to impart family life/sex education to youth. Slightly large proportion of unmarried youth (84 percent of men and 81 percent of women) as compared to married youth (79 percent of men and 75 percent of women) reported family life/sex education to be important. Majority of young men and women observed that family life/sex education should be provided to adolescents in the age group 15-17 years. Regarding the perception of youth about the best person to impart family life/sex education, the preferences differed among men and women. Majority of young men reported that the best person to provide FLE should be teacher, whereas most young women suggested that parents are ideal persons to provide such education. Around 21 percent of young men and 11 percent of young women reported that the main source of providing family life/sex education can be friends. Table 6 indicates that, nearly 15 percent of young men and 14 percent of young women received family life/sex education. Majority received FLE through schools/colleges. Among those who received formal family life/sex education, majority felt that FLE answered many of their anxieties/queries and the teacher/ trainee explained the subject well. Twenty one percent of men and 37 percent of women also reported that they felt embarrassed while attending family life/sex education. This, in a way suggests that the curriculum and the method of teaching should be contextspecific and culturally sensitive. --- Discussion and Conclusion The present study attempt to unravel the divergent views, perceptions and aspirations of adolescents and youth regarding family life education, its perceived importance, and the potential Table 3. Perception and actual experience of family life/sex education among unmarried women by their background characteristics (percentages). effects of family life education on array of reproductive health issues by using nationally representative household sample surveys in India. Young people (10-24 years) constitute about 315 million and represented about 31% of India's population. They not only represent India's future in the socio-economic and political realms, but nation's ability to harness the demographic dividend. In the course of transition to adulthood, young people face significant risks related to sexual and reproductive health. Adolescent life education program intend to ensure the rights of the large section of adolescents/youth, and to develop them as healthy and responsible members of the family and society. Adolescents in all societies learn their responsibilities towards family by observing and following the behaviour of others. Due to rapid social changes occurring all over the world, the young generation is facing an enormous challenge in coping with the consequences of attrition in the traditional family system, social life, and values. Under this volatile environment, the family life education can help the adolescents to experience successful transition from childhood to adulthood. One of the most significant findings of the study indicates that majority of youth perceived family life education to be important. This highlights that Indian adolescents realizes the range of potential health risks and challenges lurking before them and demands the appropriate knowledge, skills and training to lead a responsible and healthy life style. However, the study points out that only half of the unmarried women actually received any form of family life education. This critical mismatch between the potential demand for FLE and apparent lack of facility might lead One of the crucial issues that deem attention relates to the major sources of FLE. The study indicates that majority of unmarried women, who perceived FLE to be important, reported that parents to be the provider of FLE, followed by teacher/ school/college, brother/sister/sister-in-law and friends/peer respectively. Therefore, it becomes apparent that FLE need not be only part of formal school curriculum; it should also be equally augmented in the first place by parents at home to eliminate all the misconceptions, inhibitions and doubts of adolescents on various aspects of family/sex life. The study also indicates that relatives and friends/peers could also be important avenues that need to be appropriately tapped to help the adolescents learn about the basic issues/rules of family/sex life skills safely and comfortably either at home, school or neighbourhood. Addressing the discourse on the implementation of FLE in school curriculum in India, several scholars, administrators, and politicians have mooted the adverse impact of FLE and how it may denigrate the 'rich Indian cultural values' and ethos. However, our findings effectively nullifies all these apprehensions and convincingly illustrates that, among youth who received FLE, the awareness about various reproductive health issues and knowledge of contraceptive methods was far better and comprehensive compared to their counterparts who had no FLE. This further goes on to show that provision of FLE will benefit not only the adolescents, but many more generations to come by avoiding the menace of RTI/STI, unwanted pregnancies, HIV/AIDS, etc. In the era of globalization and modernization, there still persist steep socioeconomic divide in the knowledge, attitudes and perception of individuals in Indian society. The same holds true with regard to benefits of FLE. Whether it relates to the perceived importance of FLE, or actual prevalence of FLE among unmarried women in India, we found substantial differentials across socio-economic groups. This indicates that even after more than six decades of planned development efforts in India, large proportion of population living in rural areas, illiterate, margin-alized social groups, continue to lag behind when it comes to the adoption of modern attitudes and healthy sexual behaviour. Hence, it is crucial for policy makers and program managers to take note of these socioeconomic hierarchies in Indian society, while designing and implementing any FLE program. However, most political and religious leaders in India are unfortunately not in favour of sex education at school level. The Rajya Sabha of Indian Parliament constituted a committee to examine the implementation of the Adolescent Education Programme (AEP). The committee categorically opined against the implementation of sex education at school level, and felt that AEP may cause irreparable damage to the future of India by polluting the young and tender minds, and could invariably promote promiscuity. The report also took serious objections on the study materials and kits prepared for the implementation of the AEP in Indian schools. The report while denouncing the case for the implementation of any AEP at school level emphasized the need for appropriately passing on the message of no sex before marriage among adolescents and declaring it as immoral, unethical and unhealthy. In addition, students should be made aware of marriageable age which is 21 years in case of boys and 18 years in case of girls and any indulgence in sex outside the institution of marriage was against the social ethos [38]. Finally, we summarize the key issues that emerge from this study. There exists a wide gap between the proportion of women who perceive FLE is important and those who actually received any sex education. It was also true that women who received family life education had better knowledge and awareness on reproductive health issues than counterparts. The level of awareness and knowledge regarding Family Life Education is more among the educated, better-off sections and those living in urban areas. The growing population, changing life styles and increasing incidences of HIV/AIDS is a great challenge. In order to prepare the youth to face these challenges, introducing sex education is an important step. The nation-wide surveys clearly illustrate that overwhelming majority of young women and men are in favour of introducing family life education. The government and civil society should initiate a national debate to arrive at a consensus on this issue among various sections of the society. The study strongly argues the necessity to formulate appropriate policy regarding family life education so as to address the unmet need for scientific learning/training on matters of family/sexual life among --- Author Contributions Conceived and designed the experiments: NT TVS. Performed the experiments: NT TVS. Analyzed the data: NT. Contributed reagents/ materials/analysis tools: NT TVS. Wrote the paper: NT TVS.

67700aa1b3cf5cb9a5e639db5831f5cfc8eb8b17

An Assessment of Knowledge, Attitude, and Practices of Birth and Death Registration in Kilifi County in the Coastal Region in Kenya

Background. Countries need vital statistics for social and economic planning. World Health Organization (WHO) recommends at least 80% coverage to use registration data on births and deaths for social and economic planning. However, registration remains low in developing countries. National coverage for Kenya in 2014 was 62.2% for births and 45.7% for deaths, with wide regional differentials. Kilifi County in the coastal region in Kenya reported rates below the national coverage at 56% for births and 41% for deaths in 2013. Objective. To determine level of knowledge and practice and reasons for low coverage of birth and death in Kilifi County. Method. This is a descriptive cross-sectional study that employed multistage cluster random sampling procedure to select a sample of 420 households from which household heads and women with children below five years old were surveyed. Results. Out of the 420 households sampled, about all respondents (99%) were aware of birth registration while death was 77%. Their main sources of information were assistant chiefs at 77% for both birth and death registration and family and friends at 67% for deaths and 52% for births. Coverage for birth registration was 85% and death 63%. More deaths occurred at home (55%) than in hospital (44%) while 55% of deliveries occurred in hospital and 44% at home. Main reasons for not registering death were ignorance (77%) and transport and opportunity cost (21%) while for birth registration were ignorance (42%), travel and opportunity cost (41%), lack of identification documents (9%), and home deliveries (7%). Conclusion. Registration of birth and death has improved in Kilifi County. The drivers are legal and requirements to access social rights. Reasons for not registering are ignorance and opportunity costs. Community should be sensitized on the importance of registration, address home deliveries and deaths, and increase efficiency in registration. Further research is recommended to determine the severity of teenage pregnancy and orphanhood in the county.

Introduction Vital statistics are necessary for determining population changes, public administration, policy formulation, planning, and implementation of development policies. Ideally, birth registration is part of an effective civil registration system that acknowledges the existence of the person before the law, establishes the child's family ties, and tracks the major events of an individual's life, from live birth to marriage and death. A birth certificate provides some, albeit minimal protection against early marriage, child labour, recruitment in the armed forces, or detention and prosecu-tion as an adult [1]. The data are required to formulate programs relating to maternal and child health including nutrition, immunization, and universal education. World Health Organization (WHO) recommends at least 80% coverage, as criteria for use of registration data on births and deaths. However, coverage of birth and death registration remains unacceptably low especially in developing countries. Globally, each year, about two-thirds of 57 million annual deaths go unregistered, and as much as 40% (48 million) of 128 million births go unregistered, representing one out of three children [2]. Although it can be argued that census and other large sample surveys may be useful in supplementing demographic data in countries where vital registration system is still at infancy, they are expensive to perform on a routine basis, are frequently marred by politics, disputes about figures, underfunding, and topographical challenges, and should rather serve as complements in a comprehensive health information system [3,4]. Civil registration of vital events in Kenya started in 1904, but was limited to Europeans and Americans. However, after independence in 1963, registration was made compulsory for all residents in Kenya. The Civil Registration Service (CRS) is the government agency responsible for the registration of births and deaths. The assistant chiefs are the government registration agents for vital events that occur at home or in the community while health care workers are responsible for events that occur in health institutions. The agents submit notifications to civil registrars in civil registration offices for registration and issuance of birth and death certificates. Despite the clear path, registration coverage for Kenya is below WHO recommended levels. The national coverage was 62.2% for births and 45.7% for deaths in 2014, with wide regional differentials which suggests that factors determining coverage may vary by county. However, very few community studies have been conducted in Kenya to determine the factors responsible for the low coverage. This study was undertaken to identify factors responsible for low registration of birth and death in Kilifi County; the coverage was below the national coverage at 56 and 41 percent, respectively, in 2013. The study assessed knowledge, attitude, and practice (KAP) of birth and death registration in Kilifi County. --- Materials and Methods --- Study Site. The study was conducted in Kilifi County. The constitution of Kenya divides the territory of Kenya into 47 geographical units, and Kilifi County is one of the units. Kilifi County is located in the coastal region in Kenya and has an area of 12,245 km 2 . According to Kenya national population census, the county's population was 1,109,735 in 2009 [5] with a growth rate of 3.1 percent per annum. The main economic activities are tourism and fishing due to its proximity to the Indian Ocean. It has fertile soils and good weather pattern, and so, it is good for agricultural farming. --- Sampling and Sample Size. This study employed a multistage cluster random sampling procedure. A sample of 420 households was drawn from twelve (12) sublocations selected from four subcounties. The four subcounties were randomly selected from the six subcounties that make up Kilifi County. Thirty-five (35) households were selected systematically from each sublocation. The main tool for the study is survey questionnaire-a household questionnaire with vital event sections for deaths in the last five years to the survey and births less than five (5) years old. Interview guides were also utilized to collect qualitative data to explain the survey findings. --- Study Design and Target Population. The KAP survey was cross-sectional and targeted household heads and women with children below five (5) years old. The respondents were interviewed to elicit information on household characteristics, registration of deaths that occurred in the last five years, and births below five years old. The targeted women also provided information on their experience with the civil registration system (recent/current bottlenecks in civil registration of births) and reasons for not registering birth. To address known limitations of quantitative design, qualitative techniques (KII and FGD) were employed to contextualize and supplement the survey findings and explain the practices and attitudes in survey questionnaire responses. The qualitative study targeted registration agents to understand the CRS system and community elders to understand the sociocultural context. The qualitative interviews were aimed at describing and understanding the community's own perceptions and experience in birth and death registration [6]. --- Results To achieve the study objectives, 420 household were surveyed, and six focus group discussions were held with members of the community and seven key informant interviews with birth and death registration agents. From Table 1, out of the 420 households sampled, 88 (21%) were in urban and 332 (79%) in rural area. Over 10 and 13 percent of households surveyed were more than 10 km away from the assistant chief's office and health facility (registration agents), respectively. About 84.3 percent of the households had at least one child under the age of five (5) years, while more than a quarter (27%) of households had experienced death in the last five (5) years. Of the 420 respondents to the household questionnaire, 164 (39%) were heads of household and 237 (56%) were spouses of the heads of household. Two hundred and sixty-four (63%) of the respondents were female while 37 percent were male. Over 80 percent of respondents were between 25 and 49 years old, about 10 percent were 50 or more years old, while less than nine percent (8.8%) were between 20 and 24 years old. Thirty percent (30%) of respondents had no formal education, 55 percent had some primary education, less than 14 percent (13.9%), and less than 2% had some secondary and tertiary education, respectively (Table 2). More than three quarters (76%) of respondents were from monogamous families, less than 17 percent were polygamous, 4 percent had never married, while about 3 percent were widowed, divorced, or separated. The median household size was 7 persons. Two hundred and eighty-four (68%) of the respondents had children below 5 years (Table 2). Out of the 420 respondents interviewed, all respondents (99.5%) were aware of birth registration, while more than three quarters (322 (76.7%)) were aware of death registration. Their main sources of information on death registration were assistant chiefs (77%) and family and friends (67%). Main source of information for birth registration was also the assistant chief (77.2%) and members of the 2 BioMed Research International family and friends (51.7%). However, only 11 percent of respondents reported having heard of death registration from health workers compared to 37.8 percent for birth registration (Table 3). Almost all (97%) of the 322 respondents and of the 419 respondents who said they were aware of death and birth registration, respectively, had knowledge of at least one place where to register the respective civil event. Among the respondents aware of birth registration, higher percentage (94%) of them knew how to register birth compared to respondents who were aware of death registration where only 69 percent were knowledgeable on the process of registering death. Majority (66%) of the respondents who were aware of death registration were also aware of importance of death registration. Fifty-nine (59) cited legal requirement and 2 percent to obtain a burial permit. A sizable percentage mentioned individual benefits: 37 percent for succession and 14 percent to honour the deceased. However, 47 (11%) respondents had no idea why registration of death is done. For birth registration, almost all (93%) of the 419 respondents who were aware of birth registration were also aware of the importance of registering birth. The reasons advanced for registering birth varied from to meet legal requirement (40%), school requirement to register for national examinations and 3 BioMed Research International to access bursaries for orphans (71%), to acquire national identification card (ID) and passport (36.4%), and because it is good to obtain a birth certificate for any eventuality (17.5%). However, 28(6.7%) of the respondents had no reason why registration should be registered (Table 3). The survey reported 140 deaths and 671 births in the last five years prior to the survey. Out of the 140 deaths, 79 (56%) were male and 61 (44%) female, and more deaths occurred at home (55%) than in hospital (44%). For births, about 333 (50%) were male and 338 female (50%) and were more hospital 4). Reasons for not registering death are ignorance (54%: did know where to register and did not know the importance), not heard of death registration (23%), distance to registration office, long wait in the queue and costs associated with travel (21%), and deaths that occurred at home (9%). For birth registration, reasons for not registering are ignorance (42%), transport and associated costs (21%), distance to registration office and waiting time (20%), lack of identification documents (9%), and home deliveries (7%). --- Discussions --- Knowledge of Civil Registration System. Knowledge about death registration in Kilifi County is high at 77% but is lower than birth registration (99%). This can be explained by the number of interventions in Kilifi County; most CRS partners are implementing interventions addressing issues of late and low registration coverage for births while there is none for death registration. The main driver for death registration in the region is the legal requirement for burial permit for body disposal and succession. The low level of awareness found can be associated with low level of education among residents in this area; only about 15 percent of the respondents have attended school beyond primary level with 30 percent with no formal education. Other similar studies have found that where awareness about registration of civil events is low, coverage is also low [3,7]. According to UNICEF, unregistered children tend to be found in areas where there is little awareness of the value of birth registration [8]. The respondents found in this study to be ignorant about civil registration especially death registration and about place to register birth and death, have no individual or legal incentives to register, and are not clear about the process of registering are therefore unlikely to register birth and death if and when it occurs in their households. This shows that awareness about civil registration among the people is one of the important reasons for low coverage of birth and death registration in Kilifi County. The study also established that the main sources of knowledge on birth and death registration are the registration agents, family, and relatives. The role of media in this regard is minimal. This is not surprising as the study found most (84.5%) of the respondents had not attended school beyond primary level and therefore not amenable to source of information outside of their social circles. Any awareness campaign on civil registration targeting the community should therefore be through communal activities including meetings, wedding, and funerals. --- 4.2. Practice. Crude birth rate (CBR) and crude death rate (CDR) are indicators of levels of living or quality of life [9]. In this study, crude birth and death rates for Kilifi County were 38.9 and 8.3 per 1000 population, respectively. The CBR compared well with that reported in WorldBank report 37.6 per 1000 population in the year 2011; however, the CDR reported was in variance to the WorldBank's 11.8 (i) Lack of funds (ii) Not knowing place to register (iii) Ignorance (lack of knowledge, stillbirth, did not know the importance) 5 BioMed Research International per 1000 population in the year 2011. This may be attributed to under reporting of deaths especially for neonates which are regarded as bad omen and are interred immediately after death as explained by a respondent in FGDs: Stillbirths and deaths of newborn babies are mostly not reported, especially when they take place at home. They are buried immediately due to cultural beliefs-they are a bad omen.... Sometimes back they used to be buried under the bed or under a big tree and the whole thing (death) is forgotten. For a CDR of 11 per 1000 population [10,11] and a sample size of 3360 (420 households and household size of 8) people represented in this study, expected number of deaths is 37 per year or 185 deaths in five years as opposed to 140 deaths reported in this study. The 45 people whose deaths (185 deaths computed-140 deaths reported) were not reported might have suffered the "scandal of invisibility" [12]. The study found coverage of birth and death registration in Kilifi to be 85 percent and 84 percent, respectively. However, the death coverage is in variance with WorldBank 63.3 percent (computed based on WorldBank CDR of 0.011) which can be attributed to low death reporting implied elsewhere in this report. Birth registration was found to vary by place of residence, age of the mother, marital status, and education level of household head. Birth registration is highest among children in urban areas than rural areas which can be attributed to strong links to the mainstream mechanisms of society, such as health services. About 60 percent of births in urban areas occurred in hospitals compared to 54 percent in rural areas. Kumar et al. reported similar finding in Eastern Uttar Pradesh where birth coverage varied by place of residence with urban area reporting better coverage than rural area, parent's level of education, and social economic status and marital status of the mother [13]. However, the study found low uptake of event certificate: 19 and 13 percent for death and birth, respectively. This can be interpreted as low individual incentive for death and birth certificates in the area. UNICEF reported similar findings where 85 percent of registered children under the age of five did not have birth certificate [8]. The little demand for birth and death certificate can be explained by the low level of awareness of their importance reported in this study. The proportion of deaths with death certificate is higher than for birth certificates. This maybe because of succession and inheritance which is usually shortly after death, but unlike birth certificate which will be required when the children will be joining school at age six or seven. The birth and death registration rates reported in this study are too high compared to 56% and 41.1 for birth and death, respectively, reported in the annual vital statistics of 2013. The striking gap between the rate of death registration in the study and the vital statistics published in 2010-2013 can be explained by under reporting of deaths reported in the study or speculate loss of forms/data between the agent and CRO office. --- Reasons Advanced for Birth and Death Registration. Drivers of registration of deaths and births in this area are as follows: the need to satisfy legal requirement, to meet school and bursary requirement, to acquire passport and ID, and succession. The perception is on the need for a certificate to achieve something else [3,14]. For example, the actual death registration is highly driven by the legal requirement to obtain a burial permit for disposal of the body while for birth registration, the key motivating factor is the requirement for birth certificate to access social rights including education in future [3]. This indicates that to increase birth and death registration in this area, appropriate incentive(s) are required; lack of sufficient incentives or pressures on the citizen to register leads to low coverage [7]. Reasons advanced by respondents for not registering vital events and, where registered, reason for not obtaining birth and death certificate were distance to the registration office and associated costs, waiting time and opportunity cost for gainful work, and ignorance-not knowing the importance of birth and death registration [7,13]. 4.4. Challenges in Birth and Death Registration. The death and birth registration system faces various challenges that affect its optimal performance especially completeness and data quality. The issues include the following: (i) Shortage of Registration Materials. An assistance chief explained that sometimes he is forced to record details of a vital event that is reported in a note book and transfer them to the notification forms when supplies are replenished. (ii) Competing Priorities. Registration of vital events is not always a priority among registration agents work-it is secondary to other tasks performed by the registration agents including clinical work among health workers and public administration duties for assistant chiefs. (iii) Limited Knowledge on Event Registration among Agents. It was established that some agents especially chiefs are asking for more information than is necessary (details of the child's father) as a requirement to register a birth, while some agents in health facilities do not understand their role as registration agents (a nurse refusing to fill in notification form). The agents should be sensitized on death and birth registration especially on the requirements for event registration. ( --- Conclusion Death and birth registration in Kilifi County has improved. However, gaps in awareness, lack of clarity about the registration process, and individual perceptions are contributory factors to suboptimal civil registration in Kilifi. Leading reasons for not registering are distance, long queues/overnight stay for the services, and associated costs. Others are ignorance: never heard of civil registration, do not know the importance and process of registration, and inertia-too many births and deaths occurring at home. Drivers of registration are legal requirements and requirement to access social rights including education. Reasons for not registering are ignorance, opportunity and travel cost, and death and delivery occurring at home. Generally, respondents perceived registration of births and deaths as expensive both in terms of travel and opportunity cost, and it has little or no immediate benefits to the individuals and thus not a priority. To improve coverage for both births and deaths, the study recommends the following: (i) Enhance awareness campaign among residents on civil registration in the area. The most effective channels of awareness creation are community meetings including, weddings, burials, and community health workers (CHW). The messages should include registration procedure, place to register, and importance of birth and death registration as incentives (ii) Extend birth and death registration network to subcounty level by either opening registration offices or introducing mobile birth and death registration services. This will reduce distance residents have to travel to access registration services, consequently cut cost of transport and associated expenses, and reduce time away from daily work (iii) Enforce the law on birth and death registration (iv) Avoid stock out of registration materials-application forms (v) Undertake a validation exercise/study to ascertain system efficiency in particular the link between the registration agents and Civil Registration Offices --- Data Availability Data is available on request. --- Additional Points Paper Context. Birth and death registration in Kilifi County in Kenya is below national coverage. Reasons for suboptimal coverage are not known. This study has identified the reasons and recommended measures to address them. If the measures are implemented, coverage would improve to more than 80% and the data from the civil registration system can therefore be used for social and economic planning in Kenya. --- Consent Respondents' consent for publication is not required. --- Conflicts of Interest The authors declare that they have no conflicts of interest.

0cd44d1b336f95b6964c6e85cd8e95cd21ef395b

"Implicit, Explicit, and Structural Barriers and Facilitators for Information and Communication Tech(...TRUNCATED)

"Older adults' usage of information and communication technology (ICT) is challenged or facilitated (...TRUNCATED)

"INTRODUCTION\n\nHe -my husband-does not let me touch the cellphone as I damage it. He claims that I(...TRUNCATED)

d5498c5e3fb10b6598141002e1dcc75379d3c342

"Potential Social Conflict in Coal Mining Areas and Alternative Solutions in Indragiri Hulu Regency,(...TRUNCATED)

"Keberadaan perusahaan tambang di suatu kawasan memiliki dampak positif bagi pembangunan daerah, pen(...TRUNCATED)

"Introduction\n\nThe presence of mining companies contributes positively to economic and regional gr(...TRUNCATED)

bc57441083d2c26e3d250d2be7d9ad165ecaac7d

"Intimate partner violence complaints during COVID-19 lockdown in Spain: a cross-sectional and a cas(...TRUNCATED)

"Background: During the COVID-19 lockdown, a large proportion of the women exposed to intimate partn(...TRUNCATED)

"Introduction\n\n\n---\nD\n\nuring the last few decades, a substantial body of knowledge has been pr(...TRUNCATED)

dc4cd82657ced9affd6d3d263b22097f6e460d46

"Exploring the Intersectionality of Bisexual, Religious/Spiritual, and Political Identities From a F(...TRUNCATED)

"While there is a small but growing body of work that examines the religious and spiritual lives of (...TRUNCATED)

"\n\nRecently however, researchers have begun to move away from studying the LGBT community in its \(...TRUNCATED)