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focus on some aspect of the recruitment and retention of healthcare professionals to this rural, underserved region. An overview of the processes and actions utilized to estab lish and maintain this partnership are provided in Table 1. Four processes and action categories are as follows. Research 101 course is important because it teaches non-researchers research design, analysis, evaluation, and publications as a translation tool. Joint training also occurs. Education and training of academic faculty and staff is necessary. Ongoing training is provided in culturally appropriate strategies to support interaction with nonacademic community organizations and the public utilizing communication strategies to improve explanations of complex health matters and research results in a respectful and literacy appropriate manner. Joint training also occurs. Mandatory evaluation of the partnership and programs is required to assess effectiveness and make changes where needed. Evaluation research and program evaluation of all key program functions, processes, and activities for assessing immediate, intermediate and long-term program outcomes. We obtained external evaluation research support from MBH, Limited, an evaluation research firm in the DC area. Addressing community distrust of academic institutions is important. For community physicians, distrust of academic institutions is real and requires willingness on the part of academics to outreach to community partners for meetings by meeting outside of academia instead of requiring that community organizations always come to the university for meetings. Academic organizations must emphasize the value of community partner engagement in the success of the bidirectional partnership. The initial distrust by the Eastern Shore region health professionals was related to history and concern over losing patients to the academic institution. A commitment to transparency of motives is critically important. Policy research, advocacy, and policy activities are important to support translation/ dissemination of research results, support access to beneficial interventions and support science guided advocacy and regulations/legislation. Education of elected officials and their staffs and other policy makers is important on advances in research and health indices for their constituents. Monitoring community health data and needs helps to guide policy and legislative action. Community training in advocacy using health data and research results is effective. We observed the evolution of community health education programs and topics based on community interest, needs and requests. Topics are informed by formative and survey research and discussions at community meetings. We started with health disparities and clinical trials education, then Mini Med Schools and health literacy in a clinical trials 101 course. We then incorporated bioethics and research ethics training, and recently the importance of biospecimen, tissue donation and research advances and biospecimen science. --- Building trust between partners takes time and patience of all partners. A long-term commitment to work together is necessary to achieve common goals such as improvement in community health, leveraging funding to support sustainability of programs, partnered research to identify needs and solutions.

T his paper describes lessons learned and progress to date for a community-academic partnership model serving rural Maryland. In 1997, a bidirectional community-academic partnership was developed between ESAHEC and UMSOM OPP. UMSOM is the largest school in the University of Maryland Baltimore (UMB). Established in 1997, the ESAHEC is a nonprofit organization that serves the healthcare access needs of all the regions' nine counties. It is one of three centers in Maryland and 255 centers across the United States. 1 The ESAHEC is a trusted and respected

L ong-term care (LTC) is a relatively new public and health policy concern, one that results from successes in improving population health as well as declines in fertility across industrialized nations. Because of its relative newness, government efforts to respond to the growing demand for LTC must necessarily build on existing systems, fundamentally shaping the issues that arise. Indeed, in many cases, a government's need to act is based on pressures that the demand for LTC care places on existing public programs: Ikegami notes how overutilization of Japan's hospitals by older people (and the associated pressure on healthcare costs) was a key factor behind the introduction of its LTC insurance (LTCI) program. 1 The adoption of Germany's program was due, in part, to cost pressures on the social assistance program financed by regional government, which funds nursing home stays for the poor. 2,3 While any public program must build on and co-exist with established systems, LTC is particularly tricky because it overlaps with so many other policy areas: most obviously, a country's healthcare system, but also with housing, labor, retirement, and family policy, so that boundaries between programs differ from country to country. Moreover, because so many of these areas are influenced by contentious and shifting societal norms -particularly around the role of the family generally and women specifically -the design of LTC programs can be difficult to negotiate. This unavoidable variation across countries -in how a society sets goals for its LTC program and how it delineates LTC -reinforces Ikegami's point about the difficulty of comparing programs. For example, a key difference lies in the role of family caregivers, and the extent to which cash payments are intended to pay for their work. Ikegami includes allowances to family caregivers as a LTC expense, reasoning that they are equivalent to cash payments. While care allowances are certainly meant to compensate carers for their work, it not clear that cash payments are primarily meant to benefit family caregivers. Indeed, the goal of cash payments differs across countries. For example, in the US's Medicaid program (the largest payer of LTC in the country, funding LTC on a means-tested basis), most states' cash for care programs ban payments to spouses, and often ban payments to family members living with the care recipient. Even where permitted, not all care recipients choose to use cash payments to hire relatives. In other countries as well, cash payments are used to hire independent workers. Indeed, in some cases the political rationale for cash payments is to help develop and recruit a professional workforce. In contrast, feminists in Japan campaigned against including a cash benefit in the Japanese program, on the grounds that it would consolidate the role of women in providing LTC (a concern also in South Korea and Taiwan) -clearly assuming that a cash payment would be used to compensate family caregivers. These differences reflect the varying meanings of cash payments: whether they aim to benefit care recipients, enabling them to operationalize choice in who provides care (its predominate meaning in countries that fall into the Anglo-liberal welfare state category 4 ), only indirectly benefitting family caregivers, or whether they act as family income supplements, meant to compensate carers for the work they do (as it is in Germany -although Germans, too, use cash payments to hire independent workers as necessary). However, benefits for carers fit awkwardly with many countries' LTC programs, often constituting a separate category and funded through separate payment streams -often, because they cover situations other than eldercare. (Many such policies focus on childcare.) While benefits such as respite fall clearly into the LTC bucket, other caregiver benefits are harder to classify. For example, some US states have introduced paid family leave (which provides income to those caring for disabled or elderly persons as well as for children), typically financed out of payroll taxes. In Germany, however, the public LTCI program finances unemployment, health insurance, and LTCI contributions for carers as well as contributions to Germany's statutory pension fund, and paid leave is taken as a personal loan. If, however, a carer leaves employment, the LTCI program's cash benefit can become a family income supplement, underlining how a cash benefit is fungible in some countries, but not where there are strict controls over their use. 5,6 The case of caregiver benefits highlights the difficulty of distinguishing LTC from other services and programs. Ikegami notes another example: nursing homes, an issue that arises due to the increasingly severe health status of nursing home residents. Worldwide, countries are striving to limit nursing home admission to people with more serious health conditions, and to provide most LTC in community-based settings -ideally, in people's own homes. Rising acuity levels among nursing home residents have raised the cost of nursing homes and, in turn, created incentives to limit access. More importantly, they have blurred the distinction between the types of care delivered in nursing homes and in other settings that traditionally fall in the health sector, such as post-acute/ rehabilitative and long-term chronic care. Concurrently, such shifts have created a need to find ways of serving significantly disabled individuals in community-based settings; delivering health-related services in those settings; and ensuring quality and coordination for those services. One of the Dutch program's recent reforms was to acknowledge this distinction, formally shifting the costs of home nursing out of the LTC program and into the health sector. However, this shift, along with other changes that split responsibility for LTC, has created its own problems: namely, poor coordination across entities and the creation of incentives to cost-shift. 7 The Dutch program illustrates some issues that can arise out of a poorly-defined program, leading to high costs: the Dutch spent roughly 3.7 % of gross domestic products on LTC in 2015, compared to the Organisation for Economic Co-operation and Development average of 1.7%. 8 This can be attributed to their early adoption of social insurance for LTC, back in 1968, 9 with an initial, problematic design: the program covered a broad range of risks; utilized nursing homes heavily; had porous boundaries with other programs; and had high premiums from the very start. The program's name -the Exceptional Medical Expenses Act (AWBZ), now the Long-term care Act (Wlz) -hints at how broad its initial goals were: in addition to explicitly covering LTC, it covered rehabilitation, hospital stays of over a year, and mental health care. The program also covered people of all ages. Thus, a major cause of budget pressures resulted from demand from children with learning disabilities, autistic spectrum diagnoses, and intellectual disabilities who otherwise lacked services. To solve these problems, a 2015 reform re-allocated program responsibilities among several different programs, leading to the aforementioned concerns about increasing fragmentation and cost-shifting. This potted history of the Dutch program aims to highlight the importance of defining the core constituency of a LTC program and the needs that a program is aiming to address -as well as the influence that other areas of health and social policy can have on LTC programs. A key cost-control component of the Japanese program is that is it limited to older people and those with specified "geriatric diseases, " an approach that South Korea has copied. 10 The German program, in contrast, covers people of all ages, and recently revised its eligibility assessment to more explicitly cover people with dementia. 11 Indeed, many LTC programs cover people of all ages. The downside of a unified program is that it can create a large political constituency supporting expanded benefits (leading to expanded costs); the differing political constituencies may also have significantly different goals. On the other hand, separate programs can create discontinuities and inequalities across populations. For example, Australia operates a generous LTC program for younger people with disabilities and a less generous aged care program, creating problems as people transition from one to the other. However, other political issues can arise if it is perceived that benefits received by older people are at the expense of younger or future generations, an issue that Japan has addressed by limiting the contribution base for its LTCI program to people 40 or older. Although LTC's emergence as a "new social risk" 12 is complicated by its need to complement existing systems, the field has benefitted considerably from cross-national learning. Germany purposefully incorporated cost control mechanisms into its design. Japan built on the German program, while South Korea, in turn, learned from Japan's experience; notably, it intentionally started small, 13 as Ikegami recommends, with strict eligibility criteria and comparatively low contribution levels. Taiwan, too, has carefully studied other countries' design in developing its yet-to-be-launched program, although, interestingly, it has seen a backlash against the social insurance model recommended by its policy experts, 14,15 -a development that should remind the reader that local politics and history will nearly always trump careful planning. History also affects what citizens feel is owed them, which in turn influences how a program evolves. Although social insurance models are critiqued for creating a sense of entitlement among citizens, entitlement can arise from historical or social factors, as the evolution of Japan's program demonstrates. Ikegami concludes by advising countries to start early in developing their LTC programs, so they can start small and constrain expectations -good advice, certainly. However, things rarely goes as planned: gestation periods for LTC programs can be extremely long. While researchers and policy experts-not to mention ordinary people-understand the critical and pressing need for LTC programs, politicians often see this as a low priority in the face of conflicting demands on the public purse. In both the case of Germany and Japan, a political catalyst was needed to induce the birth of the programs; many countries, including Taiwan and the United States, await their catalysts. Meanwhile, countries developing and adapting programs can learn from LTC programs worldwide. --- Ethical issues Not applicable. --- Competing interests Author declares that she has no competing interests. --- Author's contribution PN is the single author of the paper.

The need for long-term care (LTC) represents a "new social risk, " one that overlaps with and complements systems of care that pre-date such programs, complicating LTC program design. This commentary expands on Ikegami's discussion of how these structural factors must be accommodated, as well as historical and cultural factors that influence public expectations of such a program. The commentary specifically focuses on the role of cash payments, caregiver benefits, and the sometimes indistinct line between LTC and health systems. The experiences of countries operating LTC program in a wide range of contexts can illuminate common challenges, as well as some potential solutions to these vexing design and operational issues.

ANGELA Angela (name has been changed), in her late 50s, had achieved some stability in her life after a painful childhood and a tumultuous adulthood. She had secured subsidized senior housing because of a severe mental health disability requiring weekly electroconvulsive therapy. As a family medicine physician at Kaiser Permanente Washington (KPWA), I witnessed the value of a community resource specialist in my clinical practice, but I longed for patients to share their stories. Angela volunteered. Her eagerness to share her story with me was tempered only by her occasional memory lapses. Pushing aside the 1000-piece puzzle on her table, she asked me to sit while she explained how Larnette, the community resource specialist at her primary care clinic, had provided her with the support, motivation, and hope to improve her health by addressing her social needs. During Angela's first visit with her new primary care physician, Dr Bryce, she mentioned that she wanted to find more ways to exercise in the community but didn't know where to start. After addressing her chronic conditions and ensuring her preventive care needs were met, Dr Bryce referred Angela to Larnette. Dr Bryce did not have knowledge about all the resources available in the community to help Angela start exercising; nor did she feel like she had adequate time in her 20-minute clinic visit to identify and prescribe her the right community resources. --- COMMUNITY RESOURCE SPECIALIST The community resource specialist at KPWA has many roles in the primary care clinic, but for the patient, the goal is twofold: To connect patients with resources-inside and outside KPWA-and to provide a level of supportive health coaching that primary care practitioners lack time for during quick office visits. Larnette, as the community resource specialist in Dr Bryce's clinic, typically connects to patients through a warm handoff. A warm handoff in clinic is when one member of the care delivery team introduces Larnette, as a fellow team member, to the patient in real-time and explains the role of the community resource specialist in addressing the patient's needs. After connecting to Angela, Larnette was able to identify challenges facing Angela through 10 encounters during the following 3 months. During this time, she connected Angela with several resources and coached her on how to receive the care she deserves. Because Dr Bryce had specifically referred Angela for group exercise opportunities, Larnette, in her first conversation with Angela, shared with her the "Walk and Talk" program-a free weekly event where health care teams walk for 30 to 45 minutes with community members in accessible community settings. During her assessment, however, she also learned that Angela had limited access to adequate food and received food from a local food bank. Larnette realized that she would qualify for a program called Fresh Bucks because of her food insecurity-a term that signifies Angela had inadequate food for healthy living owing to a lack of money. 1 Fresh Bucks is a program that provides vouchers matching the value of recipients' weekly food stamp allotments for use at farmers markets in King County, WA. In King County, about 12% of households are food insecure, matching the national statistic. 2,3 Angela fell within that percentage. Fresh Bucks is one solution to address the problem of food insecurity and poor access to healthful foods in King County. The program is a success by many measures. As of 2016, it had 4556 participating residents and 14,743 shopper visits and contributed $591,786 to the local economy. 4 Although she qualified for this program, Angela did not even know it existed. Larnette explained to Angela how the program works and how to apply for it. After her conversation with Larnette, Angela was curious to see if anybody else she knew had knowledge about the program. She asked her neighbors and friends at the senior housing complex about Fresh Bucks, but she was met with blank stares. She even asked the housing resident services manager, but that person had not heard about the program either. No one she knew had heard about Fresh Bucks. --- ACCESSING COMMUNITY RESOURCES In the US-because of a myriad of cultural, economic, and political factors-the ratio of spending on social services to health care is 1:1 compared with 2:1 in many peer countries in the Organization for Economic Co-operation and Development. 5 This has hamstrung the social services sector from adequately addressing social needs. King County is better off than many other counties in the nation. There was a program --- NARRATIVE MEDICINE The Best Year of Angela's Life already available and accessible to help address food insecurity. Angela was just unaware the program existed. Creation of more robust communication outlets by the social services sector would ensure people like Angela were aware of community resources and had the necessary support to access those resources. Unfortunately, the current system was not meeting Angela's needs. The community resource specialist was one way for our organization and our clinic to bridge this gap by understanding the resources available in our community and ensuring our patients were connected with these resources, especially if we were their sole means to improve their health. Now, Angela receives $40 every 2 weeks through Fresh Bucks and goes to the farmers market every Saturday. "I get fresh fruits and vegetables. My favorite dish now is spaghetti squash with mushroom, onions, zucchini, and tomatoes." She added, "Before, I didn't get any vegetables or fruits. It was just too expensive. The best part is that I get to go to the farmers market and get out on the weekends." She repeated, "Seeing other people. That's the best part." By building better connections with her community, Angela felt she had decreased her social isolation, a known predictor of increased mortality. 6 Through Larnette, we had improved Angela's health by not only addressing her food insecurity but also helping her form stronger connections with her community. --- ADDRESSING SOCIAL NEEDS IN THE PRIMARY CARE CLINIC Health care organizations have created various models to identify and address social needs. Some have created call centers to conduct telephonic outreach to patients. 7,8 Others have staffed Emergency Departments with community health workers. 9 Our approach has been to place the community resource specialist in the primary care clinic. Over time, the community resource specialist has become a vital and irreplaceable member of the primary care team. When I asked Dr Bryce about what she would have done in Angela's case if there was no community resource specialist, she paused. "I'm not sure. I don't know. I would have probably said, 'I'll look into it' because I couldn't have done anything at that visit. I would've tried to find something at the end of the day." However, Dr Bryce had an infant waiting for her at home. Adding more work to the end of the day did not seem to be the best answer. She reflected on several patients who presented to her in acute crisis with social needs. She emphasized that she could not have provided appropriate medical care to them if Larnette had not helped address the patients' social needs first. She continued, "We just need the support. I think addressing social needs is a core aspect of being an effective healer." She had no doubt that a primary care clinic should address patients' unmet social needs, particularly if their existing support network had failed to meet those needs. Angela didn't hesitate to answer the question about where social needs should be addressed. "The clinic. It's convenient, it's where I would go first, and it's where I already go for my appointments. And the doctor knows me and what I'm going through," she replied. For Angela, it was also about trust. Angela recounted a clinic visit decades ago when her son was a year old. She tried to tell the doctor about not having enough food, following a particularly painful night where she had only one can of green beans for both her and her infant. She recalled tearfully, "It just felt like they didn't care. I could tell when I looked at the doctor. It was like they didn't have time for what I was going through. They just wanted to talk about my medical problems." That day, she stated, she lost trust in her physician and her clinic. Soon after, she stopped going to the clinic regularly. It was clear that Angela and Dr Bryce treasured having Larnette at their primary care clinic. Although social needs can be, and should be, addressed in a variety of settings to ensure that every person accesses the resources needed to thrive, Angela's case demonstrates that primary care clinics must identify and address social needs. A primary care clinic's ability to address acute, chronic, and preventive care is affected by social needs, often negatively if unidentified and unaddressed. Addressing social needs does not divert resources from a clinic's core responsibilities or diminish its quality of care; it bolsters them. --- ADVOCACY AND NEGOTIATION After helping address her food insecurity, Larnette continued to help Angela in several other ways. She helped Angela navigate a complex health care system to get the right care from the right person at the right time. Dr Bryce had advised her that she needed a walker because of her gait instability and referred her to a gastroenterologist for an ongoing medical problem, but Angela was already seeing 4 other specialists and had trouble coordinating her care. She was lost and didn't know who could help. Even in an integrated health system, care can be difficult to obtain. Larnette made a 3-way phone call with Angela and the durable medical equipment company to get her the walker. Then, she made a 3-way phone call with the gastroenterology team to elaborate on Angela's history and schedule the appropriate procedure for her. Angela didn't see it as merely navigating the system. "Larnette advocates for me when I feel like I can't. It's hard. I have trouble negotiating to get what I want." For Angela, it was Larnette's advocacy and ability to negotiate that she valued the most. Negotiating is an important skill for a patient in a complex, multilayered health care system. Patients must be able to state what they want and need and compare it with what each staff member has to offer. By always making 3-way calls, Larnette advocated for Angela, helped her navigate KPWA, and taught her how to seek and receive the care she needs and deserves. Angela ended the conversation with me by saying, "Sixty is going to be the best year of my life." I was amazed at the bold statement and wanted clarification. I asked with curiosity, "Why is that?" She replied confidently, "I just know it. I'm finally getting the right treatment for my mood. I'm eating better. Larnette also connected me to a Walk and Talk program. I haven't had a chance to go yet. But I'm going to try to. Sixty is going to be the best year of my life." --- NARRATIVE MEDICINE The Best Year of Angela's Life As a team, we are providing more than health care. We are giving Angela-and other patients like her-hope by addressing all their needs, including social needs. We are realizing our mission of helping our patients achieve better health. v --- Disclosure Statement The author(s) have no conflicts of interest to disclose. --- Acknowledgment Kathleen Louden, ELS, of Louden Health Communications provided editorial assistance. --- How to Cite this Article Sundar KR. The best year of Angela's life. Perm J 2018:22:18-076. DOI: https://doi.org/10.7812/TPP/18-076

Using a patient story, this narrative demonstrates why health care organizations, specifically primary care clinics, should strive to identify and to address social needs. This story demonstrates how Kaiser Permanente Washington, by using community resource specialists, has empowered primary care clinics to address social needs in a health care setting to improve patient care and experience.

1 University of Kansas 2 University of California-San Francisco 3 University of Arkansas OBJECTIVES/GOALS: To build a multi-function health profile for older adult (>50 years) women with a history of incarceration; explore group differences by age [45-54, 55-64, 65+], race, and length of incarceration; compare with age-matched control with no history of incarceration; and identify relative contribution of life course risk and asset factors. METHODS/STUDY POPULATION: We will analyze data from the Health and Retirement Survey (HRS) (UMichigan Institute of Social Research). The sample: women >50 years who took the leave-behind psychosocial questionnaire. The sample includes women with history of incarceration (n = 118; 2.93%) and (n = 115; 2.55%), respectively, and in the control n = 4,021 women (2012) and n = 4,114 women (2014). We will use descriptive statistics to profile physical, functional, cognitive, and social health; bivariable tests to compare groups on age-related morbidity, multimorbidity, frailty, and 4-year mortality risk; measure within group differences by age strata and race; estimate GLMs for effects of life course risk on dependent variables in and between groups; and if data permit, test direct mediation by life course risks and indirect by life course assets. RESULTS/ANTICIPATED RESULTS: Our results will characterize health in 4 health domains of women over 50 who have a history of incarceration. In bivariable analysis, we expect significant differences between groups on the dependent variables. Based on previous study using this data set, life course and accumulated stress theory, and our own previous research, we hypothesize that women with incarceration history will have more and earlier cardiovascular disease, stroke, and multimorbidity, higher 4-year mortality risk, and more and earlier cognitive impairment. We anticipate significant contributors to aging-related health outcomes to include childhood challenge and trauma history and, for Black women, perceived racial discrimination. We anticipate education and social support will partially mediate relationships. DISCUSSION/SIGNIFICANCE: The CHARMS findings, based on large-sample, representative, longitudinal HRS survey data, will contribute a profile of multi-function health status, risk, and assets in older women with CLS involvement. The much-needed characterization of aging in the group will set the stage for future interventional study to guide shifts in clinical practice. METHODS/STUDY POPULATION: CIT is a six-month program that includes didactic sessions, group readings and reflections and a one week immersion experience in a Colorado community experiencing health disparities. The Evaluation Center -University of Colorado Denver provides external evaluation services to the Colorado Clinical and Translational Science Institute (CCTSI). Evaluators used three primary methods to collect data to evaluate the program; Document review, interviews, and surveys. Evaluation data were analyzed using the framework of CBPR Principles and the CBPR conceptual logic model to understand potential shifts in researchers' thinking and actions, as well as to identify the potential for longer-term impact. RESULTS/ANTICIPATED RESULTS: As of 2020, CIT trained 122 researchers. 25 CIT alumni went on to receive 33 CCTSI Pilot Grants. Out of these 33 grants, an additional $8,723,000 of external grant funding was awarded to continue projects. Community Research Liaisons are a crucial component of the program through their efforts to bridge academic researchers and communities. Survey results indicated that community partners reported high levels of satisfactions with the program and shared stories about the impact they have seen in their community.

interests, resources/support needed to jumpstart future CEnR projects, types of CPs, PA regions represented by CPs and researchers, and training resources needed to prepare CPs to engage in research efforts. Heat maps illuminating researcher/CP engagement were generated from survey results. While CEnR research projects spanned all 67 PA counties, several studies were in concentrated areas, and thus allow for opportunities to target CEnR outreach in less engaged areas. Data analysis from follow-up surveys will continue to serve as a foundation to best support existing and future CEnR projects. DISCUSSION/SIGNIFICANCE: The CHEER Initiative's purpose is to reduce health disparities and increase wellness throughout underrepresented PA communities by promoting community-engaged research (CEnR). Surveys used to capture both CEnR interests of Penn State researchers and community partners built a successful and sustainable infrastructure for meeting this goal.

guide development financing for years to come. Fortunately, the SDGs dovetails with Africa's priorities as articulated in the Common African Position, "Agenda 2063, the Africa we want" 4 . The 7 aspirations in the Agenda 2063 capture most elements of the SDGs: a prosperous Africa based on inclusive growth and sustainable development; an integrated continent, politically united based on the ideals of Pan Africanism and the vision of Africa's Renaissance; an Africa of good governance, democracy, respect for human rights, justice and the rule of law; a peaceful and secure Africa; an Africa with a strong cultural identity, common heritage, values and ethics; an Africa, whose development is people-driven, relying on the potential of African people, especially its women and youth, and caring for children; and Africa as a strong, united, resilient and influential global player and partner. This commonality of ideas helps to integrate the two aspirations and limit competitive ideas. It is widely recognized that the SDGs will only succeed, however, if they succeed in Africa. A projection of how Africa will fare in terms of reaching the goals in 2030 paints a bleak picture. The analysis suggests three categories: those that require reform, those that require revolution and those that require reversal. The first category assumes that it would take these targets more than half way to achievement by 2030 and these are economic growth (Goal 8) and strengthening domestic resource mobilization for development (Goal 17). The second category is those targets where progress needs to speed up by multiples of current rates to meet the target. These include ending extreme poverty (Goal 1), eliminating hunger (Goal 2), reducing maternal mortality (Goal 3), quality education (Goal 4), gender equality (Goal 5), access to sanitation (Goal 6), access to energy (Goal 7), industrialization in --- African Journal of Reproductive Health September 2016 (Special Edition on SDGs); 20(3): 20 LDCs (Goal 9), reducing inequality (Goal 10) and halting deforestation (Goal 15). The third category is where the targets are heading in the wrong direction. They include reducing slum populations (Goal 11), reducing waste (Goal 12), combating climate change (Goal 13), marine conservation (Goal 14) and reducing violent deaths (Goal 16) 5 . The goals are interconnected as the effect of one goal has tremendous effect on the others. However, I believe that achieving gender equality (Goal 5) will revolutionize the achievement of the other goals and is sin qua non for the achievement of the other goals and for the general attainment of the values and ideas of SDGs. The targets for Goal 5 are: 1. End all forms of discrimination against all women and girls everywhere. 2. Eliminate all forms of violence against all women and girls in the public and private spheres, including trafficking and sexual and other types of exploitation. 3. Eliminate all harmful practices, such as child, early and forced marriage and female genital mutilation. 4. Recognize and value unpaid care and domestic work through the provision of public services, infrastructure and social protection policies and the promotion of shared responsibility within the household and the family as nationally appropriate. 5. Ensure women's full and effective participation and equal opportunities for leadership at all levels of decision making in political, economic and public life. 6. Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Program of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences. 7. Undertake reforms to give women equal rights to economic resources, as well as access to ownership and control over land and other forms of property, financial services, inheritance and natural resources, in accordance with national laws. 8. Enhance the use of enabling technology, in particular information and communications technology, to promote the empowerment of women. 9. Adopt and strengthen sound policies and enforceable legislation for the promotion of gender equality and the empowerment of all women and girls at all levels 6 . Significant progress was achieved towards gender equality and women's empowerment under the Millennium Development Goals including the target of access to primary education between girls and boys. However, gender equality is still out of sight. Many of the targets under Goal 5 of the SDGs are embedded in cultural and social norms and values which make them harder to change. Legislation and policies can be invoked to reach some of the targets and they may be necessary first steps. Whereas there is no silver bullet for gender equality, girls' education is one weapon that can make a significant difference because of the potential of changing norms and values. I recall a conversation with a governor who made the point better. I was disturbed about the rate of divorce, the high number of divorced women and the ease at which women could be divorced in his state. I suggested legislation to curtail the situation including minimum age at marriage and stricter conditions for divorce. He appreciated my concern and solution but reminded me that as a politician the suggestion will not only be difficult to implement but may not be effective and raise controversies that could consume the administration. He made the point that religious, political and traditional leaders will seize on any move to legislate and create chaos. They would be fighting him until the next election. His political career will be truncated because of demonization. The solution, according to him, is to ensure that every girl attend a minimum of secondary education. Each should enjoy free education including free transportation, uniforms and meals. He thinks that by the time a girl reaches the age of 17/18, she can make many decisions that will respond to the targets of Goal 5. I believe free and compulsory education is necessary for the attainment of the many targets of Goal 5. In addition, we must pay attention to the quality and functionality of the education. There is --- Conflict of Interest: None

York at the General Assembly in September 2015 to agree to a set of successor goals to the Millennium Development Goals (MDGs) known as Sustainable Development Goals (SDGs). Tagged "Leave No One Behind", the SDGs is different in many respects from the MDGs. It is more ambitious (17 goals and 169 targets), developed through better consultative, transparent and participatory process, and commits all countries of the world. In comparison, the MDG had limited goals and targets (8 goals and 18 targets), less consultative, transparent and participatory, and are only applicable to developing countries 1 . The 17 Goals of the SDGs include: the eradication of poverty, end hunger, good health and well-being, quality education, gender equality, clean water and sanitation, affordable and clean energy, decent work and economic growth, industry, innovation and infrastructure, reduced inequalities, sustainable cities and communities, responsible consumption and production, climate action, life below water, life on land, peace, justice and strong institutions and partnerships for the goals 2 . These ambitious and all-encompassing goals are to be met by the year 2030. Africa played significant roles in the process of development of the SDGs 3 .

Figure. Contraception Options --- Media Marker and pen on paper, 9" x 6". Gender equity and sex-positivity movements have delivered several distinct, effective contraception options: implant, inject, or daily ingest. No longer are women leashed to a cycle of trepidation, relief, trepidation. Contraception offers women control over their reproductive capacity. A variety of contraceptive options means a woman can choose among methods' fit in her life. She considers questions such as these: Is her routine regular enough to ingest a pill every day at the same time? Does she want to have a device implanted in her uterus or arm? Can she stand an intramuscular (IM) injection every 3 months? (An IM injection requires a 1" to 1.5" needle, about which clinicians should warn their patients.) To receive an IM injection or pill, she must be able travel to a clinic or pharmacy at least every 3 months, or monthly. An implanted device requires making peace with a subdermal plastic rod. With all options, iatrogenic effects (eg, side effects and interactions with other medications) must also be considered. All these options are preferable to and more realistic than abstinence or blind prayer. But each asks only women to take on risk, responsibility, or discomfort. Access to safe, effective contraception, which benefits everyone, came with new burdens unilaterally borne by women. Progress on gender equity means shifting contraceptive burden to equitably distribute all risks and benefits of sexual relationships. Currently, barring physical barrier methods, contraception and its risks are borne exclusively by women. The character in the comic, a teenage girl of reproductive age, symbolizes her and other girls' and women's desires for equity in family planning and reproductive agency. Michaela Chan is a graduate student at the School of the Art Institute of Chicago in Illinois, and her comics start as questions, songs, and conversations. --- Conflict of Interest Disclosure The author(s) had no conflicts of interest to disclose. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.

Contraception Options considers the general social and cultural expectation and norm that women's bodies should be the sites of contraception. The comic represents frustration with inequitable distribution of contraceptive burden.

mentorship, a relationship-centered person-to-person approach may reduce healthcare decision-making burden among African American caregivers through cultural tailoring by promoting oral traditions, personal contact, and storytelling. The purpose of this Stage 1 intervention study is to use a stakeholder-informed approach in further developing and pilot testing the co-created Peer Support for Caregivers of African Americans Living with Alzheimer's Disease and Related Dementias (Pair2Care), a culturally sensitive caregiver peer support program. Pair2Care feasibility and acceptability will be evaluated in current (n=15) and trained former (n=15) African American Alzheimer's and related dementia caregivers. Pair2Care will be deemed feasible and acceptable by evaluating eligibility criteria, recruitment and retention data, protocol adherence, satisfaction, and feedback on program appropriateness for broader dissemination. Preliminary intervention outcomes of caregiver anxiety, depression, quality-of-life, social support, self-efficacy for surrogate decision-making, and intent to use palliative care or hospice services will be assessed to evaluate intervention effectiveness. At 6 months as compared to baseline, current caregivers will report less anxiety and depression, improved quality-of-life, social support, and self-efficacy for surrogate decision-making, as well as intent to use palliative care or hospice services as part of healthcare and advance care planning decision-making. Pair2Care poses an innovative strategy with the potential to address advance care planning and healthcare decision-making, a significant health disparity problem and thereby promote health equity. --- SESSION 3350 (SYMPOSIUM) Abstract citation ID: igad104.1127 --- EMPOWERING PEOPLE OF ALL AGES BY PROMOTING POSITIVE VIEWS OF AGING AMONG PK-12 STUDENTS Chair: Tina Newsham Discussant: Lisa Borrero Beliefs about aging and older adults form early in life and persist. People who hold positive views of aging rather than internalized ageism live, on average, 7.5 years longer. Communities where older adults retain meaningful engagement and are respected experience greater longevity and better social and physical well-being among people of all ages. Having positive interactions with older adults increases likelihood of pursuing careers working with older people. Promoting positive, accurate views of aging benefits individuals (of all ages) but is most effective when implemented early in life. Children, however, are rarely intentionally taught about aging and learn primarily negative stereotypes through media such as cartoons, books, and fairy tales. In this symposium, presenters will share projects aimed at disrupting the perpetuation of ageist stereotypes through intentional work with young children to promote positive views of aging. Laura Donorfio will present an aging education project developed for the Connecticut school system via an Administration on Aging grant. Next, Elizabeth Bergman will present two intergenerational case study projects involving elementary school-aged children, college students, and elders. Edward Miller will then the describe and sharing findings from an ongoing intergenerational tutoring intervention, begun during the early stages of the COVID-19

Pain is one of the most common comorbidities of ADRD and is experienced by 45.8% of ADRD patients. The major barrier to effective pain management is poor adherence to pain management regimens, due in part to caregiver lack of knowledge and lack of self-efficacy in administering analgesics. Pain in ADRD patients is associated with depression, wandering, agitation, and aggression. Digital applications may facilitate pain management by: (1) delivering education to increase knowledge and self-efficacy, (2) expediting pain reporting to nurses, and (3) improving adherence to pain management protocols. e-PainSupport is a self-administered, digital pain management application. It has three elements: (a) Educational Module, (b) Patient Pain Record, and (c) Pain Summary for Nurses. The efficacy of the app is currently being tested in a randomized controlled trial funded by the National Institutes of Health. The preliminary findings support the efficacy of e-PainSupport in reducing patient pain intensity and increasing caregivers' self-efficacy and knowledge. However, the current intervention relies on patients' self-reporting of pain and thus is not appropriate for all ADRD patients. Therefore, the purpose of this study is to explore facilitators for and barriers to using e-PainSupport for ADRD patients and caregivers. The data will be collected through post-intervention, semi-structured interviews of nurses and caregivers with patients in the e-PainSupport condition. Findings will inform future adaptations of e-PainSuport for ADRD patients and caregivers.

Socializing in Science Clear communication of research ideas and results is vital in order to become a successful scientist. Although conference presentations are an efficient way to share results, the one-way nature of this type of communication does not lend itself to collaboration. Setting up collaborations is often better achieved in an informal social setting, which provides an intimate environment with time to discuss things in detail. A social setting is where new colleagues are found, collaborations are established, and existing connections are strengthened. Social settings make networking easier by reducing boundaries to communication. Typically, after a keynote presentation at a conference there are relatively few questions from young scientists. This is due to a communication barrier-the junior scientist may be intimidated by the achievements of the senior scientist, or may be afraid to ask a question that might be deemed ''stupid.'' A social setting can remove the communication barrier, as the threshold for asking a question in front of a highly critical and expert audience is far higher than asking a question when sharing a drink together. More often than not, in fact, experts enjoy discussing their science with young scientists and appreciate that a fresh point of view can provide stimulating discussion. Organized social events can therefore be helpful, especially for those who don't characteristically initiate contact with strangers. An event or activity that provides the opportunity for introductions can ease any awkwardness and improve networking. --- The Importance of Networking In a multidisciplinary research field like computational biology, it is crucial to have an environment where scientists can connect and communicate directly. PhD students and postdocs will often work in a research group that consists of scientists with diverse educational backgrounds. The supervisor of a PhD student may not have a background in computational biology. Therefore, it is necessary to create a supporting network that can be called on to share experiences. Moreover, a solid network becomes a crucial element for future collaborations and taking the next steps in one's career. As junior scientists are likely to start with a limited network in their scientific field, they should look at social events as not only a way to unwind but also a tool to further a career. To this end, it is important for organizers of formal events to incorporate opportunities for socializing in their program, which has the added benefit of ensuring more interaction between event participants. Furthermore, students should be encouraged by their PIs to go to social events, as being able to succeed in a social setting is critical to becoming a well-rounded scientist. A social event can be as much about making friends as it is about sharing research-you are more likely to remember someone based on a shared interest like playing the guitar than his/her particular research topic. Ultimately though, the connection made may lead back to better science and increased opportunities for collaboration. --- How to Break the Ice The phrase ''practice makes perfect'' applies to many situations, and socializing is no exception, although the phrase ''all things in moderation'' may also apply, depending on the individual. Nevertheless, the greater the exposure to socializing opportunities, the better one's communication skills get, which is a vital skill in science. Across the world, Regional Student Groups (RSGs) have organized social events in all shapes and sizes, taking into account what will work best in the specific country. Stand-alone meetings in a pub or at a university have proven to be the event of choice in some countries. In other countries, especially the larger ones, linking a social event to a more formal event like a (national) conference is the preferred option. These types of events have even been extended to international conferences bringing together people from many countries. In each case, however, the common theme has been to provide a relaxed atmosphere. These RSG-organized social events provide great examples of events well-suited for scientific networking. A popular concept for many of the events is a combination of a scientific or soft-skill-related discussion with food and drinks during and/or afterward. RSG Australia organizes social events that consist of meeting for food and drinks and talking all things bioinformatics in an informal atmosphere. Senior researchers are encouraged to attend, to help stimulate conversation. As many of the students have multiple supervisors in disparate disciplines (computer science, molecular biology, statistics-to name a few), a conversational environment filled with people who speak the same language is welcomed. The event is always held at a location not affiliated with any particular university or institution to encourage diverse participation. Similar types of social events have been organized by RSG France (scientific breakfast and pub meetings) and RSG Netherlands (Bio-Cafe ´), in which the social event provides participants with both a possibility to extend their network and another means of acquiring knowledge. RSG India has adopted a different approach and organized a series of journal clubs. In contrast to traditional science clubs at Indian universities, RSG India's journal clubs are much more relaxed and students are encouraged to participate irrespective of their level of understanding of the paper. This is particularly good for junior researchers, for whom reading an article can be as hard as the proverbial rocket science. It also allows more senior students or young investigators to hone their mentorship skills. RSG India is currently running two such journal clubs, and the turnout is always impressive. Club meetings are held once a fortnight with no registration fee. They are immensely popular in India for their unique concept and approach. Another highly successful concept is ''scientific speed dating,'' as first organized by RSG Netherlands the evening before the Benelux Bioinformatics Conference in 2008, and since adopted at many Student Council meetings. This has proved to be an excellent way to break the ice between participants. These events are like regular speed datingparticipants are randomly paired and get three minutes to talk to each other-but with one twist: participants focus on their research topic, rather than their sex appeal. After each three-minute conversation, the participants switch to the next ''partner.'' In this way, they get an idea of the (scientific) interests of each of the other participants. Based on this, participants can decide with whom it might be interesting to have a more lengthy discussion. An added bonus is that the participants practice describing their research in less than 3 minutes. This type of social event is easy to organize and ensures more interaction during formal events following these brief ''dates.'' RSG social events such as these have been shown to be highly successful in fulfilling their intended purpose: breaking the ice and forging links. --- Tips and Tricks for Organizing a Social Event For these events to be useful, it is imperative to run them regularly and effectively. Organizing social events is itself a very useful skill, and not without challenges. For example, during initial sessions the excitement about social events is high, but once the novelty wears off, turnout declines. It can become tedious to keep people interested. Interest can wane, even in free events, which can be discouraging for organizers. Not all people who register for an event show up, especially if the event is free of charge, which may result in a much smaller audience than anticipated. Consequently, the organizers might end up with a disappointed speaker or paying for meals for people who were not actually there. Events that require an investment need consistent funding to keep the show running. Unfortunately, there are often not enough funding sources to sponsor such events. Club membership is one way to overcome this; however, this may not appeal to students, who have limited sources of income. Even aside from income, having to apply (and pay) for a membership may simply take too much effort for many students. Nevertheless, a few enthusiastic heads can come up with great, cheap ideas to create an environment for like-minded individuals to connect. To make sure a social event is a success, we provide a set of tips and tricks drawing on the experience of many RSGs. Firstly, the key to deciding on the right format for a social event is to keep in mind the cultural barriers that may exist in a particular country. The pub events organized by RSG France and Netherlands would not work in countries such as India, where social drinking is not (yet) accepted among men and women equally. Related to this, the impact of a generation gap between junior and senior scientists will also differ from country to country. Secondly, social events are easy to run as part of a more formal event such an international conference. People are generally excited about their favorite conference and have it marked on their calendar every year. By attaching a social event to a conference, it gives the event broader visibility and participation. People will also associate the social event with the conference, therefore making a lasting impression. The event can be organized during a break in workshops and guest lectures, to make the agenda less tiring. Short quizzes and games can be used to break the monotony. Thirdly, taking a cue from the journal clubs in India and the BioCafe ´in the Netherlands, stand-alone social events can also do well. The format of the event should be flexible yet have an identity of its own. However, keep in mind that it may be challenging to keep participants turning up every time. Young researchers are one of the best pools of potential attendees to tap into. Their curiosity levels and diverse research backgrounds make the event bustling and lively, and free food will make sure their salary-deprived bellies will welcome the event. Social events are knowledge-sharing, fun, and business packed in one. Traditionally, networking in science has been through conferences or similar formal events. However, scientists need to be able to convey the relevance of their findings to a wide audience in various platforms. You don't always need a 20-minute presentation to get an idea across-a napkin at a social event may suffice. Young researchers need to be encouraged to join in social events and not solely rely on formal scientific events. Communication is key in any scientific discipline and highly interactive events will encourage this. --- About the Authors Geoff Macintyre: ISCB Student Council, chair (2011-2012), RSG Australia, co-founder and president (2009-2010) Miranda Stobbe: RSG Netherlands secretary (2008)(2009)(2010)(2011)(2012) Tarun Mishra: RSG India president (2010)(2011)(2012)

When meeting someone for the first time-whether another PhD student, or the Founding Editor-in-chief of PLOS Computational Biology-nothing breaks the ice like eating pancakes or having drinks together. A social atmosphere provides a relaxed, informal environment where people can connect, share ideas, and form collaborations. Being able to build a network and thrive in a social environment is crucial to a successful scientific career. This article highlights the importance of bringing people together who speak the same scientific language in an informal setting. Using examples of events held by Regional Student Groups of the ISCB's Student Council, this article shows that socializing is much more than simply sharing a drink.

INTRODUCTION Education is a deliberate effort to maximize human potential is that they are intelligent cognitively, affectively, psychomotorically and contribute to diversity and differences in order to become tolerant human beings. The multicultural Indonesian nation consists of various tribes, languages, ethnicities, cultures and religions that must uphold tolerance education (Fitriani 2020). In the vast nation of Indonesia, there are many different religions, including Islam, Christianity, Hinduism, Buddhism, and several indigenous traditions. Therefore, religious tolerance is a must to ensure social stability in the face of intellectual pressure or in the form of physical conflicts in society. Religious diversity is meant to be acknowledged, respected, and used to cooperate in virtue. Rather than the other way around, religious differences are a motivating --- Analisa Journal of Social Science and Religion Volume 08 Number 01 July 2023 Pages 41-58 factor for bringing each other down, belittling one another, or mixing one religion with another (Fitriani 2020). At SMAN 8 Yogyakarta, there was an instance of intolerance when the principal had his Historically, philanthropy in this country (Indonesia) started from elements of Islam and Christianity related to missionary and da'wah activities with the spread of religion in the form of educational services and social activities (Fauzia et al. 2018). Indonesian philanthropic activities began with the emergence and development of a popular community organization with the term NGO (Non-Governmental Organization) around the 1970s which aimed to assist humanitarian activities (Jusuf 2007) Apart from a lack of understanding of philanthropy, also in tolerance education, that tolerance education has the meaning of gentleness, patience and leniency as well as relief from existing differences (Mumin 2018) . Religious diversity is undeniable facts and is a historical inevitability that are universal. Religious plurality should be seen as part of human life where it is something that is impossible to be eliminated but must be addressed well. Religious plurality has the potential to give birth to a variety of collision, conflict, violence, and attitude anarchy against adherents of other religions when cannot be handled properly (Malik 2021). Islam terms tolerance which means tasamuh, namely the attitude of allowing or freeing someone to disagree with our arguments and opinions and also rejecting opinions on differences that occur such as lifestyle and others (Khoiriyah 2016). --- Literature Review As for the literature review such as in their study titled "The role of philanthropic institutions for the welfare of the global community," (Case study on the Fast Response Madiun Action) Philantrophy in Education of Religious Tolerance in Kurikulum Merdeka at Elementary School Temanggung District Sigit Tri Utomo, Muhammad Ridwan, Yoyok Amirudin, Dzikrina Khoirun Nida, Ahmad Yusuf, and Muna Badru Tamama discusses the role of ACT for a global presence in the economic field for the welfare of society with waqf channeling programs(Sholikhah et al. --- 2021). In contrast to the research conducted by Sulkifli (2018) --- Conceptual Framework --- Philanthropy Tolerance of Religious Education Historically, philanthropy in this country (Indonesia) started from elements of Islam and Christianity related to missionary and da'wah activities with the spread of religion in the form of educational services and social activities in --- The Purpose and Benefits of Religious Tolerance Education Indonesia is a multicultural country with various ethnic and cultural differences including language so that it has a positive impact on mutual respect and acceptance of this diversity (Nursikin and Nugroho 2020;Wibowo 2015Wibowo , 2018)). While Indonesia is a diverse nation, religious diversity does not necessitate that believers undermine, disparage, or compare one faith to another. All followers of religions must adopt a stance of respect, acknowledgment, and cooperation between all people. The mentality that every person should possess (Sarapung 2002). A harmonious and peaceful social life will be realized if we apply an attitude of tolerance. By implementing an attitude of tolerance, our lives in society will become more peaceful and peaceful, this will create a conducive atmosphere so that we can eliminate anxiety and fear of negative actions from other religions. Society will view religious differences in a positive light and not make religious differences a big problem and have fatal consequences. But a colorful atmosphere. One of the objectives of religious tolerance is religious harmony. Several occurrences that exhibit signs of deteriorating relations between religions served as inspiration for this. Major religions are present, which has an impact on how the Indonesian nation develops and adds to its diversity. Although this diversity raises the possibility of conflict, tolerance between followers of different major religions is actually a reality in the Indonesian nation's daily life (Pitaloka et al. 2021). Bhinneka Tunggal Ika, the slogan of the Unitary State of the Republic of Indonesia, is strengthened by the attitude of religious tolerance education that is ingrained from an early age, at the very least. can be realized, several benefits of religious tolerance education such as: 1) Avoiding division, meaning a plural country like Indonesia, is a country that prone to splits. This is also because in Indonesia it is easy to spread religious issues. --- Forms of Religious Tolerance Harmony in diversity is what tolerance is. Because tolerance is a knowledge that a person The idea of tolerance is frequently cited as something to which people and communities should aim, especially in light of the fact that diversity in all of its manifestations is becoming a more prevalent trait of modern democracies. When conflicts emerge, some leaders urge "greater tolerance" of specific groups or general efforts to create "a more tolerant society" (Hjerm et al. 2020). There In order for teachers, principals, supervisors, and stakeholders to carry out activities to share best practices in implementing the Independent Curriculum both in the form of seminars and workshops independently, the prospective educational unit will then receive learning assistance to implement the Independent Curriculum independently (Nugraha 2022). --- RESEARCH METHOD This research is a qualitative field research --- RESULT AND DISCUSSION The The results of observations in the field are that some of the infrastructure is also supported, such as the infrastructure is available properly, for example during activities at Al Kautsar Elementary School the facilities and infrastructure are provided from there and when activities at Pangudi Utami elementary school the facilities and infrastructure are also fulfilled properly and for Muslim students too given a place to carry out prayers, qualified teachers and teaching teachers must have a clear plot so that students do not have misunderstandings. During the activity there were no significant obstacles in this activity. Small obstacles that occur such as crowded students but that can still be conditioned properly. This is important because at school children will meet friends who are different in character, gender, ethnicity, skin color, etc. These differences are not to be debated with each other, not to make fun of each other, but with differences as one of the things that must be used in respect. We are different, but we are one for Indonesia, because The findings of the observations demonstrate that school is a smooth bridge for being able to offer a setting for kids to exercise genuine tolerance. We feel this is important, this is urgent and must be done immediately, you don't have to wait for the central government,

The multicultural Indonesian nation consisting of various tribes, languages, ethnicities, cultures, and religions must uphold tolerance education. including the implementation of the "Kurikulum Merdeka" in educational units in schools.

Introduction ESHG have positive effects on women's economic and political empowerment, as well as social empowerment such as, women's family size decision making power and social mobility. There is no quantitative evidence to indicate positive effects on women's psychological empowerment. However, the qualitative studies suggest that women participating in ESHG perceive themselves as psychologically empowered. ESHG with a training component, such as financial and business education or life skills training, have a larger effect than programs that do not involve training. Important mechanisms which facilitate empowerment are gaining financial skills (economic empowerment); gaining the capability to speak in front of others, access to household decision making (psychological empowerment); improved networks and the experience of mutual support from and solidarity with fellow group members (social empowerment); and access to wider social participation combined with an increased understanding of political contexts and individual rights (political empowerment). There is no evidence of increased levels of domestic violence. Qualitative data indicate that ESHG may decrease domestic violence as women gain respect from their partners, families and access to household decision making. Few qualitative studies report experiences of disappointment, mistrust and stigma among women who attended ESHG. ESHGs do not reach the poorest citizens. The 'poorest of the poor' do not participate for economic and religious reasons, and mechanisms of self selection. (Dasgupta, 2001) [1] emphasis in his study 'Informal journey through Self Help Groups' by stating that microfinancing through informal group approach has helped to bring quite a few benefits for the rural poor in the form of saving habits, credit accessibility, effective credit structure, low transaction cost, effective recovery rate, outstanding empowerment of poor women. --- Literature review He emphasis in his study by stating that SHG's through microfinance should be treated as one of the best means to offset social and financial citizenship not as an end in itself. (Rasure, 2002) [5] , in his article "women empowerment through self-help-groups" reveals that the microfinance through SHG worked as a tool to empower the rural women in the country, as they provide easy access to micro credit for self-employment. The study concludes that the SHG activities motivate the rural poor to go for savings which in turn help them to come out of the vicious circle of poverty. (Nedumaran, 2001) [4] conduct a study on the performance and the socio economic impact of the SHGs in Tamil Nadu and this study compares the pre-SHG situation and there is a remarkable improvement in the socio economic aspect of the rural women in the post SHG situation. It concludes that Socio economic conditions of the rural self help group members were considerably improved after joining the Self Help Group. (Jaya, 2002) [3] in her paper "Study of Self Help groups in empowering women-A Case study of selected SHGs and NHGs' reveals that the membership in the SHG group has benefited them in a way of getting informal banking at their doorstep. SHGs also help them to get awareness on the new economic opportunities which are available. The study identifies a drawback that non-availability of incentives to the group leaders is the factor leading to their decreasing interest and gradual decline in the functional efficiency of the successful group. (Silvia, 2004) [6] studies Self Help Groups in Tumkur district (Karnataka) in her study she states that the women participation in SHG activities help them to increase their income, create awareness about savings, lending's, repayment, personal skills and ability which results in the overall empowerment of community. --- Statement of problem and research gap Women empowerment is one of the mesmerizing issues which have attracted the attention of the government and NGOs across the globe and especially in the developing countries. To allay the sufferings of the rural women many schemes/programmes have been conceived and implemented by the government from time to time. SHG is one among such programme which primarily focuses on the self-help and mutual help for the development of the society. The strategies adopted under SHGs in the forms of various activities have focused on the overall empowerment of women as it carries activities like, skill development, microcredit, savings, awareness, and so on. SHGs at the grass root level have enabled the women to secure their future through the effective financial support. Participation in SHG has been much hypothesized to bring the women economic empowerment. Though there is large a number of research on microfinance services and empowerment but the study on the issues of impact assessment and empowerment of women through micro-finance activity has not received much attention so far. Therefore, the present study assumes great importance in micro-finance industry. The study therefore purposes to assess the impact of women participation in SHG on self-economic empowerment. --- SKDRDP Shri Kshethra Dharmasthala Rural Development Project, popularly known as SKDRDP, is a charitable trust promoted by Dr.D.Veerendra Heggade. SKDRDP concentrates on the empowerment of rural women by organizing Self-help Groups (SHGs) on the line of Joint Liability Groups (JLBs) of Bangladesh and provides infrastructure and finance through micro credit for the rural people. The Shri Ksherta Dharmasthala Rural Development Project encompasses all the aspects of enriching the rural life. SKDRDP is active with its Community Development Programs throughout the state of Karnataka and holds its presence in six coastal towns under the Karnataka Urban Development and Coastal Environment Management Project. --- Objective of the study  To analyse women empowerment through Self Help Groups with respect to the SHG members in Villupuram District of Tamil Nadu.  To study the social and economical conditions of the SHG members.  To analyse the attitude of the members of the SHGs towards social impact. --- Research methodology The study is based on primary and secondary data. The primary data were gathered from 300 SHGs women entrepreneurs visionaries through purposive testing technique. Purposive testing is utilized as the examining strategy as it requires catching information on the aptitude level of woman business people having a place with SHGs in Vilupuram locale who are into the animator's job. The data collected were broke down to look at the self-help groups on economic empowerment and self, social mindfulness utilizing measurable instruments like rate examination, Garret Rank, ANOVA test and Friedman test. The translation for the equivalent has been expressed. The secondary data were collected from books, journals, newspapers and websites. Hypothesis Ho: There is no significance difference between empowerment of woman after joining SHGs among various self-help group members. --- Results and discussions --- Limitation of the study The study is restricted to only three villages in the taluk. Randomly 100 respondents have been chosen for the study. Respondents lack of time to give information and casual attitudes. The opinions of the respondents are time bond and may change over a period of time. The study can't be generalized as the sample size is too low. Findings of the study 1. Majority of the respondents are less than the age group of 30. 2. Most of the respondents are educated, out of 100 respondents 59 per cent of respondents have completed their schooling. 3. Of the total respondents 67 per cent are married. Nearly all respondents are Hindus and majority of them live in nuclear family. 4. 67 per cent respondents live in a nuclear family. 5. 36 per cent respondents earn an income above Rs. 7000. 6. The study shows the impact of SHG on the monthly income of the respondents before and after joining the group. Before joining the groups only 5 per cent of respondents are earning a monthly income above Rs.7000 but after joining the group 29 per cent of the respondents opts for income above Rs. 7000. 7. The study shows the impact of SHG on the monthly expenditure of the respondents before and after joining the group. Before joining the groups only 5 per cent of respondent's monthly expenditure are above Rs.3000 but after joining the group 44 per cent of the respondents opts for expenditure above Rs. 3000. 8. 47 per cent of the respondents reveal that increase in the monthly saving is achieved within one year of membership in the group. 9. There is a significant difference in the mean income and expenditure of the SHG members after joining the SHG group. 10. The study shows that the SHG activity made a positive impact on the economic empowerment of SHG members. --- Conclusion Microfinance programme for the rural empowerment has resulted in improving the socio-economic status of rural women. The SHGs under SKDRDP have made a long lasting positive impact on the lives of the women in the areas taken for the study, a drastic change is seen in their quality of life after becoming the member of SHGs. Based on the result it can be acclaimed that the functioning of SKDRDP are contributing significantly in increasing the status and livelihood options of women in every sphere, so as to make the women lead a empowered life. Therefore such institution should be promoted to enhance the status of women in the society. Thus it can be concluded that the blow of SHGs through micro finance is significant in bringing rural women empowerment through confidence building, courage, and skill development among the financially excluded section of the society.

This study focuses on the impact of women's economic self-help groups (ESHGs) on women's economic, social, psychological, and political empowerment. Both governmental and nongovernmental institutions spend formidable resources facilitating SHGs in low-and middle income countries in South Asia and other developing countries, under the premise that access to microfinance, training, and group support can enhance women's empowerment. We found that women's economic SHGs have positive effects on economic and political empowerment, women's mobility, and women's control over family planning. The estimated effect sizes range from 0.06-0.41 standardised mean differences. We did not find evidence for positive effects of SHGs on psychological empowerment (Hoop, 2017). The research further suggests that the positive effects of SHGs on empowerment run through mechanisms that are associated with familiarity in handling money, independence in financial decision-making, solidarity, social networks, and respect from the household and other community members. However, the included evaluations often did not include sufficient information about the specifics of the activities that were implemented by the SHGs. As a result, it remains unclear which of the various SHG models are most effective. Finally, our triangulation of the quantitative and qualitative findings indicates that SHGs do not have adverse consequences for domestic violence.

Introduction On May 31st, 2021, The Decision on Optimizing Fertility Policies and Promoting Long-term Balanced Population Development was deliberated and adopted, and put forward for the first time that a couple can have three children, which aroused widespread concern and discussion in society. However, the full liberalization of the "three births" has not achieved the expected policy effect. Relevant statistics show that women, especially highly educated women, have a low desire to have three children [1]. Looking at the domestic scholars' research on the birth policy, most of them stay under the comprehensive two-child policy, and the research methods are mainly qualitative research, lacking reliable data support. Moreover, the object of this kind of research is mostly the whole female group, and the female group is not subdivided, which makes the application scope of the research conclusion vague [2]. In this paper, R city is selected as the research area by sampling design, and 45 female teachers in colleges and universities are taken as the main research objects. By designing questionnaires and conducting in-depth interviews, grounded theory is used to analyze the real dilemma and realistic needs they face in their fertility wishes, and the survey data are coded step by step to build a model of influencing factors of fertility wishes. It provides a reference for the timely follow-up of the corresponding supporting measures of the "three-child" policy [3]. --- Overview of the research --- Research object In order to ensure the representativeness of the research object, this paper uses the method of combining three-stage sampling (PPS sampling) with convenient sampling [4], selects 45 female teachers in R city undergraduate colleges as the research object, adopts telephone interview survey, follows the saturation principle of grounded theory, and stops the interview when no new information appears in the interview for female teachers [5]. Among them, the main factors considered in the selection of interviewees are age, work and childbearing status, and their information status is shown in Table 1. Among the 45 interviewees interviewed, their age is mainly in the fertile stage of 25 to 45 years old, a few are over 45 years old, and a few are under 25 years old; The interviewees are all female teachers in colleges and universities, including 19 women with one child, accounting for 42.2%; There are 23 people who have two children, accounting for 51.5%, and there are 0 people who have three children; Among them, 9 people, accounting for 20%, are at the middle and high level. --- Data sources (1) Access: Relevant information mainly comes from telephone interviews and face-to-face interviews. In addition, there are online interviews. In this study, the method of sampling survey is used to select and determine the interviewees according to the pre-established sampling conditions, ask thick questions according to the interview outline, and then conduct in-depth interviews according to the specific conditions of the interviewees. Finally, this paper synthesizes the data of all interviewees to form 20 most representative cases [6]. (2) Sampling method: The validity of qualitative research results does not depend on the number of samples, but on whether the samples can answer the questions to be studied relatively completely and accurately [7]. This study adopts the standard sampling strategy, and the sampling object must meet the following conditions: 1) Female teachers who teach in R city's colleges and universities. 2) Have normal fertility and are not evasive or sensitive to fertility topics. --- Coding process --- Open coding Open coding refers to the analysis and comparison of the collected original data, and the conceptualization and categorization of key phenomena around the research theme [8]. In order to ensure the authenticity and credibility of the coding to the greatest extent, the result is constantly adjusted during the coding process until it reaches saturation. By sorting out and summarizing the initial concepts, merging the overlapping concepts and screening out the contradictory concepts, it is finally refined into 10 initial categories as shown in Table 2. --- Spindle coding Spindle coding is a process of analyzing the organic connection between the initial concepts formed by open coding, reorganizing them according to certain logical relations, forming categories and reflecting certain ideas [9]. In this paper, scattered and disorderly raw materials are reorganized according to certain logical relations, and various generic relationships between major concepts and secondary concepts are explored and constructed. Finally, according to the types of free nodes obtained by initial conceptualization, eight categories are summarized as shown in Table 3: Note: In the relationship column, "part" means that this initial concept is a part of the corresponding category, and "influence" means that this initial concept has an influence on the corresponding category, as shown in Figure1. Selective coding process, that is, all levels of generic form a related whole around the core coding. According to the ten categories in Table 4, this paper summarizes three main categories: parenting factors, self-factors and social factors. Parenting factors include education cost, economic pressure, companionship and father's parenting. Self-factors are mainly based on the actual situation of female teachers in colleges and universities to decide whether to have children, from their own considerations, including the influence of age and work pressure; Social factors are mainly medical security, old-age security and trusteeship system. Based on the above three main category codes, this paper determines the core code of "Influencing Factors of Female Teachers' Fertility Desire in Colleges and Universities" as shown in Table 4. Figure 1: Theoretical model of influencing factors of "triplet" fertility will --- Theoretical saturation test In this study, the remaining six interviewed samples are used to test the theoretical saturation to determine whether the sampling is effective or not. The results show that the three main categoriesself, child-rearing and social factors-which affect the fertility desire of female teachers in colleges and universities are gradually developing and improving. There are neither new categories nor new initial concepts in the existing categories during the inspection process. Therefore, the test results show that the "model of female teachers' triplet fertility will and its influencing factors in R city" constructed by grounded theory is saturated in theory. --- Conclusions and recommendations --- Research conclusion 1) Self-factors. The willingness of female teachers in colleges and universities to have three children gradually decreases with the increase of age, especially among teachers over 35 years old. The reason is that, on the one hand, the reproductive risk of elderly women increases, on the other hand, most female teachers of this age group have one or two children, and the time, energy and economic conditions are relatively insufficient, which greatly reduces their willingness to have children. 2) Parenting factors. In recent years, with the development of China's economy and society and the evolution of modern family structure, children have gradually become the core of family consumption, and the cost of childcare has increased exponentially. Parents with high academic qualifications spend more resources to train their children. At the same time, they need to invest more time and energy in the pursuit of academic achievements, job title selection and position promotion. The comprehensive cost of all aspects makes the female teachers in colleges and universities generally have a low willingness to have three children. 3) Social factors. It is found that female teachers in colleges and universities are mainly subjective in their own fertility wishes, which is independent and autonomous. Highly educated female teachers have a good educational background and advanced concept of fertility, and will comprehensively consider various factors in giving birth to triplets. Some interviewees pointed out that providing infant care resources with reasonable price, convenient proximity and high credibility will improve the willingness of triplets to have children to some extent. --- Enlightenment and Suggestions 1) Expand media publicity and create a good social atmosphere. At present, China is constantly strengthening the construction of multi-category and multi-level news public opinion positions with party newspapers as the core and television and internet as the important means, giving play to the propaganda role of the media in the society, promoting people's understanding of China's three-child policy and creating a high-quality social atmosphere for highly educated women. 2) Improve relevant supporting policies and expand the input of public resources. As people's views on the traditional view of "raising children to prevent old age" have gradually changed, the state should reasonably improve supporting policies, constantly guide social investment and public resources to tilt towards school-age groups, and let women of childbearing age have systematic guarantees such as system, finance, public services and socialized services [10]. 3) Improve the employment assistance policy and promote the insurance policy. As far as the fertility environment of the whole society is concerned, most enterprises and employers do not want their employees to have fertility wishes during their employment. Some school-age employees will choose to have fewer children because of work reasons. Therefore, relevant departments should strengthen supervision and management of enterprises and employers to alleviate the contradiction between women's choice of family and work.

Since the implementation of the "three-child" policy in China, its influence and response are far less than that of the "two-child" policy. Therefore, in order to deeply study the current situation and root causes of women's response to the "three-child" policy, and then put forward feasible countermeasures for the implementation of the "three-child" policy. In order to explore the fertility desire of female teachers in colleges and universities and its influencing factors, this paper uses grounded theory to analyze and summarize the original interview data, and finally extracts 16 initial categories, 8 main categories, and 3 core categories: family factors, social factors and parenting factors. The research shows that female teachers in colleges and universities have extremely low willingness to have three children. It is of great significance to strengthen the construction of the old-age security system, improve the education security system and consolidate the construction of the trusteeship system and mechanism for providing maternity support for female teachers in colleges and universities.

1. Enabling EU citizens to lead healthy, active and independent lives whilst ageing. 2. Improving the sustainability and efficiency of social and health care systems. 3. Boosting and improving the competitiveness of the markets for innovative products and services, responding to the ageing challenge at both EU and global level, thus creating new opportunities for businesses. This triple aim should be realised by 2020 in the three policy areas of prevention and health promotion, integrated care and independent living of older people. To achieve such aims, it is important to have researchbased evidence available and also to know where such evidence is still lacking. In October 2011, a Road Map for Future Ageing Research in Europe has been presented to the European Parliament as the outcome of the 2-year coordinated action FUTURAGE (http://futurage.group. shef.ac.uk/). The Roadmap claims to be the most comprehensive effort ever undertaken to further European ageing research, striving to set research priorities for the next 10-15 years in all major areas from biogerontology and the health sciences to the behavioural and social sciences. The trade of the European Journal of Ageing is the dissemination of research findings. Now in its 9th volume, the Journal plays an increasing role as an outlet of research reports from Europe and other parts of the world including North America and Asia. Thus, it potentially helps to inform debates and best practices. This dissemination is increasingly effective as the Journal gains visibility. We as editors are happy to note that the Journal's visibility is certainly growing. For example, last year we saw an almost doubling of our impact factor (from 0.61 to 1.11), and we are confident that it will continue to rise. Amongst the 28 Gerontology journals included in the Social Science Citation Index, the rank of our Journal rose from 23rd in 2009 to 15th in 2010. The number of full text downloads shows a steady growth, as does the number of subscribers to Table of Contents alerts. In parallel with these developments, the number of submissions is growing, and the publisher has allowed the Journal 30% more pages. We realise that the viability of our Journal rests on the contribution of both authors and reviewers. A special role is for the Editorial Board, whose members help to determine the policy of the Journal and serve with high-quality reviews of submitted articles. In order to keep the Editorial Board effective, we felt that it should include a fair share of early-career researchers. Thus, during the past year, we renewed one-third of its members. In this issue, we welcome all new members, and send our heart-felt thanks to the members who have left the Board after having contributed so much to our Journal. The new Editorial Board can be found on the last page of this issue. The current issue very appropriately sets the stage for the European Year of Active Ageing and Solidarity between Generations with a special section on 'Comparative Contexts of Care: Findings from the Survey of Health, Ageing and Retirement in Europe'-for an introduction, see the contribution from guest editor Howard Litwin (2012). Whilst the data for the Survey of Health, Ageing and Retirement in Europe (SHARE) are collected mainly in western European countries, still a lot needs to be learned about Eastern Europe. Therefore, the article by Nikolai Botev (2012), titled 'Population Ageing in Central and Eastern Europe and its Demographic and Social Context' in the section Critical Positions in Ageing Research is a very timely contribution. From demographic data, the author shows developments in individual eastern European countries that are often very different from those in western European countries. The article makes a strong case against the tendency to extrapolate developments from western to eastern European countries, as well as the tendency to generalise across all eastern European countries. In particular, the article provides ample evidence that contradicts the premise for the European Year of Active Ageing: 'Europeans are living longer and staying healthier than ever before'. Certainly, such a wake-up call leads to new research questions, several of which are proposed in the article. As a contrast to all the statistical evidence from survey and demographic data reported in the articles described so far, this issue includes one report from a qualitative study of people's responses to being notified that their pattern of nutrition holds health risks (Reimer et al. 2012). The European Journal of Ageing receives an increasing number of submissions based on qualitative studies. We feel that this is a good development, because it enables the Journal to show the breadth and depth of the full range of ageing research from social, behavioural and health perspectives. Moreover, both types of research, quantitative and qualitative, are likely to contribute their share to an informed debate and policy measures that have a real impact-the exact aims of the European Year for Active Ageing and Solidarity between Generations. Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

This action indicates an increased awareness of the urgency to make progress in finding solutions to what some perceive as the ''problems'' of ageing societies. However, ageing societies also present opportunities for Europe. Based on the premise that Europeans are living longer and staying healthier than ever before, the European Commission states that the time has come to realise these opportunities. Hence, the main aims of this year are stated as: maintaining the vitality of older people, enhancing their involvement in society and removing barriers between generations. The emphasis clearly is on employability and workability, given the dramatic demographic shifts in the workforce all over Europe, but also on living independently, health care, social services, adult learning, volunteering, housing, IT services and transport. Under the flag of Europe, a series of initiatives are launched, ranging from conferences and events, information campaigns to exchange of information and best practice. Many national, regional and local authorities as well as social partners and businesses in Europe launch initiatives in parallel. These initiatives should raise awareness, stimulate debate and have a real impact on fostering a sustainable active ageing culture. All initiatives can be found on the official website http://europa.eu/ey2012.

INTRODUCTION In the last 20 years, India's economy has seen a great deal of change as a result of the globalization. Information is power in any sphere of development, information and communication technologies (ICT) have recently included social media, putting this power at the people's fingertips [1]. The rapid expansion and extensive use of social media platforms, in recent years, have brought about a significant change in communication and networking across different sectors [2]. One such sector that recognized the potential of social media is agriculture where this approach has emerged to address the significant issues such as shortage of skilled personnel, trustworthiness, civic participation, social and economic disparities. It involves using Information and Communication Technology (ICT), information networks, internet and multimedia learning system to enhance information accessibility for farmers, research scientists and agricultural professionals [3]. In olden days, information exchange has been heavily influenced by media such as newspapers, radio, television and magazines. However, in recent years, there is an increase in technical knowledge and awareness, computer literacy, smart phone and internet usage across all people in India. At present, a variety of cyber extension tools are utilizing by the farming community which provides timely, pertinent, and usable information to farmers [4]. Social networking is described as "a group of people and the relationships among them" by Penuel and Riel [5]. These social networking services that supports the growth of online communities of individuals can be found nowadays. Users can share photographs and ideas online, talk with friends and family, and make new friends on these sites, something they cannot do offline. Social media offers additional advantages that broaden users' perspectives on society, themselves and humanity [6]. According to Digital 2023: Global Overview Report, social media makes it easier for people to communicate with one another online. It is the digital and online method of transmitting information. Social media encompasses a wide range of applications and platforms including Facebook, Instagram, Twitter and YouTube, that let users share content, communicate online and create communities. More than 4.7 billion individuals, or nearly 60% of the world's population, utilize social media. Nearly 467 million are active social media users among the total population of India [7]. The users of social media have a platform to actively engage in knowledge seeking and sharing. The present study was carried to document the major social media apps used, utilization index and the relationship between profile of farmers and their utilization pattern and this research was carried out to fill the gap. --- METHODOLOGY The study was undertaken in Coimbatore district of Tamil Nadu, considering the widespread usage of digital tools and the vast coverage of farmers where 84 % use social media on a regular basis with a frequency of 94% daily users. Among 12 blocks, two blocks namely, Annur and Kinathukadavu were selected randomly due to the diversity in farming community. Totally, four villages were chosen randomly from two blocks. A total of 120 farmers viz., thirty farmers from each village, using smart phones who were using social media applications are randomly chosen. Ex-post facto research design was used. The primary data were gathered through personal interview with the help of structured interview schedule. The thirteen variables, including age, gender, educational status, occupational status, farm size, farming experience, annual income, innovativeness, information seeking behaviour, perception, experience and digital literacy level were chosen to measure the profile of farmers. The scores were recorded for all the independent variables to find out their relationship with utilization pattern (dependent variable). The measurement on the dependent variable namely social media usage pattern was referred as the farmer's ability or capacity to perceive, sense or to be responsive of different social media sources. To measure the utilization pattern, they were given 13 statements which includes source of joining, frequency, time spent on each day, format, language, pattern of response, purpose of usage and the factors influencing the perceived effectiveness and the responses were noted. Based on the respondents' overall score, it was divided into three categories: low, medium and high, with the help of mean and standard deviation. The data were analyzed using the Statistical Package for Social Sciences (SPSS) for computing percentage, mean, standard deviation, correlation, regression and garret ranking. A three-point rating system was used for measuring the utilization index of social media tools. When questioned about the usefulness pattern of the sources of information they used, respondents received one of three possible scores: 3, 2 or 1 respectively, fully, partially and never. --- UI = Where UI = Utilization Index, Oi = Sum of respondents' utility scores for each information source and S = The total possible score --- RESULTS AND DISCUSSION The results, along with pertinent discussions are presented under the following main headings as listing the various social media tools used, utilization index of various activities done in social media and the contribution of profile in utilization pattern of social media. --- Profile Characteristics of Farmers From the Table 1, it is evident that the respondents were found equally among all age groups where in 37 per cent are young, 30 per cent are from 36-45 years of age and 32.5 per cent are old aged. Nearly more than half of the respondents are male (56.70%) and nearly threefourth completed school level education (74%) with farming as predominant occupation (67.50%). The respondents mostly are small farmers with 2.5-5 acres (40%), with an experience of less than 10 years (57.5%), had medium level of income of 1.1-3.5 lakhs (50.80%). The results are in relevant with Khou and Suresh [8]. Table 2 revealed that majority of the respondents seek medium level of information (78.3%) from different sources such as television, family members, neighbors, friends and fellow farmers. Nearly three fourth of the respondents had medium level of innovativeness (62.5%) with medium perception (60.8%) on social media. The respondents had medium level (70%) of experience in using social media with high level (71.7%) of literacy in digital media. Most farmers step towards adopting different innovations and regular updates media and have credibility and reliability towards the information gained social media. It is believed that one of the fastest and quickest way to reach people. Also, when farmers use social media more frequently and become more aware of its advantages, their opinions may also shift and lean in favour of them. --- Ranking Associated with Major Social Media Apps Used among Farmers Social media are online platforms and websites that allow users to produce and share information, communicate with others and take part in virtual communities. WhatsApp, Facebook, YouTube, Twitter, Google, Uzhavan app, Weather based apps, OTT platforms like Hotstar, Amazon are some of the major social media platforms popular among the farmers. --- Utilization Pattern of Social Media Social media platforms are made easier to share information, concepts, messages, and multimedia assets like text, photos, videos and audio. Mainly used for entertainment purposes, connecting friends and family, helps in updating with news and current events and mainly acts as content sharing platform. The data shown in Table 4 represents the utilization index by farmers for different activities carried out in social media platforms especially WhatsApp, YouTube and Facebook. Messaging friends and family using WhatsApp was found maximum with utilization index 78.06 followed by posting or sharing photos or videos ranked second with utilization index 75.56 whereas looking for funny content ranked minimum with utilization index of 33.33 for WhatsApp users. YouTube is a popular media sharing platform as looking for entertaining content along with news and current events ranked first and second by the users with the utilization index of 88.33 and 72.50 respectively. YouTube as a messaging platform becomes minimum with utilization index 43.61 as there is no option for messaging privately, only comment sections for videos are available. Similarly, Facebook ranked first in watching funny content with utilization index 89.17 followed by updating with news assigned second and researching brands & products assigned third rank with utilization index 70.00 and 60.56 respectively. These findings are in line with those of investigations carried out by Meena and Goyal [10]. The content preferred while watching videos are diversified based on the farmer's preferences, taste, personal interests and the dynamic nature in seeking contents. Comedy, meme or viral videos ranked first in all the three media. Educational videos ranked second with utilization index 65.00 followed by product review videos assigned third with utilization index 60.28 which is commonly shared among all the farmer's WhatsApp chats and creates a global learning community. YouTube is often used for watching music and entertaining videos by the farmers which ranked second with utilization index 68.33 whereas least ranked is watching educational videos. Facebook is mostly used in watching product review and educational videos which assigned second and third with utilization index 63.61 and 54.44 respectively. The content mostly heard by the farmers in online audios is maximum from friends or family through WhatsApp with utilization index 66.11 while others are found to be least. Both YouTube and Facebook ranked first in listening to music streaming services with utilization index 71.67 and 89.17 respectively whereas minimum is found in receiving or listening audio clips from friends or family. --- Relationship between Profile of the Farmers and their Usage Pattern of Social Media This method is used to look into the connections between the quantitative factors that explain how much the independent variables contribute to the way social media usage is utilized to exhibit significance. [11] where most of the respondents who are young, educated and familiar with digital technology showed positive relationship in using social media. Also, concluded that higher education makes it easier to access online resources for information and the older people favour traditional information sources, whereas younger and middle-aged people are more engaged in social media for information sharing and seeking [12]. --- CONCLUSION The study on farmers' social media usage pattern revealed the growing significance of digital platforms in farming communities. Social media is being embraced by farmers more and more as a useful tool for networking, exchanging knowledge, and gaining access to the resources. The findings indicated that majority of the farmers prefer WhatsApp as the primary and predominant for its robust features, large user base, privacy focused and compatibility while YouTube and Facebook are more for entertainment. Also, it revealed that young educated and digitally experienced farmers have positive relationship with utilization pattern. Farmers also have opted for marketing and brand development on social media. The farmers expressed that the platform not only enables them to learn about cutting-edge farming practices and effectively market their products, but also gives them a simple and convenient way to connect with a larger agricultural community across geographical boundaries. --- COMPETING INTERESTS Authors have declared that no competing interests exist.

Social media is an innovative, interactive communication tool used for social networking, sharing of text, audio, video to individuals, groups and mass audience over internet and social media platforms. According to Global Digital 2023 as of February, social media users in India is about 467 million. Considering the wide use of social media by the farmers and public, it is imperative to understand the usage behaviour of farmers, as it is essential for researchers, extension officials and policy makers to develop appropriate strategies for improving the technology delivery among farmers. Hence, a study was conducted among 120 randomly selected farmers in Annur and Kinathukadavu blocks of Coimbatore district during 2023 to find out the utilization pattern of social media. This study mainly focused on the understanding the usage pattern of farmers of Coimbatore

INTRODUCTION The Web 2.0, interactive hypertext-based e-Participation became a standard for electronic means of communication between governments and citizens [1,4]. Modern e-Participation platforms, especially those integrating popular Social Media like Facebook or Twitter have been recognised by the scientific community for their ability to overcome major participation barriers like: physical distance, time affordance, accessibility and transcend of the economical divide resulting in significantly greater engagement of citizens. Nevertheless some authors report major issues with online participation. Researchers point out that online, textual communications alter people behaviour in comparison to face to face interaction. In particular, Parycek et al. [3] argues that anonymity online may lead to more aggressive tones of discussion. In principle, anonymity results with a high volume of unconstructive and abusive postings. More importantly the work by Sia [5] on computer-mediated communications showed that reduction of social presence (by reduction of visual cues like in the case of textual communication) leads to increased discussion group polarization hence putting a significant obstacle to healthy political deliberation. This notion is corroborated by more recent study by Grafsgaard et al. [2] which argues that due to non-verbal sparsity of textual communication, participants need to rely on implicit interpretation of transmitted information (that could use emoticons or images to support their message) which limits the effectiveness and restricts the applicability of textual communication alone. In this paper, we argue that the next-gen, immersive and affordable VR technologies provide for the first time an opportunity to enrich large-scale online participation communication with vivid multi-modal (non-verbal) communication elements. Therefore VR technologies could be considered as a viable support for improved political deliberation and more effective e-Participation in comparison to state-of-theart current text-based technological platforms and solutions --- ENRICHING E-PARTICIPATION WITH NON-VERBAL COMMUNICATION USING VR TECHNOLOGIES We acknowledge that explicit non-verbal communication elements and visual cues that are lacking in the textual mode of communication occur in teleconferencing and similar existing technologies. Nevertheless, due to technical challenges, teleconferencing solutions with large amount of participants do fail to scale. In fact, major commercial solutions like Skype, Google Hangouts, WebEx or GotoMeeting support limited number of participants. Therefore, we argue that state-of-the-art technologies providing non-verbal communication such as teleconferencing cannot support large-scale e-Participation. We argue that beyond the-state-of-the-art solutions such as VRbased e-participation technologies could deliver very rich nonverbal communication support. Specifically, in the last couple of It is clear that mobile solutions thanks to low entry price and ubiquity seem are viable candidate for advanced communication. In particular, Google Cardboard, thanks to significant availability (very affordable) is the absolute leader. Nevertheless, the poor performance of this early solution disqualifies CardBoard as mainstream communication support tool. The more advanced mobile platforms like Samsung Gear VR or Google Daydream show to be the perfect candidate with a balanced performance and availability. From the non-verbal communication perspective, the advanced head tracking enables nodding as well as bowing and other head expressions. Moreover, mobile solutions presented are constantly rolled up with a growing set of accessories improving the already significant immersion and interactivity that has been out of limits for the past, PC-Onlinebased virtual reality solutions like Second Life2 . Among the accessories are pointers, wands and game controllers that enable a wide range of virtual gesticulation, expression and interaction. The late VR gloves provide full hand expressions so important for face to face communication (that can be also of significant value for hearing impaired). Finally the VR environments can provide any suitable setting (room, beach, concert hall, city hall) that can be selected accordingly to fit any meeting purpose (for instance dependable on topic and theme -forest, lake) and audience size. By integrating these mobile VR technologies with massive computational resources available on the Cloud, a rich non-verbal communication for e-Participation at scale becomes feasible. --- DISCUSSION The --- CONCLUSION The innovation brought by the late, affordable VR mobile solutions create a significant opportunity to improving the existing e-Participation channels in respect to the quality of communication by introduction of essential visual clues and overall better expressiveness. The future research should bring more detailed case studies and experiments employing VR for specific e-Participation cases.

1 While progress in the development of e-Participation platforms has been significant and the emergence of new Social Mediadriven platforms appears to bring significant (by quantity), citizen engagement, little attention has been paid by researchers to the limitations of the pervasive textual communication for political participation. In this paper, we describe the major sociotechnical challenges of classic e-Participation solutions and how the emerging next-gen Virtual Reality (VR) technologies can be leveraged to alleviate some of the issues identified.• Information systems ➝ ➝ Data management systems engines • Information systems ➝ ➝ Collaborative and social computing systems and tools.

Introduction In spring 2020, the world faced the global Covid-19 pandemic. Society had to adapt to restrictions, including social distancing practices. The pandemic caused lock-downs and mobility restrictions, bringing a shift to home offices [7], and causing many practical challenges for everyday life in families [2]. The social distancing measures to stem the pandemic included both government set restrictions, as well as voluntary recommendations. Mobile applications, such as Crowdless or Mind the Gap, have been adopted as a tool for helping people to keep safe while conducting their mandatory everyday mobility and interactions with people, and to minimise the social encounters with people exposed to Covid-19 [1,4]. Mobile tracing applications have been introduced in several countries, and their nationwide use has been promoted in order to prevent Covid-19 from spreading. We introduce a mobile application concept and user interface (UI) design that aims to help people to avoid crowded places during pandemic outbreaks. The design target is to support people to conduct their daily activities whilst minimising the probability to become exposed to, or transmit, the disease. We organized a user study with two focus groups to evaluate the application concept and to discuss the ideas of mobile app supported social distancing. Whereas prior art has evaluated an asocial hiking app for avoid people on a hiking route [6], we address the UI design and concept of supporting social distancing in everyday mobility. --- Social Distancing Mobile App Concept The Smart Social Distancing mobile app concept supports users to foresee possible crowded places on a map, and plan how to schedule and navigate from one place to another more safely, Fig. 1. The design process started from defining the main functions, exploring different information visualization techniques, studying existing applications, and then proceeding to drafting the UI design flows, wireframes, and finally the UI graphics. The features in Fig. 1 present the main functions of the Smart Social Distancing (SSD) mobile app concept. A heatmap function shows the crowded areas on a city map. The user can plan a daily schedule by adding calendar events. Figure 1-right illustrates the application menu. Route recommendations create an optimized route to navigate by avoiding crowds, and the 3D map shows the hotspot map in 3D. In addition, the user can search how crowded a specific place is. Risk notifications give the user warnings about, e.g., which of the frequently visited places are crowded during the day. --- Focus Group Study --- Set-Up of the Study To study user perceptions of social distancing and evaluate the SSD mobile app concept, two of the focus groups sessions were organized. Each focus group included three female and one male participant (total n = 8), age between 20 and 45 (mean 28) years. Each focus group session lasted for one hour. The focus group session had three main sections with specific questions. First, the participants were asked what kind of applications they have been using to prevent themselves being in crowded places now during the time of Covid-19, and what other means they had applied to maintain physical distance to other people. The answers were collected using post-it notes. First, the participants got to see and try out the prototype. After that they received a paper questionnaire, where each of the eight main application functions were rated on a scale from 1 (not useful) to 7 (most useful). After this, the participants reflected, using post-it notes, which features they liked most, which ones the least, and how they would use the application after the pandemic time. Finally, the participants answered questions relating to their anticipated future behavioural changes after the pandemic. Also here, postit notes were used to support the discussion. --- Findings The participants had been using applications such as video calls, food ordering, sending messages, social media tools, and generally tools to help them to take care of everyday practicalities remotely. However, they had not used applications where the main use case was to avoid crowds. Such applications are hardly available to Finnish users in particular. Therefore, participants had used other ways to avoid crowds, such as planning to run errands outside of the assumed crowded hours, or checking peak times from Google search. They had to come up with new rhythms for their day while trying to avoid crowds. As the most useful feature of the application, the participants perceived the hotspot map, where the red color illustrated how crowded a place was, see Fig. 1. This feature was voted to the most useful by 62,5% of the participants in the evaluation questionnaire, and it also gained the most comments with the post-it notes. After the hotspot map, the most liked functions were the risk notifications, how to avoid crowds by scheduling the day, and the ability to see the busiest hours of different places. When ideating how they would use the application after the pandemic, the answers focused mostly on avoiding crowds and rush hours. Recognizing the most visited places was also suggested, as well as organizing Pokémon Go type games, which would include moving from one place to another. As a long term behavior change, participants estimated generally a bigger desire to avoid crowds, even after the pandemic. Altogether, the Smart Social Distancing application was seen to have potential. A mobile app to support social distancing while planning everyday tasks requiring mobility was embraced. --- Discussion In our work, we have presented a mobile application concept and UI design for a Smart Social Distancing application to support avoiding crowds while conducting normal everyday mobility, and evaluated it with focus groups. The participants found the concept of Smart Social Distancing mobile app useful, and especially seeing the crowded areas with one glance on a map was embraced. Even though Koronavilkku, a Finnish government supported app for notifying if the user had been exposed to Covid-19, is widely used, an application which would generally guide avoiding crowds is not, to the best of our knowledge, available in Fin-land. The participants were not using any specific mobile apps to guide them for social distancing, although they generally used tools that supported remote operations, such as ordering food. Prior art has introduced different concepts of that relate to avoiding crowds, and utilizing context information [3] has gained a strong foothold in application design. Recognizing crowd density and move-ment patterns in urban events has been addressed by prior art [8], as well as automatically adjusting navigation to avoid traffic jams [5]. Considering their behavior after the pandemic, most of the participants answered that they would continue to use the proposed mobile application to avoid crowds. This may indicate that the pandemic time has caused a permanent change in social behavior, and that life routines adopted during pandemic might actually remain in people's everyday lives. This would be an interesting topic for future research.

The COVID-19 crisis has caused social distancing practices to be part of everyday life. We present the concept and user interface design of a smart phone application that enables planning daily schedules in a manner which seeks to optimise the social distancing. We present the application UI design and its evaluation in two focus groups (n = 8). The findings highlight the need for and positive attitude towards a mobile application that supports avoiding crowds during and after the pandemic time.

The African continent has experienced a marked increase in its population over the last few decades. The current population of Africa is five times its size in 1950 and the continent's rapid population expansion is set to continue with its inhabitants doubling from 1.2 billion to 2.4 billion between 2015 and 2050 and eventually reaching 4.2 billion by 2100 [1]. By using the estimates and projections by the United Nations Population Division, UNICEF's Generation 2030 Africa report takes a look into the demographic shifts in Africa and into the driving forces that have contributed and continue to contribute to the continent's population increase. The increasing number of women of reproductive age (15-49 years) in Africa is one of the components driving Africa's surge in births and children. The number has risen fivefold from 54 million in 1950 to an estimated 280 million in 2015 (Figure 1). This total is projected to increase further to 407 million in 2030 and then to 607 million in 2050, reaching almost 1 billion (991 million) by the end of the century [1]. This population surge will pose substantial challenges for countries in providing services, particularly reproductive health services, antenatal and postnatal care. Another key factor for the African population increase are its continued high fertility levels. Africa's average fertility level currently stands at 4.5 children per woman of reproductive age, far above the global average of 2.5 children per women. Even though Africa's average fertility rate is in decline, and has been for decades, its rate of decline is slow and the continent's fertility rates particularly in Sub-Saharan Africa remains far higher than anywhere else in the world. On current projections, this trend will continue at least until mid-century. Fertility in Africa is projected to drop from around 4.5 children per woman in 2015 to 3.8 in 2030, and to 3.0 by 2050, and further decline to 2.1 children per woman by the end of the century [2]. With the exception of countries with already low levels of fertility rates, significant drops in fertility rates are projected for most African countries over the course of the centuryparticularly in those countries with the highest rates at the present. But even under the assumption of declines in the fertility rate, the continent's number of births is not estimated to fall until the 2080s because of the increasing number of women of reproductive age. In fact, the absolute numbers of births are also set to increase massively. On current trends, 700 million babiesslightly under the entire current population of the European continentwill be born in Africa in the next 15 years (2015-2030), with a further 1.1 billion births on the continent between 2031 and 2050. At the country level current fertility levels on the African continent vary widely from 1.5 children per woman in Mauritius to 7.5 children per women in Niger. In 2015, in 15 African countries women have on average 5 or more children (Figure 2). Often high fertility countries are low income countries and marked by conflict and fragility. Within countries, women in the poorest wealth quintiles tend to have more children than women in the wealthiest quintiles. For example, in Chad, Mali, Niger, Nigeria and the United Republic of Tanzania women in the poorest quintile have on average 2 to 4 children more than women in the wealthiest quintiles [1]. The report underscores that African women also have among the longest lifetime period for births because of the high rates of adolescent fertility. Africa's present average adolescent fertility rate is 98 births per 1,000 adolescent girls aged 15-19 years, more than double the worldwide average of 45 births [1] and quadruples the world rate in some of the poorest countries. From 2010 to 2015, 14 per cent of all babies in Africa were born to adolescent girls and women under age 20, compared to 9 per cent globally. Today worldwide, almost two thirds of women of childbearing age who are in a union are using contraceptive methods. In Africa, this proportion drops to a third of all women. On the continent, 32 African countries have contraceptive prevalence levels below 40 per cent. Half of these countries have an estimated level of contraceptive prevalence below 20 per cent. Unmet need for family planning reflects the gap between childbearing desires and contraceptive use. Globally, 12 per cent of all women of childbearing age are estimated to have an unmet need for family planning in 2015; for the African continent this proportion rises to 23 per cent [3]. Unmet need for family planning tends to be lowest in countries where contraceptive prevalence is already high (above 60 per cent). In Africa, 38 countries are estimated to have high unmet need levels, ranging from 20 per cent to 35 per cent of all women of reproductive age who are married or in a union (Figure 3). In 28 of them the contraceptive prevalence is below 30 per cent. High levels of adolescent fertility are associated with elevated rates of unsatisfied demand for reproductive health services, including family planning. In 18 sub-Saharan African countries, more than 50 per cent of adolescent females report unmet need for family planning [4]. A report released by the United Nations Population Division in December 2013 [5] underscored that most countries in sub-Saharan Africa have not seen a notable reduction in unmet need since 1990, in contrast to other regions. However, recent success stories in sub-Saharan Africa (such as Ethiopia, Malawi and Rwanda) show that meeting demand for family planning can be accelerated if reproductive health becomes a higher governmental priority. Figure 3 In about half of the countries in Africa at least a fourth of the women of reproductive age in a union have an unmet need for family planning. Percentage of married or in-union women aged 15 to 49 who want to stop or delay childbearing but are not using a method of contraception, 2015. Source: UNICEF: Generation 2030 Africa. New York: UNICEF; 2014. A discourse must emerge on how to extend access to greater reproductive health services to Africa's familiesincluding culturally sensitive reproductive health education and services for women and particularly adolescent girls to reduce the unmet needin an equitable and socially sensitive fashion that also encourages utilization, is non-discriminatory against any child or woman, and does no harm. Expanded programmes to end child marriage (as defined as a union in which one or both parties are under age 18), which is highly prevalent across the continent, must also be included as part of efforts to invest in and empower girls and young women. Child marriage is a determining factor in sustaining elevated rates of adolescent pregnancy and high lifetime fertility rates for women, and in excluding girls from education. Studies clearly show that educated women delay their first pregnancy, and space their births more widely than women who lack education [4,6,7]. Prioritizing girls' educationas well as ensuring quality education for allin Africa will therefore also be among the most powerful measures to build an Africa fit for all. The majority of the world's countries that report high adolescent fertility and low school life expectancy (i.e., the number of years of schooling that a girl pupil can expect to spend from the beginning of primary through secondary school) are in sub-Saharan Africa, where out-of-school rates are also highest [8]. Empowerment of women and girls in Africa must go beyond the statistics, as elsewhere, to the roots of discrimination, marginalization and violence that undermine their rights. Cultural, social, economic and political barriers that perpetuate the disempowerment of women must be urgently addressed. --- Competing interests The authors declare that they have no competing interests. Authors' contributions DY, LH, DA contributed to drafting the first manuscript. All authors contributed to editing the manuscript. All authors read and approved the final manuscript.

UNICEF's Generation 2030 Africa report released in August 2014, focusing exclusively on Africa, provides an in-depth analysis of child demographic trends. The report highlights the marked increase that Africa population has experienced in the last few decades and the rapid population expansion that is set to continue, with its inhabitants doubling from 1.2 billion to 2.4 billion between 2015 and 2050. A factor driving Africa's population increase is that the number of women of reproductive age has risen fivefold from 54 million in 1950 to 280 million in 2015 and is set to further increase to 407 million in 2030 and 607 million by 2050. The increasing number of women of reproductive age in Africa will lead to an increasing number of births in Africa even under the assumption of large declines in fertility levels. Adolescent fertility remains high in many African countries and it is estimated that almost one fifth of women in Africa have an unmet need for family planning. The report calls upon investing in and empowering girls and young women and on improving reproductive health of African adolescents.

AN AGENTIC PERSPECTIVE ON AGING PREPARATION Yaeji Kim-Knauss, and Frieder Lang, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nuremberg, Bayern, Germany When imagining one's future life in old age individuals may respond to an uncertain future with proactive and preparatory activity aiming to maximize possible rewards and minimize risks or costs. The current research applies an agentic perspective on aging preparation that emphasizes the role of individuals' beliefs and attitudes in determining their engagement in actions. The present research aims to investigate the associations between action-related beliefs (perceived utility/ risk) and situational cues (experience/appraisals of agingrelated life challenges) with individuals' engagement in aging preparation. Data comes from the "Ageing as Future" project, which includes multicultural (i.e., Germany, US, Hong Kong, Taiwan, Czechia), longitudinal (i.e., five measurement points spanning from 2012 to 2020), and lifespan data (i.e., aged 18 to 98). Results from a series of analyses indicate that perceiving more utilities, having experience in caregiving, and having health-related worries at the peak of the COVID-19 pandemic were associated with engagement in aging preparation. However, the magnitude of these associations varied depending on the time perspective and cultural context. Findings suggest that individuals engage in aging preparation to attain desirable or to avoid undesirable outcomes in the future based on personal values and belief systems. The dynamic interplay of personal belief systems with temporal and cultural contexts was also highlighted that differently shapes individual's agentic engagement in aging preparation. Hospice is a model of care for individuals with a life expectancy of less than six months who choose to focus their treatment on quality-of-life rather than extending life. In 2019, half of all Medicare decedents elected to receive hospice care. Behavioral health comorbidities are prevalent in hospice patients; approximately 40% experience significant depression and/or anxiety. Such comorbidities are associated with poor outcomes including increased physical symptoms, worse function, and lower quality-of-life. Despite the impact of behavioral health comorbidities on hospice patient outcomes, little research has focused on the use of behavioral health interventions in the hospice setting. We conducted a scoping review to characterize the types of behavioral health interventions administered to patients receiving hospice care. We searched four databases, generating 6,842 unique citations over any time period. 70 texts were reviewed and 31 were retained for analysis. Studies examined both psychotherapeutic (n=10) and psychopharmacologic (n=10) interventions, as well as other non-pharmacologic interventions (n=11). Duration of study follow-up was available for 17 of the studies, ranging from six days to six months. 14 studies reported information on interventionists, who were most commonly music (n=3) or massage therapists/acupuncturists (n=3). Average interventions were 47 minutes for six sessions. 18 studies presented statistically significant results related to primary outcomes, most commonly depression (n=9), anxiety (n=6), and pain (n=4). Our findings demonstrate a dearth

on health. These findings provide an empirical foundation for understanding the possible implications of heterogenous retirement pathways for health in later life and labor market policies in very old populations.

M arc Jamoulle proposes to us a challenging concept, quaternary prevention (P4). [1][2][3][4] This concept challenges the positivist ideal of modernity which argues that science and progress of society are constant and always for the better. This concept refers to the idea of positive iatrogenia of Michael Foucault to remind us that medicine has acquired the ability to damage by proper exercise and not only by skill or ignorance. 5 Get away from the conception of modern science allows us to separate ourselves from the idea that science is something that only deals with knowledge and is divorced from ethics and the influences of politics and economy. The medicalization of life, 6 overdiagnosis 7 and even evidencebased medicine (EBM) have brought economic and political aspects to the everyday practice of medicine. These "excesses" of medicine itself cause damage and unnecessary deaths and the waste of the never abundant resources that countries allocate to health. As Jamoulle says, P4 has spread worldwide but especially in South America, Asia and, to a lesser extent, Europe and North America. This is no coincidence, it is on the fringes of the centrality of the hegemonic thinking of modernity (Europe and USA), where its failure is most noticeable and where the suffering consequences of poverty, exclusion, inequality are greater and all directly impact over the health, and where better spaces for creative solutions are generated. Coinciding with Jamoulle, we emphasize that EBM is one of the vehicles of strongest penetration of overdiagnosis. It is in that way because the soundness of clinical controlled trials randomized, quintessential EMB, is threatened by the scandalous relationship between pharmaceutical companies and the editors of scientific publications of more impact. 8,9 That influence is so big that a major publisher of the BMJ, Richard Smith, 10 has said that "what is happening is that greater scientific invention, the randomized work is being degraded due to market. " The degree of infiltration and corruption is also so big that some Anglo-Saxons editors ask: "Who pays for the pizza?" 11 This leads to consider that "there is no free lunch" and think seriously that all doctors should renounce all funding from pharmaceutical companies. Family physicians or general practitioners (GPs) have also emerged in response to the inadequacies of hegemonic medical model, described by Eduardo Menéndez, 12 which characterizes it as biologist, depersonalized, ahistorical, asocial, with fragmented assistance and mercantilist. The family medicine or general practice is called to retrieve the ethical values and the exercise of a profession that proposes a medical patient relationship serving to people's humanity and in defense of patients in their condition as mourners and weakness situation without abuse of the power that society gives us doctors. The P4 is played at each visit and the family doctor or GP must be specially trained to deal with the complexity of this situation, with their social and psychological components. These aspects are essential for human communication to improve adherence to treatment, change of habits and, especially, continence expected by any person in an interview with his/her doctor who has to be able to recognize that he/she has in front of him/her a person with desires, fears, anxieties and he/she must be able to adapt his discourse to the needs of others. At each visit the prevailing product of the social imaginary of the values and worldviews of each society is reflected. Doctors contribute to their formation so we must not abandon our capacity for reflection and dialogue with society about what we believe health means and contributing our particular look. 13 In the recent Conference on Prevention Quaternary within the Programme of the fourth Latin American Congress of Family and Community Medicine, held in Montevideo, Uruguay, where the Working Group P4 WONCA-CIMF was established, the communication tools were included as constitutive part of P4. It was also noted, that we should be wary of attempts to denature the P4, subtracting hierarchy of ethical and limit it to a foundation for cost control. We have the obligation to think over the current way of being a doctor 14 because another human medicine possible. This is the great contribution of Jamoulle. Thanks Marc. --- Ethical issues Not applicable. --- Competing interests Authors declare that they have no competing interests. --- Authors' contributions Both authors contributed equally to the development and revision of this paper.

The concept of quaternary prevention (P4) refers to the idea that medicine has acquired the ability to damage through the proper exercise. Family medicine or general practice has the duty of recovering the ethical values and the exercise of a profession with the doctor-patient relationship serving to people's humanity. In the fourth Congress of Family and Community Medicine, held in Montevideo (Uruguay) last March 18-21, 2015, it was established the Working Group P4 WONCA-CIMF with communication tools included as constitutive part of P4. It was also remarked that we should be wary of attempts to denature the P4, diminishing its ethic value and limiting it to a reason for cost control.

Introduction It is important to highlight that domestic violence against women [1], in different and many ways, does not end after separation. One of these dimensions is where women and their children will live after they decide to separate. Is it safe/better to stay home? Is it safe/ better to look for another place to rebuild life? The knowledge about this particular period of women's life is not very well-known. Bowstead [3] (2017:109) says: "Tens of thousands of women and children within the UK are forced to relocate due to domestic violence every year, (...) The specific role of domestic violence in residential mobility and internal migration has been underexplored in the UK (...)". Bowstead [3] puts lights in what she calls: forced exile, forced away from their homes, forced relocate and forced mobility. During this process Bowstead [3] emphasizes the complex jurneys women have to be/feel safe. In hers research with 20 women the numbers of moves, the distance and the time it took for them to feel secure need to be known and analyzed, so protection strategies can be better developed. "The interviewed women had made up to 10 moves. Their journeys included considerable stays in interim places -from months to over a year -as well as considerable travelling; and the total time from first leaving the abuser to relatively settled rehousing ranged from 7 months to 5 years, with an average of two years and two months." Bowstead [3] (2017:115) --- Bowstead [3] (2015: 335-336) also highlights the journeys and lack of network "Overall, there were around 10,000 migration journeys a year (n=10,161 in 2008-2009) to access services in England owing to domestic violence.(...) They are travelling because of their individual need for safety, not because they would have otherwise wanted to move at all; and they therefore try to reduce the dislocation by going to the type of place they are familiar with. Women therefore leave all types of places, but also go to all types of places. Women leave everywhere due to domestic violence. Women are recorded as travelling from every They also go to every type of area, tending -as discussed aboveto go to similar types of places to the ones they left. As a result, most local authorities have around the same number of women leaving and arriving per year. Therefore, despite around 10,000 migration journeys a year to access formal services in England, there is a lack of net effect at the local authority level.(...) The major city of Birmingham has over 200 women a year arriving in its services, and over 200 leaving to access services elsewhere (as well as over 350 relocating within the city)" Humphreys [2] (2016: 3-5) developed a research in Australia and analysed the possibilities for women to stay at home after separation as "A Right". In this perspective is important to know what should be done to offer women all protection they need. "The 'safe at home' strategy is not without its problems and critics. It is clearly not an option for all women and their children. For many women it will be too dangerous. Separating is the point of increased danger (Bennett Cattaneo, & Goodman, 2005) and ousting the man from his home may provide an excuse for further escalation of his violence (McFerran 2007). The 'safe at home' principle is well founded within the human rights discourse (Crinall & Hurley, 2009). It supports the entitlement of women and children to live free from violence and due diligence of governments to protect and uphold this right, as per the Convention on the Elimination of all forms of Violence Against Women (CEDAW 1979) and the Convention on the Rights of the Child (Logar 2003). The strategy recognises that it is the victim, not the abuser who should be entitled to stay in their home should they choose to do so, and is an effective way of avoiding the social and economic consequences of escaping domestic violence, such as homelessness, disconnection from community, unemployment, and disruption to children's schooling (Edwards, 2004(Edwards, , 2011;;Murray, 2008)." (Humphreys 2016: 3) [2]. --- As Humphreys [2] (2016: 4) Descirbes it is Necessary a Very Complex Models to Garantue that Women will be Safe at Home "Features of 'safe at home' models include: enhanced family violence crisis and outreach support; the development of partnerships and protocols between services; intensive coordination of police and specialist service responses; installation of security and alarm systems; provision of dedicated emergency mobile phones; and the securing of a safe room in the house with connection to police emergency services. Programmes may involve one or a number of these services, in combination with a protection order that has conditions to exclude the violent partner [4]. The literature shows that there is no single approach to 'Safe at Home' interventions, rather services have developed programs to meet the specific needs of their client group, their agency context and available resources (Crinall & Hurley, 2009)" --- Questions for Debate The different ways that violent man develops to keep control, including using children/adolescents after separation, replaces the importance of different services work together. It also replaces the question about the role of education and health in protecting children and women from domestic violence and abuse. How refuges could improve their protection? Are protection orders supporting women's decisions? According to the women's reports they were more likely to be subject to further abuse and harassment when staying in their home, as protective orders were more often breached.

This review is part of a postdoctoral research entitled: "Separation, risks and feminicide: challenges of protecting women from intimate former partner in Brazil and England", developed at King's College University, under the supervision of Prof. Cathy MCILWAINE, with CNPQ/Brazil funding. The seriousness of the gender-based violence -domestic abuse against women -and their recognition at the national and International levels, indicate the relevance of the theme and the potential contributions from a comparative study between Brazil/England on existing social policies/programs of protection, in post separations situations. Not recognizing the existence of violence against women by their former partners, nor recording them, results in the absence of medium-and long-term strategies for their protection. The knowledge about this particular period of women's life is not very well-known. This review aims to present the discussion about the hidden dimension of domestic abuse after separation: is it safe/better to stay home? Is it safe/better to look for another place to rebuild life?

percent. In addition, between 2010 and 2020 approximately 12,000 adults 65 and older were admitted to the emergency room due to injuries sustained during encounters with police or private security. To illuminate the scope of negative consequences that may occur during such encounters, the present study examined the 2020 arrest of a 73-year-old communitydwelling woman living with dementia who walked out of a big-box store with $13.88 worth of merchandise she did not pay for. During her arrest, she sustained multiple injuries at the hands of two officers, including a dislocated shoulder and a broken arm. Despite her injuries, she did not receive medical care for six hours while in custody. The methodological approach to this case draws on elements of interpretative phenomenological analysis, and narrative analysis to explore publicly available archival data sources, including surveillance and police body-worn camera footage. Supporting data sources include police filings at the time of her arrest and legal filings by a civil rights attorney representing the woman's family. The analysis demonstrated that deeply entrenched ageism, failure to recognize the signs of dementia, and the systemic normalization and defense of police use of force against non-normative behavior when interacting with neuro diverse older adults. This has critical implications for family caregivers and trusted others who struggle to balance the dialectic between safety and independence for people aging in place with dementia Abstract citation ID: igad104.2906 --- DETECTING UNDUE HARM ARISING FROM ELDER ABUSE SCREENING: INNOVATIVE METHODS FROM THE EASI-LTC© PILOT STUDY Stephanie Ballard 1 , and Machelle Wilchesky 2 , 1. Donald Berman Maimonides Centre for Research in Aging,Montreal,Quebec,Canada,2. McGill University,Montreal,Quebec,Canada Screening for elder abuse can cause victims to experience feelings of unpleasantness and/or relive painful memories which can be an ethical concern. Ensuring the safety of all participants/users, in our case long-term care (LTC) residents, is of the utmost importance. Drawing from approaches used in the intimate partner violence and clinical trials literature, we developed a novel typology of harm and a series of procedures to evaluate any negative consequences that might be incurred as a result of participating in the Piloting the Elder Abuse Suspicion Index-long term care©: A Mixed Methods Feasibility Study. Our typology includes subjective and objective reporting from a multitude of sources, including: 1) Interviews with LTC residents using a modified Consequences of Screening Tool, adapted from MacMillan et al, 2009; Opinions of the 2) Study social worker conducting validation assessments and 3) LTC residents and institutional stakeholders; 4) Feedback from study research assistants who administer the tool using a specialized Adverse Events Form; and 5) Chart reviews. Procedures include the creation of an independent interdisciplinary pilot study safety committee, chaired by a geriatric psychiatrist and convened to conduct interim evaluations after the first 5, 10, and 20 residents have participated, the liberation of social work teams, who are to be on standby and available to intervene as necessary, and the creation of participant resource cards displaying pertinent phone numbers for immediate assistance. To our knowledge, Downloaded from https://academic.oup.com/innovateage/article/7/Supplement_1/903/7490359 by Hochschule Luzern user on 19 February 2024

the support of various community service subjects, the utilization of community care services could improve the subjective wellbeing by improving their health status, sleep quality and declining feeling of pain. In this regard, this study proposes policy suggestion in optimizing the types of community care service projects, building elderly care service consortiums, and improving community health management service capabilities to coping with deep aging and fewer birth.

INTRODUCTION The ever-developing technology has a lot of influence on people's lives. One of the benefits that can be felt is that this technology can make it easier for people to live their lives, such as social media as a means of long-distance communication, can also be a medium of information and others. Thus, it is not uncommon for a person's behavior in real life to be no different from his behavior in cyberspace. With the development of existing technology, Microsoft is conducting research related to "Civility, Safety and Interactions Online" through a Digital Civility Index survey of 32 regions with 16,000 respondents covering adults to teenagers regarding online interactions, including in terms of spreading hoax information, fraud and scams, hate speech, and discrimination.(Indonesia News Center 2021) From research conducted by Microsoft, Indonesia ranks 29th out of 32 countries, showing Indonesian society as a country that has an impolite or uncivilized character with an image of the moral and ethical crisis that has occurred in Indonesia. (Gloria et al. 2022) Based on research conducted by Microsoft, it shows that there is a moral crisis in Indonesian society. If this continues to happen, it will certainly have a negative impact in the future for social life in Indonesia. As we know that Indonesian citizens have been known as friendly people, but the research above seems to provide a rebuttal that in cyberspace Indonesian society is not as friendly as real life. So that this phenomenon is a concern for writers as academics. Therefore, this research is important to do in the hope of minimizing impoliteness that occurs in Indonesian society in cyberspace. Besides that, it can also provide an understanding to the public that bad behavior both in real life and cyberspace will have an impact on a person and the surrounding environment. --- RESEARCH METHODS The method used in this paper is descriptive qualitative, namely research that and put together to be processed in order to obtain information. Then analyzed and can describe the phenomenon. The stages in processing the data that have been collected can then be carried out in the data reduction process, namely by sorting the data that has been obtained to make it easier to draw conclusions. Then, after the reduced data, a temporary conclusion is drawn as a result of the data that has been put together before.(DQLab 2020) --- RESULTS AND DISCUSSION Indonesia, with the largest Muslim population in Asia, makes this research a must. Yogyakarta is a student city with various kinds of students coming to study in this city, so it is not surprising that many Muslim students study in Yogyakarta. From the results of the research that the author has done, that as many as 80% of Muslim students in Yogyakarta have never uttered hateful sentences, harsh words and other things because they are deemed unnecessary to do so. This is also influenced by their environment which does not make it a habit to normalize harsh/hateful sentences, cyberbullying and other utterances, so that their behavior in everyday life is not much different from their behavior in cyberspace. Unlike the case with the figure 20% of Muslim students in Yogyakarta have uttered hateful sentences, harsh words, and others in using cyberspace. This is influenced by several things such as a person who is in an emotional state so that he cannot control his behavior in using social media, besides that some people are forced to say harsh sentences on social media because of several cases that occurred in the Indonesian government. Based on the data that has been presented, fewer Muslim students in Yogyakarta often utter harsh sentences/express hatred, discrimination, and others when compared to those who do not. The results of this data indicate that Muslim students in Yogyakarta still have good morals in real life and cyberspace. As stated in the Qur'an letter Muhammad verse 21 which states that: ْ ‫م‬ ُ ‫ه‬ َّ ‫ل‬ ‫ا‬ ً ْ ْ ‫ي‬ َ ‫خ‬ َ ‫ان‬ َ ‫ك‬ َ ‫ل‬ َ ‫ه‬ ‫اّٰلل‬ ‫وا‬ ُ ‫ق‬ َ ‫د‬ َ ‫ص‬ ْ ‫و‬ َ ‫ل‬ َ ‫ف‬ ٌۗ ُ ‫ر‬ ْ ‫م‬ َ ْ ‫اْل‬ َ ‫م‬ َ ‫ز‬ َ ‫ع‬ ‫ا‬ َ ‫ذ‬ ‫اِ‬ َ ‫ف‬ ٌۗ ٌ ‫ف‬ ْ ‫و‬ ُ ‫ر‬ ْ ‫ع‬ َّ ‫م‬ ٌ ‫ل‬ ْ ‫و‬ َ ‫ق‬ َّ ‫و‬ ٌ ‫ة‬ َ ‫اع‬ َ ‫ط‬ Jurnal Mahasiswa FIAI-UII, at-Thullab, Vol.5, Nomor.2, Special Issue, 2023 ISSN: 2685-8924. e-ISSN: 2685-8681 256 "Obeying and saying good words (is better for them). If the war order has been fixed (they don't like it). But if they are true (faith) in Allah, surely that would be better for them." That based on the verse above we as Muslims are encouraged to say good things as proof of a Muslim's faith in Allah SWT. As a good servant, of course obeying all of his orders is important to do. The results of this data must be maintained by Muslim students in Yogyakarta, so that the manners of Muslim students in carrying out social interactions in cyberspace are getting better in the future. In addition, in one of the hadiths found in the book of al-Tirmidhi index number 2022, which means: "Has told us Ibn Abi 'Umar said: Has told us Sufyan, he said" Has told us 'Amr ibn Dinar , from Abi al-Darda, in fact the Prophet SAW said: "There is nothing that is heavier on the scales of a believer's kindness on the Day of Judgment than noble character. And indeed Allah hates people whose speech is dirty and rough. Based on this hadith, it implicitly gives a message to Muslims to always be careful of their words, both in real life and in cyberspace. The hadith gives a message to Muslims to carry out good social interactions with humans, especially maintaining speech. (Azharudin 2022) Based on the explanation above, we can see that to minimize social impoliteness in behaving in cyberspace, it is necessary to have the cooperation of all elements of society, both by families, schools, and also all government agencies. A) the family as a person's closest environment is expected to instill good moral values, exemplify good behavior and others. Parents as people who are responsible for their child's behavior certainly play an important role in regulating the activities carried out by the child, (Kadir et al. 2020) which of course has an impact on children's behavior in cyberspace. B) school as a second place for someone to study makes the school have an important role in shaping the character of the nation. C) government agencies, in this case all parties representing the state, need to contribute to showing a good attitude in managing the country either in the form of binding regulations or visible behavior. For example, there is the ITE Law which provides sanctions for people who do not comply with the rules, such as saying harsh sentences or other things. However, it turns out that this does not have a significant enough impact on the community to be able to control their behavior in using social media.

Globalization that occurs requires people to be literate about technology. This should not affect the public in using the internet. This research is a descriptive research through interview, surveys, and observations with Muslim students at universities in Yogyakarta as research subjects. Compared to other countries in Asia, Indonesia is the most impolite country based on a survey conducted by Microsoft. This figure is higher when compared to the previous year. The amount of hoax and fraud news influences the level of public decency. From the resulting sample, as many as 20% have spoken harshly on social media and the other 80% have never, this difference is influenced by the environment around each youth which is different. With the majority of Muslim students not being able to say impolite sentences, it needs to be maintained, whereas if they still say harsh sentences/discrimination in cyberspace, it needs to be minimized through cooperation by all levels of society, from families, schools to government agencies.

Since March 2020, around 150,000 of the Cambodian garment industry workforce were suspended or laid off, as the effects of consumer and manufacturing lockdowns spread through global supply chains (Arnold, 2021). A 'double crisis' emerged, garment workers losing their employment and income, and hunger amassing amongst a population compelled to adjust and reduce their consumption of food to make ends meet (Mishra & Rampal, 2020, p. 1). Coming into the COVID-19 pandemic, Cambodia already had levels of hunger that were designated 'serious', ranking 76th out of 107 countries in the 2020 Global Hunger Index. Studies of the garment sector in Cambodia had also found that workers were medically malnourished, consuming an average intake of 1598 calories per day, which is half the recommended amount for a woman working in an industrial context (Labour Behind the Label, 2013). That garment workers are going hungry with the COVID-19 pandemic in Cambodia (Brickell et al., 2022) is an experience more widely shared in other countries, including Bangladesh, El Salvador, Ethiopia, Haiti, India, Indonesia, Lesotho and Myanmar (Kyritsis et al., 2020). In Cambodia, the country's two other most important economic sectors, construction and tourism, were also heavily impacted and in 2021 strict lockdowns left what was described by some commentators in the Cambodian press as a humanitarian crisis with whole areas of Phnom Penh barricaded in for weeks on end. It was garment workers and their translocal households, however, for whom the issue of food deprivation and hunger has been most systematically encountered in the country. This is because the garment sector in Cambodia sits at the epicentre of the national economy, employing at its pre-pandemic peak around 1 million workers (Lawreniuk & Parsons, 2020). Moreover, garment factory positions in urban areas had become vital stalwarts in the livelihood profiles not only of women workers themselves, but also their rural-based households, whose members rely upon their wage-financed remittances to pay for everyday expenditures, including food. --- | REDUCED FATES OF THE BODY DURING THE COVID -19 PANDEMIC During the COVID-19 pandemic, garment workers therefore struggled to meet the cost of food for themselves and their families on severely reduced incomes. It is in this context of 'double crisis' that our commentary focuses on the diminished eating and reduced bodily fates of garment workers during the COVID-19 pandemic. To aid this process, we draw upon Berlant's (2007, p. 768) thinking on eating and obesity as linked to the logics of capitalism and the 'reduced fate of the body under regimes of production of value for others'. Taking the United States as the analytical pivot, Berlant brings into tension the life-building dimensions of food consumption against the life-damaging role of the global processedfood regime in the country's obesity epidemic. The regime's hugely profitable circulation of unhealthy commodities, in concert with its political and marketing strategies to undermine public health contributes, Berlant argues, to the disproportionate 'pressure of obesity' on the organs and skeletons of poor communities and communities of colour. For Berlant then, the obesity epidemic, is 'a way of talking about the destruction of life, or bodies, imaginaries, and environments by and under contemporary regimes of capital' (Berlant, 2007, p. 764). 1 Thinking with Berlant encourages and supports scholars to contemplate and articulate how the 'production of value for others' can reduce the 'fates of the body' of those living and labouring at the sharp end of the capitalist system. The ReFashion research underscores the salience of Berlant's (2007, pp. 766-7) contention that 'mass emaciation and obesity are mirror symptoms of the malnourishment of the poor through the contemporary world'. Despite our concord here, they under-explore the wearing out and displeasure that comes from having to restrict food consumption. Experiences and feelings of 'wearing out' and depletion are replete in hunger and linked anxieties tied to survival in times of economic crisis especially. As one worker's experience speaks to in the ReFashion study: I begged them not to suspend me. I begged them for work because I had no money … I was screaming and crying loudly … I'm having to endure eating salt and fermented fish only until I have a full salary. (Chantou, suspended Cambodian garment worker) Even for garment workers who were not suspended or permanently dismissed, their encounters of harsher working conditions, higher production targets, more irregular or reduced pay, and inflation all contributed to a chronic situation of hunger for workers and their families during the COVID-19 pandemic. Eating might indeed be a form of 'ballast against wearing out' (Berlant, 2007, pp. 778-779), but it is not guaranteed. Over 15 months from January 2020, the average monthly wage fell from a peak of $237 per month in January 2020 to lows of $145 and $147 per month in May and October 2020, respectively. Before the pandemic, on a typical day, the mean cost of food that workers' household eats was US$4.07 but this had dropped to US$3.67 when our quantitative survey was administered in November-December 2020. At this time, 23% of women reported eating less meat than before COVID-19, 13% reported eating fewer vegetables, and 11% reported eating less fish. For workers who caught COVID-19 and were mandated to mass quarantine centres, several report putting on much needed weight given the provision of food there: There is more than enough food. They provide it at a regular time, two options and with dessert too. We rarely eat this kind of food. As you know, workers can only eat 3000 riels (US$0.75) of food per meal, and which has little protein and is plain tasting. While I received treatment for the COVID-19, I could have seafood and dark chicken soup, which is way more delicious than my daily food. I heard that each patient has a food budget of about US$15 per day. If the food is not enough, they will provide more. Sometimes, the patient could not even finish her meal at all because it was too much. (Lida, quarantined Cambodian garment worker) The provision of plentiful and nutrient-rich food during quarantining could be understood in Berlantian terms as a 'small vacation' from the grind of hunger and food insecurity. In Berlant's (2007, p. 779) discussion of obesity in the United States, this idea of a 'small vacation'-an 'episodic intermission'-is articulated through food as 'one of the few spaces of controllable, reliable pleasure people have' and as a result it offers a rare space of pleasure in precarious lives. Garment workers typically spoke of being unable to buy or savour delicious food they enjoyed and focused pragmatically instead on eating 'just to get full' so as not to disappoint themselves or their families. To expect food to provide emotional 'self-medication' as Berlant (2007, p. 777) posits, is to inflict an everyday trauma which workers looked to protect themselves from. They described re-orienting their relationship to food by focusing less on the orosensory pleasures of eating which their lack of food choices largely denied. Here then, but in different ways conceived of originally by Berlant, the body becomes communed in the survival work and production of felt resilience. Garment workers typically cope with economic precarity not through the compensatory pleasures of eating excessively, but rather through the unpleasurable denial of food (Brickell et al., 2022). --- | CONCLUSION What connects these two seemingly divergent phenomena of bodily detriment-impoverished US households reliant on the consumption of unhealthy processed food and Cambodian garment workers dramatically reducing their dietary intake and diversity to the staple of rice-is how food and 'fates of the body' are intimately caught up in the market economy. In this sense, as Berlant (2007, p. 774) recognises 'excess weight and mass hunger are not antithetical states', but rather symbiotic components of social reproduction under late capitalism. Berlant's work not only establishes then a 'direct relationship between laboring within capitalism and food consumption, suggesting that how we work, and how capitalism works on us, affects how we eat', but also asks 'What is the experience of encountering one's environment in the form of food?' (Ward, 2013, n.p.). The 'double crisis' of unemployment and hunger which garment workers talked to us about during the COVID-19 pandemic reflected the realities of labouring within a labour-intensive, low value-added production regime in which women's bodies and eating habits were shaped by the global capitalism and exploitation of the fashion industry intent on pursuing business-as-usual profit-making in crisis times. --- DATA AVAILABILITY STATEMENT --- ENDNOTE 1 See Ward (2013, n.p.) for a critique of Berlant's 'foundational presumption that consumption drives obesity, that excessive bodies are, in part, produced by excessive consumption, and that fat people consume food people differently than folks that are not fat'. In geography, see also Colls and Evans (2014) for critical discussion.

As the COVID-19 pandemic took hold in early 2020, #PAYYOURWORKERS became widely circulated by trade unions and labour rights organisations campaigning for immediate support for garment workers globally. Photographed in the modest rental rooms which they both sleep and cook in, affected Cambodian garment workers held up the rallying hashtag on hand-written cardboard signs. The campaign's landing page (https://www.payyo urwor kers.org) featured one such worker and led with the message: 'Garment workers can't feed their families. Fashion brands are turning their backs'. Well known brands had contravened contractual obligations to cancel orders and withhold payments as demand for clothing in the US and Europe plummeted and raw material supply chains were severed. Between March 2020 and March 2021, it is estimated that garment workers were deprived of $11.85 billion in income (Clean Clothes Campaign, 2021). During this time, millions of workers worldwide were suspended from their positions with little or no pay and others permanently lost their jobs as factories closed (Lawreniuk, 2020). Flexibilisation, already synonymous with the global garment industry, was being intensified at speed by brand responses to the pandemic, which prioritised the profit bottom line over workers' welfare. Two-years of longitudinal research across the pandemic with the same cohort of 200 garment workers in Cambodia sought to understand and amplify their experiences of navigating its economic impacts (see www.refas hions tudy.org).

Many sincere compliments should be addressed to Bezalel Peleg and Hans Peters, the authors of the book Strategic Social Choice. Stable Representations of Constitutions published last year by Springer. Our experience with the previous books of these authors on game theory (Peleg 1984; Peleg and Sudhölter 2003;Peters 1992Peters , 2008) induces very high expectations with respect to this jointly written monograph. And we have not been disappointed with their new project. The book studies stable representations of constitutions. The authors follow Gärdenfors (1981) who modeled constitutions as effectivity functions, a term introduced independently by Moulin and Peleg (1982) in the general context of game theory and its relation to social choice. An effectivity function assigns to each group in a society a collection of sets of social states. The manuscript is based on work that has appeared over the last thirty years, but it also contains many new results and new or improved proofs of existing results. Among various sources of the results collected in the book, the authors used, e.g., Abdou (1988), Abdou and Keiding (1991), Holzman (1986), Keiding and Peleg (2006), Peleg (1998Peleg ( , 2004)), Peleg andPeters (2006, 2009), Peleg et al. (2002). The emphasis in the book by Peleg and Peters is on strategic stability of game forms that represent effectivity functions. As the authors mention themselves, their aim is not to contribute substantially to the purely philosophical literature on constitutions, and equity or fairness, but they focus on representation and game-theoretic stability, and rather contribute to the economic literature on mechanism design taken in a wide sense. The volume of about 160 pages is divided into two parts, and contains in total 11 chapters, preceded by a clear summary of the whole contents. Each chapter begins with a short motivation and summary section, followed by its main sections, and then it finishes by a short section with notes and comments. Apart from clearly presented definitions and numerous results, the authors deliver many illustrative examples. The first part, built by the first seven chapters, focuses on properties of game forms representing effectivity functions: strategic stability properties, Pareto optimality of equilibrium outcomes, and continuity properties of the game forms. In the introductory Chapter 1, after recalling Arrow's model of a social welfare function, Peleg and Peters present a definition of a 'rights-system' by Gärdenfors. The latter definition of a constitution and a more detailed formalization of the concept of rights by Peleg (1998) are adopted in the book. In Chapter 2 the authors formally describe a constitution and the effectivity function that it induces. They present a new proof of the representation theorem. Chapter 3 deals with a Nash consistent game form, i.e., a game form that has a Nash equilibrium for every profile of preferences. Necessary and sufficient conditions on an effectivity function to have a Nash consistent representation are delivered. The authors consider the case where the set of alternatives is finite, and then generalize the results to compact Hausdorff topological spaces of alternatives and topological effectivity functions. They also discuss the relation between their results and the Gibbard Paradox (Gibbard, 1974), and the 'liberal paradox' (Sen, 1970). Chapter 4 is devoted to acceptable game forms, i.e., Nash consistent game forms such that all Nash equilibrium outcomes for all preference profiles are Pareto optimal. A complete characterization of the effectivity functions which can be represented by an acceptable game form is delivered. Chapter 5 considers strongly consistent representations. Strongly consistent game forms admit a strong Nash equilibrium for any profile of preferences, where a strong Nash equilibrium is a strategy profile which is resistant to deviations of all coalitions (including one-person coalitions). First the authors study necessary and sufficient conditions for the existence of strongly consistent representations in case the set of alternatives is finite, and then they extend their results to topological effectivity functions and deliver a new result. Chapter 6 concerns representations by Nash-consistent game forms when even-chance lotteries on subsets of alternatives are allowed. The authors show that in such a case, constitutions have Nash consistent representations without the restrictive intersection assumption. In Chapter 7 Peleg and Peters investigate the continuity of the outcome function of a representation when the outcome space and the strategy sets are compact metric spaces. In particular, they present a new result on Nash consistency of upper semicontinuous representations. The remaining four chapters of the book constitute its second part and consider a special kind of game forms, social choice functions. Since a social choice function assigns an alternative to any profile of individual preferences, it is a game form with the strategies of the players being their individual preferences. Chapter 8 is an introduction to the second part of the book. In particular, the authors recall the Gibbard-Satterthwaite theorem for social choice functions and discuss some approaches to the implications of this theorem. Peleg and Peters investigate exactly and strongly consistent social choice functions, i.e., social choice functions that have for each profile of (true) preferences a strong Nash equilibrium which yields the sincere outcome. They briefly discuss voting on restricted domains, and the concept of equilibrium with threats. The class of exactly and strongly consistent social choice functions is analyzed in the rest of the book, where several existence and characterization results are presented. In Chapter 9 these social choice functions are investigated by using feasible elimination procedures. The authors present a new proof of the characterization result. In Chapter 10 the analysis of exactly and strongly consistent representations is extended to general effectivity functions. It contains characterizations of elimination stable effectivity functions, i.e., effectivity functions such that the set of alternatives resulting from applying feasible elimination procedures is non-empty. Chapter 11 concerns consistent voting systems with a continuum of voters. In particular, Peleg and Peters extend the Gibbard-Satterthwaite theorem and the concept of feasible elimination procedures to this framework, and extend most of their results of Chapters 9 and 10 to voting games with a continuum of voters. An almost complete characterization of anonymous exactly and strongly consistent social choice functions in this model is presented. The book has several merits. First of all, I think that the choice of the subject in question for the book was quite fortunate. It was a long time ago when a specialized book on effectivity functions in social choice appeared. I have in mind, of course, the book by Joseph Abdou and Hans Keiding (1991) in which both formal properties of effectivity functions and their applications in Social Choice Theory (in particular, in the implementation problem) have been presented. While some parts of the book by Peleg and Peters owe to several publications by Abdou and Keiding, this new book has taken a different road. In particular, as the authors mention themselves, the theory in their monograph should be distinguished from what is typically called implementation theory. Moreover, during the last twenty years significant contributions on the subjects in question have appeared in the literature, and it is important that we can find them all recalled in the book by Peleg and Peters. Another merit of the book, desirable although not always evidently found in a scientific production, is the very high expertise and professionalism. When we take the book in our hands for the first time and combine the information on the contents of the monograph and on its authors, we feel immediately that what we are going to read is an excellent book. The authors do know perfectly what they are writing about, something that is also confirmed by the list of cited works: almost 20% out of 73 references are the own contributions of the two authors. Moreover, as I have already emphasized when describing the contents of the manuscript, the book is very well written and perfectly organized, something we also recognize in the former publications of the two authors. Despite that the topics are far from being easy, the material is presented in a clear way. Very helpful are motivating discussions and numerous nice examples. Finally, we can fully enjoy the beauty of the results and their rigorous proofs presented in the book. Summarizing, I can highly recommend the book by Bezalel Peleg and Hans Peters: a real pleasure for scholars working on effectivity functions and social choice functions, and a great learning opportunity for those who are not that familiar with the topics in question. It is an excellent contribution, bringing together a lot of material in a single manuscript in a coherent way. However, one warning should be repeated as well. If you are searching for an easy and straightforward literature, you should rather look for something else. Also, if you like to investigate a new field which could easily contain many open questions, this book is not your best choice. The authors present material that is dense and contains many deep results, and consequently they do not provide 'tips' for further research. And if one could still find an open question in the book, like the one in Chapter 11 on characterization of anonymous exactly and strongly consistent social choice functions in the model with a continuum of voters, it will be indeed a real challenge. Let me finally express one more thought, in line with what I have just written above. Reading the monograph by Bezalel Peleg and Hans Peters brought to my mind a comparison with climbing in some beautiful and challenging mountains. It is very difficult to climb there and in principle not everybody can do it. First of all, you need a formal rigorous training, otherwise you are lost after one minute of the escapade, in the first chapter. And there might be moments that you say 'Come on! Why am I doing that? Would it not be better just to stay quietly at home and not to lose so much energy with something that I can never achieve? ...' But! If you are determined and patient enough, step by step you go up and up, and finally there is this desirable moment when you are on the top of the hill. And it recompenses all suffering that you have just experienced. You are so happy and proud of yourself, and you enjoy so much the beauty of the landscape, the beauty of mathematics ... And then you notice another hill, even higher and more tempting ... and you move to a subsequent chapter, to a more complicated demonstration of another result ... Since no particular criticism has struck me during reading the book, I did not force myself to search artificially some drawbacks. I like to wish to all readers of this excellent book many wonderful moments of climbing in the beautiful challenging mountains called Strategic Social Choice. Stable Representations of Constitutions.

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Introduction --- A dolescence is often conceptualized as a developmental phase, whereby the young person transitions from the guardianship of parents towards independent adulthood. The quality of communication with parents during adolescence remains a strong determinant of health and well-being, being predictive of adolescents' self-esteem, well-being, self-rated health and ability to navigate health risk behaviours. Evidence from predominantly crosssectional studies indicates that adolescents who report easy communication with their mothers are more likely to report excellent or high-rated health, and are less likely to be current smokers or frequent alcohol drinkers. 1,2 Moreover, finding it easy to talk with their mother or father about things that bother them, acts as a protective factor for adolescents' mental well-being and a strong predictor of resilience. 3,4 European studies suggest that the quality of parent-adolescent relationships is determined by different factors: individual (such as age and gender) and external (cultural and socio-economic), 5,6 including at the national level differing social and family welfare policies. 6 Consideration of international trends in adolescents' communication with their parents offers an opportunity to begin to explore the relationship between changes in family lifestyle and socioeconomic contexts and other trends in adolescent health and well-being. An advantage of using the Health Behaviour in Schoolaged Children (HBSC) analyses is that the same instrument is used for measuring the quality of parent communication in all countries over three survey rounds. The aim of the article is to describe trends in adolescent's perception of communication with mothers and fathers by gender among young people in early-to-mid adolescence across 32 European and North American countries for the first decade of the 21st century. --- Methods Data were drawn from the cross-national HBSC study, collected during the 2001-02, 2005-06 and 2009-10 school-years. A total of 425 699 young people, aged 11, 13 and 15 years, from 32 countries/ regions reported on their perceptions of the quality of communication with both father and mother. The survey question explored young people's perceptions of how easy it was to talk to their mother or father about the issues that were of importance to them. Individual outcomes, reported quality of communication with father and mother were dichotomized into two categories: easy and difficult. The analyses were performed separately for boys and girls for the pooled dataset and separately for 32 countries, employing General Linear Model (a procedure MANOVA) from SPSS (version 21, 2012, IBM Corp., NY). Paired Bonferroni test was used to describe changes in quality of communication of Adolescents' with their parents from 2002 to 2010, controlling for age and family affluence. The pooled analyses used country weighting to control for the different size samples. --- Results Significant positive trends in prevalence of ease of communication with both parents were found in the vast majority of countries (figure 1), these consistent positive trends were identified across all ages (not reported in this article). However, significant differences Trends in adolescents' perceived parental communication 47 in adolescent-parent communication trends were found both between countries and genders. In most countries, significant increases in the prevalence of ease of communication with both mothers and fathers were observed, with the greatest positive changes over time in Estonia, Denmark and Wales. However in a minority of countries, the opposite trend was found with the greatest negative changes occurring in France, Slovenia and Poland. Across the pooled dataset, a significant positive trend was observed for ease of communication with father, for both boys and girls and for ease of communication with mother for boys only. Communication difficulties between boys and their mothers reduced across surveys, but communication difficulties between girls and their mothers remained almost unchanged (table 1). In all surveys, the proportion of young people reporting ease of communication with their mother was higher than the proportion reporting ease of communication with their fathers and proportions reporting ease of communication with fathers was higher for boys than for girls. --- Discussion This study of young people in early-to-mid adolescence identified that across the majority of European countries and North America, there is a significant positive trend in terms of an increase in prevalence of ease of communication with parents over the past decade. Positive family communication has been identified as an important protective health asset for young people, related to an increase of thriving behaviours and to a decrease in participation in health risk behaviours. 7 Consequently, the trends reported here may indicate an important contributory factor to positive improvements in the health and well-being of young people. Generally, the identified increase in prevalence of ease of communication can be attributed to young people reporting a distinctive positive shift in the character of fathers' interaction with their adolescent offspring. This is a significant change as ease of communication with fathers has been suggested to have a particularly protective role on the health and well-being of young people in unique ways from mothers, and is associated with positive emotional well-being, less aggressive behaviour in boys and good body image among girls. [8][9][10] Accounting for why such changes in reported experiences of communication with fathers has occurred is likely to be a reflection of complex interactions between shifts in domestic gender roles changes in the construction of masculine identities and social policies, including increased recognition of the importance of fathers' role in child development. 11 There is some evidence to support a shift in patterns of parent and child interaction away from gendered, stereotypical parental roles such as authoritarian decision-making roles for fathers and caregiving roles for mothers, towards shared care giving. Moreover, this shift in parenting values appears to foster democratic approaches to communication that develop autonomy and develop mutual respect between the child and parent rather than value obedience. 12 There are notable differences remaining between countries in terms of the proportion of young people within countries reporting easy communication with their parents. The biggest positive changes were identified in Estonia, Denmark and Wales. The biggest decrease in perceived quality of communication, (with both parents) was reported by young people in Slovenia, France and Poland. The reconciliation of work and family life has been recognized as a key 'happiness' factor in determining what families have to say about their quality of their lives. 13,14 Those countries where individuals are purported to feel they have a good balance between work and family life 13,14 are also those countries identified in this study as having a more positive perception of parental communication (e.g. Denmark 24%; Estonia 31%). Moreover, those young people perceiving the lowest levels of ease of communication with their parents coincide with countries that have been identified as having a poorer self-reported perception of family life-work balance, for example, France 19% (workers personally satisfied with work life balance) and Slovenia 18%. 13,14 In Poland, however citizens do tend to report a more positive perception of 'life-work balance' (27%). However one dimension of work-life balance that may relate to family interaction, strainbased conflict (proportion of workers having difficulties in fulfilling family responsibilities due to the intensity and time allocated to paid work) is in Poland well above the EU average (62 vs. 50%). A situation that has intensified over the past decade with large scale parental economic migration, resulting in the temporary separation of Polish families. 15 Overall, understanding the dimensions of work life balance that might be reflected in trends in family communication may aid in conceptualizing the impact work-life balance has on family life. Further work is needed to account for the decline in ease of communication in France over the past decade, especially against trends towards increased ease in communication. There is some evidence to suggest that young people in France experience lower levels of Trends in adolescents' perceived parental communication parental supervision and have weaker emotional bonds with their parents than is the norm for young people in other European and North American countries. 16 However, comparative analysis is required to identify how young people interpret their parenting experiences and if they have an awareness of cultural differences in family life. Additional consideration is also needed to explain the gendered character of the trends described in this article, it is currently unclear why in contrast to the findings for fathers, positive increases in communication prevalence with mothers were found only for boys. --- Conclusion The temporal trends reported on in this article demonstrated an increase in a positive health asset for many young people, that of family communication. This was especially notable in relation to the quality of communication between adolescents' and their fathers suggesting that a qualitative change in the nature of fathering and interaction with their children during adolescence has occurred over the last decade. Further work is needed to examine if economic conditions are a barometer for the quality of family communication and how they interact with socioeconomic and cultural changes, such as parental migration or changes in cultural attitudes concerning effective parenting. --- Girls Boys --- Key points Over the past decade, across the majority of European countries and North America, there is a significant positive trend in terms of an increase in prevalence of ease of communication with parents. A distinctive positive shift in the character of fathers' interaction with their adolescent offspring was identified. Suggesting possible changes in the role of fathers in childrearing and potentially an increased understanding of the contribution of fathers to child development. The promotion of thriving behaviours is a key issue for public health policy across Europe. This article highlights the importance of considering the quality of family communication as a health asset that can contribute to thriving among young people.

The quality of communication with parents is a determinant of health and well-being during adolescence, being predictive of self-esteem, self-rated health and the ability to navigate health risk behaviours. Methods: This article describes trends in adolescent's (aged 11, 13 and 15 years) perception of communication with mothers and fathers by gender across 32 European and North American countries from 2002 to 2010. Analyses were performed on 425 699 records employing a General Linear Model (MANOVA). Results: In most countries, significant increases in the prevalence of ease of communication with both mothers and fathers were observed, with the greatest positive changes over time in Estonia, Denmark and Wales. In some countries, the opposite trend was found with the greatest negative changes occurring in France, Slovenia and Poland. Across the pooled dataset, a significant positive trend was observed for ease of communication with father, for both boys and girls and for ease of communication with mother for boys only. Conclusion: The temporal trends demonstrated an increase in a positive health asset for many young people, that of family communication. Positive trends may be a feature of the economic boom over the past decade coupled with cultural changes in attitudes to parenting, especially fathering.

Introduction Background of the study "The tie which links mother and child is of such pure and immaculate strength as to be never violated" --- Washington Irving In India, about 35% of total populations are children below 12 years of age. Today's kids are tomorrow's pallor's of our country. The investment on our child in terms of developing environment both physical and emotional is going to reap rich individuals in future. "What is done to children, they will do to the society" [1] Karl -Menninger The childhood period is vital because of socialization process by the transmission of attitude, customs, and behavior through the influence of the family and community. The environment of a child can be referred to holistic in various aspects of its influence-physical, social, intellectual, moral, emotional, spiritual and psychological areas [2] . The significant contributions made during the early ages of an individual's life determine the whole some personality. School age is an important period in which the child learns through a formal teaching. The surrounding at home and school are going to make a great change in the children's emotional and behavioral characteristics. Another one important factors is the mother's external employment which has both positive and negative effect on their both physical and emotional growth. On an average around 29% of the world's children suffer from psychosocial problems. Recent evidence indicates that psychosocial disorders frequently lead to poor school performance and to dropping-out of school. This wastes educational resources seriously impairs the economic and social potentials of such children [2] . Children are considered as the most potential unit of our future human resources in a country like ours, which relies great deal on its human resource strength therefore, it is necessary in the interest of our country to look after the health and welfare as they form the most vulnerable segment of the population. A better tomorrow depend much on the well being safety and development of the children today. Research suggest that parenting has an important role to play in helping children to become adjusted and the 1st few months and years of a Childs life are especially important in establishing pattern of emotional, cognitive and social functioning which will in turn influence the Childs future development and in particular, their mental health. ~ 44 ~ Parenting programmers may therefore have a role to play in improving the emotional and behavioral adjustment of infants and toddlers. Behavior problems in children are an important social, educational and health issues. The prevalence of these problems, their stability over time, their poor prognosis, and their costs to both individuals and society, all point to the need for primary prevention and early effective interventions. --- Needs of study "There is a reason behind everything in nature" --- -Aristotle The recent studies estimated that only about 50% of the emotional problems of the children are identified by their primary physician or parents, 12-25% of all American school-age children and 13% preschoolers have emotional/behavioral disorders. The psychosocial problems increased from 6.8% to 18.7%. Attention problems showed the greatest absolute increase (1.4%-9.2%) and emotional problems showed the increase (0.2-3.6%). The percentage of children with attention deficit/hyperactivity problems receiving medications increased from 32% to 78%. These increase in psychosocial problems were associated with increase in the proportions of single-parent families, parents get divorced, mothers employment and parent child relationship [3] . At least 3% of school children suffer from serious emotional disturbances, such as depression, suicidal thoughts, psychosis and serious attention problems. Attention deficits and hyperactivity is the most common behavioral disorder of childhood. The prevalence of attention deficits and hyperactivity among pediatric out patients in New Delhi was 11.2%. Sarkar, Kapur and Kaliaperumal (India) reported a prevalence rate of psychological disturbance of 10-54%in school going children of the age of group 8-13 years. The psychological problems found to be in 44% of the children. Anxiety related symptoms 67%, emotional problems, particularly depression 62% and conduct problems 49% were found. A big group of the population in any city/country is that of students and the life of students is becoming more and more stressful. Family is the nuclear of all social groups because of its functional importance of the child. It is where healthy habits are learnt by the child. According to Tyrer and Tyrer (1974) absenteeism in the later years of schooling is predictive of depression in adult hood [4] . American Academy of Paediatrics Division of Child Health Research, the majority of paediatrician surveyed found that mothers should not work outside the home from their child's infancy to early school age. The connection of children with their mothers at a young age will allow a close bond. This will make the communication between parent and child easier especially during the middle school and high school years. The attention and moral values the child receives will help to guide the child in a positive direction as they get older [5] . The effects of maternal employment on children have negative action and positive action. Hence there is a need to study the difference in psychosocial problems of children of working and non-working mothers. This will helps the working mothers to improve the care given towards their children. This will also help them to concentrate on their emotional and behavioral characteristics. This intern reflects their personality Research question 1. Does your child show aggressive behavior? 2. Does your child have poor coping skills with their environment or peers? 3. Does your child feel excessive anxiety? 4. Does your child share problem with you --- Statement of the problem "A comparative study to assess the emotional problems among children (8-13 years) of working mothers and nonworking mothers in rural and urban areas of bhopal (m.p.)". --- AIM The aim of the study is "To assess the emotional Problems among Children (8-13 years) of working mothers and non-working mothers in rural and urban areas of Bhopal (M.P.)". Objectives of the study 1. To assess the emotional problems among children of working mothers. 2. To assess the emotional problems among children of non-working mothers. 3. To compare the emotional problems between the children of working mothers and non-working mothers. 4. To find the association between emotional problems among children of working mothers and non-working mothers and their selected demographic variables. --- Research hypothesis H1-There will be a significant difference between the emotional problems among children of working mothers and non-working mothers. --- Assumption  The study assume that 1. The emotional problems will be more among children of working mothers. 2. The emotional problems will be comparatively less among children of non-working mothers. 3. There will be some difference among the occurrence of emotional problems in children of working and nonworking mothers. --- Delimitations The study is limited to the children with the age group of 8-13 years. --- Conceptual frame work Theory can be developed using only conceptual approaches. Conceptual frame work is deliberately formed from experience and it conveys the human experiences of the concept. Conceptual frame work is created by considering all three sources of experiences related to the concept the word; think it, and the associated feelings. The same word may be used to represent more phenomenon. The conceptual frame work of the present study was developed by using general model concepts of input process and product. This study aimed at to assess the emotional problems among children (8-13 years) of working mothers and non-working mothers in rural and urban areas of Bhopal. It is divided into three phases 1. Input 2. Process 3. Output  INPUT: It has been defined as any form of information and material that enters into the system through a boundary. In this study, it refers to emotional problem among children of working mothers and non-working mothers, demographic variables and existing emotional problem in children (8-13 years). In this their initial knowledge will be assess by the based on structured questionnaire.  OUTPUT: Output is any information or material that is transfer to the environment. In this study, output refers to gain in knowledge to assess the emotional problems among children (8-13 years) of working mothers and non-working mothers through the structured questionnaire. --- Research methodology This study was conducted in urban and rural areas in Bhopal. Urban area which is situated in Navibagh and Rural area which situated in Itkhedi. These working mothers and non-working mothers were selected purposively for geographical proximity, time constraint, and better cooperation from the subjects and authority. In this comparative study was used. --- (B.) Assessment of emotional problem among children of working mothers and non-working mothers The emotional problem among children (8-13 years) of working mothers and non-working mothers through structured questionnaire. Assessment of emotional problem was conducted by using structure questionnaire was given on the same day. On the 7 day assessment of emotional problem was conducted by administering the questionnaire. The data was analyzed by using descriptive and inferential statistics. The result revealed that Differences mean of working mothers score 12.2 was significantly higher than the non-working mother score was 2.9 Thus structured questionnaire is effective to assess emotional problem. --- Section-A Analysis of the selected socio demographic variables of the respondents This part deals with the data pertaining to the demographic profile of the respondent. The demographic data is analyzed using descriptive statistics. The socio demographic data obtained from 30 children of working mothers and 30 children of non-working mothers are analyzed using descriptive statistics and is presented in terms of frequency and percentage. The sample characteristics include place of residency, age group of children, type of family, number of family member, education status of the mother, family income, mother occupation and religion. Section -C The data depicted in table explain the emotional problem among children (8-13 years) of working mothers and nonworking mothers through structured questionnaire. Differences mean of working mothers score 12.2 was significantly higher than the non-working mother score was 2.9. Thus structured questionnaire is effective to assess emotional problem. According to the result of study, majority of the emotional problem among children of working mothers was higher than the children of non-working mothers. Hence the structured questionnaire among children of working mothers was higher than the children of non-working mothers facilitated to assess more about emotional problem which is evidenced in the mean score. --- Section -B --- Conclusion After the structure questionnaire, the result shows that there is a significant difference in the emotional problem among children of working mothers and non-working mothers. Thus it is concluded that the emotional problem is high among children of working mothers than the non-working mothers.

The childhood period is vital because of socialization process by the transmission of attitude, customs, and behavior through the influence of the family and community. The environment of a child can be referred to holistic in various aspects of its influence-physical, social, intellectual, moral, emotional, spiritual and psychological areas, so the investigator felt a need to assess the emotional problems among children of working mothers and non working mothers.

I n his perspective "Navigating between stealth advocacy and unconscious dogmatism: the challenge of researching the norms, politics and power of global health, " 1 Ooms argues that actions taken in the field of global health are dependent not only on available resources, but on the normative premise that guides how these resources are spent. However, these are currently not explicitly revealed in discussions on 'bestbuys' in global health. Indeed, the level of resources that are presented as available for global health by donor countries are dependent on how (or in this extent) how much of a priority health or specifically global health is. Yet, rather than explicitly acknowledging the value judgements implicit in decisions on funding for global health -and having an open debate about the politics guiding funding and interventions -these remain ignored. Discussions focus on which best 'technical' or 'scientific' interventions should be adopted within a given field, such as maternal and child health or HIV. Here criteria for decision-making are mostly presented as apolitical focused on how to (a) save the greatest number of lives or (b) reach the greatest number of people (with the ultimate objective of saving or improving their lives) within the constraints of a specific budget. This masks wider political agendas that may be underlying decision-making processes as well as a frank discussion on who has power in global health and on how to hold those actors accountable. Ooms argues that actors in global health are either aware of their normative premise but seek to hide the motives advocating by stealth, or are unconscious of the dogma that guides their decision-making. Researchers and scientists working in the field of global health are currently caught in this paradigm. They -we -try to present different interventions or policies as scientifically sound while seemingly and at all cost avoiding head on discussion of the value judgements that determine decisions and research agendas. The 'real' reasons for why a set of interventions are chosen over others often lie outside of the realm of biomedical research but are dependent on actor power and on politics. To understand why certain policies fail while others succeed does not depend simply on identifying the best medication, the most effective intervention or technology, but rather it is the contestation between different underlying values ie, Ooms' normative premise, and how these play themselves out in the policy process within a given context. Ooms is right to argue that the engagement of social sciences with the field of global health to date has been limited. Global health has its roots in biomedical sciences, building strongly on empirical observation, replicable experiments and proof of an intervention working 'effectively, ' rather than questioning the basic premise or underlying agenda that is so badly needed to address the core questions in global health. Gilson and colleagues have in the past examined the potential contribution of social sciences to the field of health policy and systems' research (and thus to questions of global health). 2 Their insight of the different knowledge paradigms underlying biomedical and social science research explain some of the limitations we currently experience in global health research. A positivist worldview underlies much of clinical, biomedical and epidemiological research. This type of research focuses on investigating facts and knowledge in a single reality that can be observed -ie, the empirical focus that global health research has taken. It contrasts with social science which often centres on the relativist knowledge paradigms, where realities are constructed by actors who bring empirical and replicable findings to life in relation to their specific social context. Such research acknowledges the validity of multiple realities as opposed to the idea of 'one absolute truth' that has guided biomedical research informed by the normative knowledge paradigm. --- The Need for Health Policy Analysis Focused on Process Here two areas of research offer particularly valuable insights and potential for the field of global health. First, the domain of health policy analysis focused on process, and relating these to outcomes. The work by Gill Walt, Lucy Gilson, and Jeremy Shiffman has much to offer. [3][4][5] Rather than assuming a 'black-box' of issues from which policies and priorities arise, Shiffman's framework of agenda-setting (building on the work of John Kingdon) explains why maternal mortality emerged as a priority in global health at a specific time. 5 Gilson's analysis highlights the role of front-line health workers to understand why a policy succeeds and why it fails. 6 These studies show how important it is to examine the different processes that govern the development of policy and its implementation in detail. They demonstrate that rather than focusing solely on the content or what might be termed the 'ingredients' of a policy, procedural questions, actors involved, their values and ideas, as well as broader contextual issues are what determines whether a policy developed in Geneva, Seattle or Washington, DC can successfully be replicated in different low-and middle-income settings. Second, increasingly attention of researchers in global health has focused on the rise of evidence-based policy-making in health, and the extent to which the use of 'evidence-based policy-making' itself has been political. 7 For example, the initial abstinence only focus of the US President's Plan for AIDS Relief (PEPFAR) was critiqued for presenting an approach informed by religious values and beliefs as empirical evidence. 8 This type of research, analysing the policy process and 'how' evidence is used, go to the core of understanding how the normative issues in global health shape action and inaction as well as success and failure. The importance of process (and the factors shaping it) to understanding outcomes of global health policy have implications for the type of research and focus required to address the most pressing issues in global health to date. While outcome data, and quantitative analysis are essential, these will in many instances need to be informed and addressed by qualitative research, mixed methods to understand context and actors and research focused on complexity. To enable discussion of the normative challenges at the heart of global health will thus require new knowledge, new types of evidence and significantly greater investigation of the policy process and the very nature of what is conceived of as evidence to inform decision and policy-making in global health. The application of critical social science theory to interrogating some of the core questions of global health is only just beginning (Ooms provides as an example for this treatment of antiretroviral medicines for HIV and AIDS in low-and middle-income countries). Social science methods have already been employed to understand better why some policies and initiatives succeed and others fail. But not enough. Many of the central questions of global health: whose interests' are served by interventions adopted and funded in global health, who decides on the overall resource envelope for global health challenges, remain unanswered. These types of political economy questions, investigating underlying power relations and normative premise can only be answered through greater, more rigorous application of social sciences to the field. And a focus on health policy analysis and research focusing on the role of evidence and ideas in health policymaking. --- Governance of and for Global Health One aspects of global health research where the potential for greater insight through more and more rigorous research of this type seems particularly important is governance. The health challenges facing the world are many and they are complex. Infectious diseases continue to threaten health and the very fundamentals of our society as evidenced by the recent Ebola outbreak, the rise of non-communicable disease and the health impacts associated with globalisation (notably, migration, and inequalities in health). These call for a coordinated response involving the many different types of actors working in the field of health, from national governments, international organisations to private sector actors and foundations. 9 Governance of and for global health has received increasing attention during the past decade. 10,11 Governance for global health was subject to a Commission, 12 and has its own academic journal associated with it. Yet, a pervasive framework for understanding relations between the different global health actors and their actions is still missing. And while the Commission and its Commissioners have highlighted the importance of acknowledging the political determinants of health, 13 this has so far resulted in only a limited amount of actual research. Developing a pervasive framework of governance for global health, as well as for the analysis of such governance will be essential to addressing global health challenges and developing the field. However, to bring such 'social science muscle' to the field of global health will require substantial resources and investment. Despite the developments of the field of global health, including focused on governance, the majority of funding continuous to be awarded to large, often single focus programmes. These often have as an ultimate goal a health outcome or even eradication of a disease. This pattern of funding limits the types of research that needed to ultimately succeed in these endeavours of improving health and eradicating disease. Much has already been achieved by current approaches in global health, and many lives saved and improved. Yet, so much more could be accomplished if the current approach of large ambitious health programmes focused on 'technical' or biomedical solutions was equalled by attention and focus on process and power relations. So while Ooms argues it is not about resources but about informed debate on how these are spent -such debate itself requires resources. --- Why Does the Gates Foundation not Have a Programme on the Political Economy of Global Health? In sum, the greater and more rigorous application of the social sciences, a focus on process and power relations in global --- health is essential to addressing the normative challenge Ooms' outlines. Policy analysis offers particular value here, as does research focused on the role of and contestation of evidence. To enable such research will require a significant refocusing of resources currently available in global health research, and a restructuring of how policies and programmes are designed to ensure they are informed by the type of social science research highlighted. While the value of this type of research and knowledge is increasingly acknowledged and articulated this has not been translated into tangible actions and resources. Why does the Gates Foundation not have a programme on the political economy of health? Or on health policy analysis? And the same question could be asked of many other global health funders and actors. The continued failure to refocus efforts and resources will mean not only limitations in the field of global health. It will ultimately result in the failure to address the big challenges posed by growing health inequalities, the re-emerging threats of communicable disease and the rise in non-communicable disease. --- Ethical issues Not applicable. --- Competing interests Author declares that she has no competing interests. --- Author's contribution JH is the single author of the paper.

In his perspective "Navigating between stealth advocacy and unconscious dogmatism: the challenge of researching the norms, politics and power of global health," Ooms argues that actions taken in the field of global health are dependent not only on available resources, but on the normative premise that guides how these resources are spent. This comment sets out how the application of a predominately biomedical positivist research tradition in global health, has potentially limited understanding of the value judgements underlying decisions in the field. To redress this critical social science, including health policy analysis has much to offer, to the field of global health including on questions of governance.

e128 Conclusion: The specific health challenges faced in urban settings can benefit from an interprofessional approach informed by the experiences and needs of patient communities. This elective was innovative in engaging students in interprofessional learning on how health and social agencies collaborate to tackle social determinants in urban spaces. Half of the world now lives in urban settings. 1,2 The specific needs of vulnerable urban populations remain underrepresented in health training. 3 We describe a novel interprofessional elective focused on urban health, taught through the lens of the social determinants of health (SDOH). St. Michael's Hospital is an inner city hospital in Toronto that trains over 3,000 learners each year from 27 disciplines. An environmental scan found that teaching on urban health at the hospital was limited in most disciplines to a single didactic lecture. An interprofessional course committee was formed with health providers, students, and hospital leadership to design an interprofessional course on urban health. The elective engaged students in immersive education on SDOH. 5,6 Collaboration with community partners and agencies provided real cases to illustrate patient needs in the urban context. 7,8 The facilitated visits at community agencies provided students a new perspective on caring for individuals and communities. 9 Community members and front-line workers led these sessions -discussing experiences of stigma, discrimination and how systems failed -to prevent them from lapsing into "safari tourism," where privileged health professionals explore exoticized people in poverty. 10 Consequently, trainees were provided with tools and language for use in advocacy that reflected the input of communities affected. 11 The positioning of people with lived experience as experts was an essential learning element. 12-15 This elective was innovative in engaging students in interprofessional learning on how health and social agencies collaborate to tackle social determinants in urban spaces, and introduced trainees to the social causes of health inequities, similar to efforts in social paediatrics. --- 16-18 Such curriculum can increase awareness of community resources, challenge assumptions and make the SDOH "real." As intervening on the SDOH is increasingly embraced, 6,19-21 health providers will require training on how to develop and implement solutions in close partnership with the people affected by these issues. 1. --- Introduction to urban health Led by the course organizers, and held at St. Michael's Hospital. This session outlined definitions of urban health and introduced the social determinants of health. A case study of a young woman living with HIV was used to explore how determinants of health, such as race, income, housing status and chronic disease, intersect. Students were introduced to advocacy at individual and community levels. A long-term physician and advocate discussed his experience in calling for improvement in HIV care and care for people with addictions. Lastly, a policy expert introduced a framework for understanding policy change and the role of health professionals in influencing political decision-makers. The Wellesley Institute, a Toronto based think tank and research organization, with a strong focus on health equity and social determinants. --- 2. Housing as a determinant of health This session explored housing as a key determinant of health through a number of causal pathways. Course organizers defined the spectrum of homelessness, and used a case study to examine how illness was related to insecure housing. Students were introduced to individual-and system-level solutions, including Housing First. 22 The session was held within a large men's shelter, and included a variety of perspectives. A shelter manager described how it operated and connected with the community, while a person with lived experience of homelessness provided his perspective on the connection between housing and health. Finally a family physician who served as the medical director of a clinic within the shelter, and who had led research studies on homelessness, discussed his experience of introducing managed alcohol programs. 23 The session ended with a tour of the shelter. Seaton House, Canada's largest men's shelter. --- Indigenous health in urban environments This session was held in a community centre that serves Toronto's Indigenous community. Led by an Indigenous scientist and family physician, this session introduced students to an Indigenous model of health and well-being. The facilitator used her work with urban Indigenous populations to highlight the issue of the relative invisibility of Indigenous communities in urban centers and discussed racism and discrimination experienced by patients in the health system. 24 The session concluded with a tour of the health centre. --- Anishnawbe Health Centre, an Indigenous community health centre. --- 4. Food and income security as determinants of health The strong connection between food security and income security was the focus of this session. The session was facilitated by a scientist studying food security, who provided a critique of the traditional charity response to hunger. Her research has exposed the limited role of food banks in solving food insecurity. 25 The session also featured a family physician with experience in advocacy work around income security. Students worked through a case study highlighting these issues. The session concluded with a tour of the facility, which offers a drop-in, food bank, community cooking, and other services. The Stop Community Food Centre, a unique organization that evolved from a traditional food bank into a community development hub. --- 5. Youth and adolescent health in urban environments The session examined the determinants of health of youth and adolescents. The session was held at Covenant House, a shelter that provides housing and crisis services to youth experiencing homelessness. A unique runaway prevention program, "Reality Check," was described. 26 Trainees had an opportunity to tour the shelter. Covenant House, a large youth and adolescent shelter. 6. Chronic disease management in urban environments Chronic disease management and the challenges faced by those living in poverty in urban settings was the focus of this session, which took place at St. Michael's Hospital. The session was led by a pharmacist and a chiropractor, who explored the global burden of non-communicable chronic diseases. 27 They then used HIV as an exemplar to highlight biological, psychological and social changes that occur with chronic disease. Finally, a clinician-scientist discussed improving care for diabetes patients, and the role of the built environment. 28 The role of the Community Care Access Centre, which supports the delivery of home care to individuals across Toronto, was discussed. --- Toronto Community Care Access Centre, a government funded agency to help patients access home care services 7. --- Mental health and addictions in urban environments This session focused on mental health and addictions and was hosted at Toronto Public Health. Speakers included a psychiatry resident physician, a community client of the mental health system, and the manager of a needle exchange program. Finally, a community worker from a community health centre also spoke about hepatitis C prevention and the importance of including harm reduction in any program. The Works, a harm reduction service and needle exchange run by Toronto Public Health 8. Legal status as a determinant of health Legal status as a determinant of health was discussed at Romero House, an agency that provides housing, settlement, and advocacy services to refugees. A family physician who directs a large clinic serving refugees discussed clinical care and the role of advocacy. A second family physician, with a focus in women's health, spoke about her recent advocacy to maintain funding for a bus that brings health services to immigrant and refugee patients. The work of a local advocacy organization, No One is Illegal, was highlighted. The session concluded with a tour of the shelter. Romero House, a large shelter for refugees, and No One is Illegal, an advocacy organization. --- Conflicts of interest: There are no conflicts of interest for any of the authors. --- Appendix A Readings and resources --- Introduction and Advocacy

Background: More than half of the world's population now lives in cities. Health professionals should understand how social factors and processes in urban spaces determine individual and population health. We report on lessons from an interprofessional urban health elective developed to focus on the social determinants of health (SDOH). Methods: An interprofessional committee developed an urban health elective based in downtown Toronto. Course objectives included promoting collaboration to address SDOH, identifying barriers to care, accessing communitybased resources, and learning to advocate at individual-and community-levels. Results: Seventeen students from eight disciplines participated during the 2011-2012 academic year. Sessions were co-facilitated with community partners and community members identified as experts based on their personal experience. Topics included housing, income and food security, Indigenous communities in urban spaces, and advocacy. Students collaborated on self-directed projects, which ranged from literature reviews to policy briefs for government. Students particularly valued learning about community agencies and hearing from people with lived experience.

OBJECTIVES/GOALS: As hospitals across the nation respond to the need to address community violence, there is a dearth of Hospitalbased Violence Intervention Programs (HVIPs) in the South despite having disproportionate rates. This research aims to identify key factors and strategies for implementation of an HVIP among rural patient populations in a southern state. METHODS/STUDY POPULATION: Semi-structured interviews will be conducted with medical providers, social service organizations, and patients transferred from four high-risk rural areas in Arkansas. Data will be analyzed using Framework Analysis, a rapid analysis approach involving framework development, code application, impactful statement identification, and content analysis. Evidence-Based Quality Improvement (EBQI), a group consensus making process, will be conducted to identify key implementation strategies and factors to adapt based interview findings. Priority areas for adaptation will be identified via systematic rating. The EBQI team, including researchers and key rural stakeholders will engage in a series of discussion, vote on final strategies, and develop a guide for future HVIP implementation and pilot testing. RESULTS/ANTICIPATED RESULTS: Findings from this study will result in a prioritized list of barriers and facilitators across sample groups. Factors will be rated by level of importance. Cluster maps will display the relationships among factors. Go and no-go zones will be identified based on importance and feasibility. Implementation strategies will be mapped to barriers and facilitators. DISCUSSION/ SIGNIFICANCE: The findings will result in a culturally and geographically relevant HVIP model and package of implementation strategies to test in future hybrid trials (feasibility pilot & multi-site RCT); and shape the future of violence prevention efforts in healthcare settings across the rural South. --- A Mixed Methods Analysis of Disparities in the Management of Low-Risk Febrile Infants Colleen Gutman 1 , Paul Aronson 2 , K. Casey Lion 3 , Carla Fisher 1 , Antionette McFarlane 1 , Carma Bylund 1 , Rosemarie Fernandez 1 1 University of Florida 2 Yale University 3 University of Washington OBJECTIVES/GOALS: Febrile infants are a model population for exploring communication, implicit bias, and health disparities in the pediatric emergency department. Using mixed methods, we performed an in-depth analysis of disparities and physician-parent communication, a potentially modifiable driver of inequities. METHODS/STUDY POPULATION: We performed a multicenter cross-sectional study of febrile infants with low-risk for invasive bacterial infection evaluated between 2018-19 across 32 institutions. We performed logistic regression to assess the association between 1) race and ethnicity (Non-Hispanic White [NHW], Non-Hispanic Black [NHB], Hispanic [H], Other Race and/or Ethnicity [O]) and 2) limited English proficiency (LEP) with the standard of care, discharge without lumbar puncture and without antibiotics. We concurrently performed in-depth semi-structured interviews with physicians to explore physician-parent communication and implicit bias in the management decisions for febrile infants. RESULTS/ ANTICIPATED RESULTS: Of 3629 low-risk febrile infants, 74.2% received standard of care. NHB, compared to NHW, infants were more likely to receive standard of care (aOR 1.3 [95% CI 1.0-1.7]; aOR H: 1.1 [95% CI 0.9-1.4]; aOR O: 1.0 [95%CI 0.8-1.4]). There was no association between LEP and standard of care (aOR 0.8 [0.61-1.1]). When accounting for documented use of professional interpretation, families with LEP without documented professional interpretation were less likely than families without LEP to receive standard of care (aOR 0.6 [95% CI 0.4-0.9]). Thematic analysis of 13 physician interviews is expected to elucidate aspects of the physician-parent interaction that influence management decisions. DISCUSSION/SIGNIFICANCE: Infant race, ethnicity, and use of professional interpretation, are associated with the management of low-risk febrile infants. Physician behaviors that are influenced by the physician-parent interaction may represent modifiable targets for future interventions to promote health equity.

The goal of this study is to explore the effectiveness of a digital health education curriculum aimed at increasing syphilis beliefs and screening behavior among young African American females residing in Jefferson County, AL. METHODS/ STUDY POPULATION: Study Population: African American, cisgender women, aged 18-29, who reside in Jefferson County, AL Sample Size: N = 50 Measurements: 1) Champion Health Belief Model scale adapted for measuring syphilis perceptions and syphilis screening behavior Analysis Plan: IBM SPSS Statistics 29 will be used to analyze intervention data. Pre-and post-intervention data will be analyzed to calculate a screening request rate for each period. We will use Cohen's D effect sizes to measure screening requests rate differences post intervention completion. The small sample size and exploratory nature of this project make the descriptive statistics valuable. RESULTS/ANTICIPATED RESULTS: We anticipate that the digital syphilis prevention intervention will positively influence participants' beliefs regarding syphilis and their syphilis screening behaviors. DISCUSSION/SIGNIFICANCE: Innovative preventive approaches to reducing syphilis disease spread is a national priority as rates have risen annually throughout the last decade. African American women experience the greatest disease burdens associated with syphilis. This study leverages tailored strategies to effectively address this ailment in the target population.

Issue: In the Netherlands, the National Public Health Foresight Study (PHF) is published every 4 years, as starting point for national and local public health policy development. As these policies impact citizens' health and lives, it is important to include their voices. We piloted an approach to strengthen this engagement to learn and to inspire PHF in other (country) settings. Problem description: PHF is usually expert-based. Citizen engagement, beyond consultation, is not yet common practice. In the Dutch PHF-2024, we engage citizens both as advisors (citizen council, N = 30 and panel, N = 500) and as target group (focusgroups N = 40). Intentionally the scope is diffuse, allowing for unexpected input. What can we learn from this approach, and how do the citizens contribute to the PHF? Results: -Citizens of all ages, backgrounds and education types are well able to discuss health (determinants), data and indicators; -They have intrinsic motivation to contribute to better knowledge, feel responsible for effective engagement and are eager to engage across different backgrounds and population groups; -Integration of outcome into the PHF process is valuable, enriching scientific with experiential knowledge and facilitating results communication; -Fundamental questions, e.g., about foresight time frames (''why look so far ahead as the world is in crisis right now!'') are raised by the citizens, showing that these need to be better addressed in order to make PHF relevant for a broader public. --- Lessons: -More permanent engagement of the citizens is needed to enable learning and development; --- Background: Foodborne botulism is a neuro-paralytic disease caused by the ingestion of botulinum neurotoxins (BoNTs). Given its high fatality rates and economic consequences, prompt management of human cases requires collaboration among public health authorities, supporting hospitals in rapid diagnosis, food inspections, and formal analysis. This study aims to investigate the food source responsible for a botulism outbreak in Northern Italy, which resulted in the hospitalization of a person. --- Methods: Faecal specimen from the patient, and suspected food were collected (industrial-made asparagus cream, both packages consumed and still closed). BoNT presence and identification was performed by mouse-test. After the enrichment in TPGY broth, samples were plated on CMM medium to observe the proteolysis, and on EYA medium for colonies isolation. DNA was extracted and genome was sequenced by Illumina MiSeq. Typing was performed by MLST. SNP-based phylogenetic analysis was conducted, including isolated strains from outbreaks occurred in the same year and geographic area. --- Results: The strains were identified as group I proteolytic Clostridium botulinum, with BoNTB responsible for the outbreak. Faeces and the ingested food exhibited the same Sequence Type (ST178), differing by only one SNP. Notably, the closed package had a distinct ST (ST29), and a significant divergence from the outbreak strains (7282 SNPs). Conversely, the other strains displayed SNP differences ranging from 11116 to 46536. --- Conclusions: Genome characterization enabled the identification of the outbreak source as the ingestion of BoNTB present in asparagus cream, suggesting also the circulation of several different strains of Cl. botulinum causing foodborne outbreaks. These findings highlight the ongoing public health concern of foodborne botulism, even in industrial-processed foods. Our study underscores the importance of source attribution and effective outbreak management in preventing hazardous botulism outbreaks. --- Key messages: Genome sequencing enabled the source identification of a foodborne outbreak caused by Cl. botulinum toxin B. Our study emphasizes the current significance of foodborne botulism as a public health issue. --- Background: Food and nutrition literacy (FNL) are of growing interest in the field of public health and health promotion. Several tools have been developed to measure the FNL in different populations. However, there is no such tool applicable across

resources were presented. Outputs range from health literacy sessions in schools to contingency plans for public health emergencies. Health governance responsibilities' redefinition evidenced a knowledge gap and drove the need to consult academia to develop evidence-based health policies. By creating this methodology, the authors defined strategic pillars and tailored operational recommendations for municipalities, which rely on ongoing indicator monitoring and, ultimately aim to improve population health through concerted efforts.The decentralization of health competencies granted local autonomy in shaping health policies. To support decision and policy-making, a comprehensive tool for health diagnosis assessment was designed. The need for a concerted local action with definition of territorialized development strategies, highlights the value of a deep connection between decision-makers and academia as a consulting entity.

Introduction Tuberculosis (TB) is one of chronic infectious disease which is caused by Mycobacterium tuberculosis and becomes the leading causes of morbidity and mortality worldwide [1,2]. It is a key public health concern in Ethiopia: in 2009/2010, it was the second most important cause of death [3]. Ethiopia is ranked seventh among the 22 high-burden countries that account for 81% of all cases of TB and 80% of all TB deaths worldwide [4]. Ethiopia is also one of the 27 countries identified as having a high prevalence of multidrug-resistant TB (MDR-TB). The burden of MDR-TB in these countries accounts for 86% of cases worldwide [3,5]. Stigma stands as decreasing attribute which arises from social interaction and is related to the power dominance and difference [6]. Social (enacted) stigma refers to experience discrimination by other people which results from inferiority in the society while perceived stigma refers to the shame and expectation of discrimination that prevents people from talking about their experiences and sense of unworthy and guilty [7][8][9][10][11][12][13][14][15][16][17][18][19]. TB is highly stigmatized disease which can be experienced and felt at a different social setting like home, workplace, and community [7]. Perceived stigma has a considerable impact on health that renders patients to refuse disease and medical services through discouraging health-seeking behavior which leads to distortion of health condition making difficult to treat that increases infectivity and communicability of the disease [7][8][9][10][11][12][13]. It is more common in patients with tuberculosis. Some studies conducted in Egypt Chest Hospital and in southern Thailand and Nepal showed that the prevalence of perceived stigma was 41.5 % and 63.3%, respectively [20][21][22]. Therefore, understanding tuberculosis-related perceived stigma has importance in improving the quality of these populations. Therefore, this aimed to assess prevalence and associated factors of perceived stigma among TB patients in Ethiopia. --- Methods . . Study Setting and Population. Institution based crosssectional study design was conducted from March 2016 to May 2016 at Wolaita Sodo University Referal Hospital, Woliata Sodo, Ethiopia. Tuberculosis patients whose ages were ≥ 18 years were included in the study, while critically ill patients were excluded from the study. Single population proportion formula was used to get the required sample size. Because there was no prior study on the subject area, to get maximum sample size we used prevalence of perceived TB stigma as 50% (P=50%), 95% CI, margin error of 5%, and 10% none-response rate; the required sample size became 424. Seven patients were excluded from the study due to critical condition of the illness. Among tuberculosis patients who had treatment follow-up TB clinics during the study period in the mentioned hospital, we had recruited 417 tuberculosis patients. Systematic random sampling technique was employed to select the study participants. . . Data Collection. Our data collection instruments had included a structured interviewer administered questionnaires on sociodemographic characteristic which mainly focuses on age, sex, education, occupation, marital status, religious view of the study participants, and others. We have also used Oslo item 3 social support scales which is 3-item questionnaire commonly used to assess social support related issues in clinical and community settings [23]. The variable of interest (outcome variable), TB stigma felt by TB patients, was collected by 12-item perceived TB stigma scale that consisted of four-point Likert scale questions concerning perceived isolation, guilt, shame, and disclosure of their tuberculosis status. It was validated in Thailand among TB and HIV patients; its goodness-of-fit was good (TLI = 94, LFI = 0.88, and RMSEA = 0.11), internal consistency was excellent (Cronbach's alphas 0.82-0.91), and test-retest reliability was moderate. It has good psychometric properties that measure stigma associated with tuberculosis and HIV/AIDS and allow assessment of stigma from community and patient perspectives. Participants were classified as having or not having perceived stigma using the mean of the stigma variable as cut-off point [21]. This scale was adopted and translated to Amharic language and it was highly reliable in the study with Cronbach's 𝛼 of 0.95. . . Data Processing and Analyses. We used SPSS version 22 to analyze the data. The association of each independent variable with perceived tuberculosis stigma was examined in bivariate analysis. Those confounding variables that could potentially be associated with both TB and perceived stigma like anxiety, depression, substance use, social support, and other variables with p value less than 0.2 during bivariate analysis were entered into the multivariate analysis to identify potential confounders. A p value of less than 0.05 was considered statistically significant, and adjusted odds ratio with 95% CI was calculated to determine association. --- Results . . Sociodemographic Characteristics of the Study Participants. The study recruited a total of 417 tuberculosis patients; the mean (±SD) age of the respondents was 32.3 years (±9.23). Concerning sociodemographic characteristics, 241 (57.8 %) were male, 189 (45.3%) were from protestant religious background, and 199 (47.7 %) were never married. In addition, 287 (68.8 %) patients were diagnosed with pulmonary TB, 270 (64.9 %) were in intensive phase of TB treatment, and 229 (54.9%) had good social support (Table 1). --- . . Prevalence of Perceived Stigma and Associated Factors among the Study Participants. Prevalence of tuberculosisrelated perceived stigma by using Perceived Tuberculosis stigma scale was 42.4%. Prevalence of isolation, guilt, disclosure, and their relationship to social support is 42.4 %, 37.9%, 40.1%, and 36.6 %, respectively. Using of binary logistic regression analysis revealed that having pulmonary TB (AOR=2.49, CI:(1.24, 4.87), (P<0.01)), being in intensive phase of tuberculosis treatment (AOR=1.42, CI: (1.19, 2.58), (P=0.02)), having comorbid HIV illness (AOR=3.54, CI:(1.37, 9.12), (P <0.01)), having poor social support (AOR=2.45,CI: (1.18, 5.09) (P <0.01)), and current substance use (AOR=1.78, CI:(1.28, 3.17), (P = 0.01)) (Table 2). --- Discussion Prevalence of TB related perceived stigma in the current study was 42.4% (95%, CI: 39.28-45.52). This finding is in agreement with study conducted in Egypt Chest Hospital and southern Thailand [20,21]. Nevertheless, a study result was lower than study conducted in Nepal [22]. This difference might be related to variation in study design, data collection tool, sample size, and study participant's variation. The difference also attributed due to variation in culture which is supported by findings from a systematic review and other studies that revealed cultural variations is potential for stigma [24][25][26]. Perceived stigma was mostly prevalent in patients with pulmonary tuberculosis when compared to those who had extra pulmonary tuberculosis. In addition to this, there was significant association between TB related perceived stigma and intensive phase of treatment. This finding is in agreement with the other study [22]. TB related perceived stigma is often a product of exaggerated notions of contagiousness. Community awareness and patient education may help to mitigate the isolation and rejection of TB patients and encourage TB suspects to seek initial care. Tuberculosis patients who had comorbid HIV infection were more likely to have perceived stigma. This might be evidenced by having diagnosed with HIV illness by itself associated with high levels of stigma. Hence, TB/HIV coinfected patients can be at higher risk of having perceived stigma [27,28]. Tuberculosis Research and Treatment The study also showed that those patients who had poor social support were significantly associated with perceived stigma. Having poor social support and somatic illness may lead to increased psychological distress [29]. Tuberculosis patients who had family history of mental illness were more likely to have perceived stigma. This finding was consistent with other findings [20,30]. This might be due to the fact that anxious patients are more prone to use substances like alcohol and cigarette to relief themselves from the internalized stigma. Study conducted in Nigeria among patients with pulmonary tuberculosis showed that no formal education and patients who are in the working age group of 20 to 50 years had perceived TB stigma. Nevertheless, in this study there is no statistically significant association. --- Conclusion Prevalence of Tuberculosis-related perceived stigma by using perceived tuberculosis stigma scale was high (42.4%). Having pulmonary TB, being in intensive phase of tuberculosis treatment, having comorbid HIV illness, having poor social support, and using substances like alcohol and cigarette were associated with perceived stigma. Health professionals who are working TB clinics should give more emphasis to their patients and giving psychosocial counseling daily basis is recommended. Health education programs should be conducted to reduce TB stigma and improve patients' compliance. --- Limitation of the Study This study did not do detailed validation study for perceived HIV related-stigma scale and Oslo 3-item social support scale. We did not include BMI in our assessment. --- Data Availability The data used to support the findings of this study are included within the article. --- Ethical Approval Ethical clearance for this study was obtained from the Research and Ethics Review Committee of College of Medicine and Health Sciences, Gondar University and Amanuel Mental Specialized Hospital. Permission letter was obtained and submitted to Wolaita Sodo University Referral Hospital. Study participants were informed about their rights to interrupt the interview at any time and written informed consent was obtained from each study participants. Confidentiality was maintained at all levels of the study. TB patients were found to have TB related perceived stigmas referred to psychiatry clinics for further psychosocial counseling and support. --- Conflicts of Interest The authors declare that they have no conflicts of interest. --- Authors' Contributions Bereket Duko conceived the study and was involved in the study design, reviewed the article analysis, and was involved in report writing. Asres Bedaso, Getinet Ayano, and Zegeye Yohannis were involved in the study design and reviewing in articles. Bereket Duko drafted the manuscript. All authors read and approved the final manuscript. --- Stem Cells International

Background. Tuberculosis is a historically stigmatized disease and the stigma associated with it affects the institution, community, and interpersonal factors. Therefore, understanding tuberculosis-related perceived stigma has importance in improving quality of the patients. Objective. The aim of this study was to assess prevalence and factors associated with perceived stigma among patients with tuberculosis attending Wolaita Sodo University Referral Hospital, Ethiopia. Methods. Institution based cross-sectional study was conducted among a total of 417 tuberculosis patients who had treatment follow-up at TB clinics and were recruited for the study. Systematic random sampling technique was used to recruit study participants. A 12-item perceived TB stigma scale was used to assess tuberculosis-related perceived stigma. In addition, Oslo social support scale was used to assess social support related factors. Results. Prevalence of tuberculosis-related perceived stigma by using perceived tuberculosis stigma scale was 42.4%. Patients who had pulmonary TB [AOR=2.49, (95% CI: 1.24, 4.87)], being intensive phase category [AOR=1.42, (95% CI: 1.19, 2.58)], TB/HIV coinfection [AOR= 3.54, (95% CI: 1.37,9.12)], poor social support [AOR=2.45, (95% CI: 1.18, 5.09)], and using substance (alcohol, khat and cigarette) [AOR=1.78, (95% CI: 1.28, 3.17)] were more likely to have perceived TB stigma when compared to their counter parts. Conclusion. Health education programs should be conducted to reduce TB stigma and improve patients' compliance.

BACKGROUND The first case of Coronavirus disease 2019 was identified in China in December 2019, and the first case in Japan confirmed a month later (Kawana, 2020). By April 2020 the Japanese government issued stay-home advisories to citizens, and while some measures are believed to have been effective (Hiroi, 2020), these had a pronounced effect on people's social Takahashi, Oe, & Kurosawa, 2020). Older adults in particular are less physically fit, have lower immunity and are more susceptible to severe and fatal infections than are the young (Westmeier et al., 2020), and for this reason seniors' awareness toward COVID-19 infection has been comparatively high. The impacts of the COVID-19 pandemic on older adults included social isolation and loneliness, which are associated with anxiety, depression, cognitive decline, and mortality (Gorenko, Moran, Flynn, Dobson, & Konnert, 2021). The impact of the COVID-19 pandemic has not been confined solely to individuals, but continues to affect families. Since its emergence, deterioration of family relationships and decline in family functions have been observed over the course of time (Soejima, 2021). In recent years in Japan, the nuclear family, declining birthrate, aging society, and increasing divorce have all contributed to deteriorating family functions (Kumagai, 2010;Hohashi, & Honda, 2012) and the COVID-19 pandemic might have further aggravated family functioning. COVID-19's impact on families varies depending on changes outside the family, involving, as it does, requests to remain at home, school cancellations and so on (Soejima, 2021). It is therefore necessary to consider the impact of the pandemic on the family environment. In addition to the primary impact, such as closures of schools and day-care centers, chained effects in the form of secondary impacts, such as the increase in parents' time spent together with children, and tertiary impacts, such as the increase in negative interactions between children and parents, are also believed to have occurred (Gadermann et al., 2021). The Japanese archipelago consists of as many as 14,125 islands (not all of which are inhabited) (Geospatial Information Authority of Japan, 2023). The geographical locations of some of these small islands make accessing them inconvenient, and moreover their industrial activities have Hohashi, 2016). The impact of COVID-19 on these islands, with their own unique cultures, is also considered to be unique. The Concentric Sphere Family Environment Theory (CSFET) proposed by Hohashi is a middle-range family nursing theory that holistically captures the family environment that affects the well-being of the family system unit (Hohashi, & Honda, 2011). Based on CSFET, the family environment consists of five systems: the supra system, the macro system, and the micro system, which constitute the family external environment system; the family internal environment system; and the family chrono environment system. The theoretical basis of CSFET enables the obtaining of a comprehensive understanding of the impact on families that are in interaction/transaction with the family internal and external environments. In addition to the primary impact, we believe this enables the tracking of successive impacts, such as secondary and tertiary impacts, over time from the perspective of the family chrono environment system. Based on the above, the purpose of this study was to clarify the impact of the COVID-19 pandemic on families with older adults residing on remote islands. --- METHODS --- Design The study undertaken was a qualitative The operational definitions of terms (Hohashi, 2019;Hohashi, Honda, Shimada, & Michigami, 2016) were as follows (Figure 1): 4) family external environment system: "the family environment outside of the family system unit (supra system, macro system, and micro system)." 5) family internal environment system: "the family environment that exists within the family system unit, which is the area within the family system unit where individual family members interact with each other." 6) family chrono environment system: "a concept to indicate the process of temporal change and transformation of the family internal environment system, family external environment system and family system unit in a time frame from the past to the future." 7) family system unit: "another term for family to clarify that the family is a system and a unit." 8) impact: "the result of the action by one thing on another." The term "impact" is used to include the chain of effects that may accompany one effect (primary impact) and cause other effects (secondary impact, tertiary impact, and so on). --- Participants and Setting The area of study consisted of four islands incorporated as a city in Japan. The city has a total population of approximately 34,000, of which some 14,000 are aged 65 or older (Goto City office, 2021). Following Semi-structured interviews were conducted from August to September 2022. The interviews lasted approximately 120 min per family and were recorded with an IC recorder. --- Data analysis Verbatim transcripts of the semistructured interviews were produced. Directed content analysis (Hsieh, & Shannon, 2005) based on CSFET was performed on the contents of the transcripts and field notes (Elo, & Kyngäs, 2008), with the flow of analysis as follows: (i) the impacts of the COVID-19 pandemic on the families were extracted, and were divided into small, meaningful units, or codes; (ii) the codes were classified by focusing on similarities and differences, and codes that were found to be conceptually similar were grouped into more abstract concepts termed subcategories; (iii) the subcategories were grouped to create categories and abstraction levels were heightened; and then (iv) categories were classified into CSFET's five systems. --- Trustworthiness Researchers skilled in family ethnographic research were assigned to conduct the semi-structured interviews. They continued to perform coding and analysis at the end of each interview, from the first family to the last. Interviews were terminated when the same answers were obtained with no new contents, at which point the interviews were considered saturated. In the subcategorization and categorization, category names underwent repeated reviews until all four researchers were in accord on category terminology, upon which their perceptions corresponded. To ensure trustworthiness, nine experts in family nursing and qualitative research supervised the process. • Occurrence of greater psychological distance between island visitors and family members • Family's resistance to becoming a source of infection on the island • Family's psychological instability due to the cancellation of community and traditional events S --- RESULTS • Family decision-making more influenced by island conditions Chr P • Raising awareness of infection prevention among family members due to the infection history of family members • Increasing family's reassurance of safety for travel on and off the island by vaccination and testing • Changes and adaptations in the form of visits to family graves according to infection status • Growing consideration of the life span of older adult family members • Resuming homecoming of family members residing outside the island N • Emergence of acquiescence toward infection in the midst of thorough measures that can be implemented against infectious diseases S • Emergence of a digital divide between families regarding vaccination Note: Int = family internal environmental system; Fsu = family system unit; Mic = micro system; Mac = macro system; Sup = supra system; Chr = chrono system; P = positive impact; N = negative impact; S = context-sensitive impact. such as "I want to take my grandmother to various places now, while she is still healthy" were heard. --- "Emergence of acquiescence toward infection in the midst of thorough measures that can be implemented against infectious diseases," was a negative impact of acquiescing to infection because the individual had been taking all possible measures against infectious diseases, such as going out only when as necessary, performing disinfection and wearing masks. Statements such as "I've done everything I can do as usual, so it can't be helped if I get infected," were voiced. --- DISCUSSION All families made remarks that they differentiated between on-island and offisland. This does not necessarily mean onisland and off-island in the simple sense of the term, but reflects the participants' perception that a large functional distance exists between on-island and off-island, such as not carrying a new strain of coronavirus to the island. Consequently it is appropriate to classify the impacts on the family, which relate to it being a closed area surrounded by the sea, not as a micro system that includes local living spheres, neighbors, and so on, but rather as a supra system that includes a biosphere, national and regional characteristics, and so on. --- Impact of COVID-19 on the macro system The location of the study is classified as a remote island in the government's medical plan, and emergency patients are transported to mainland hospitals by Hohashi N., et al (2023) helicopter. The island has a large population of older adults, who are generally at higher risk of serious illness because of COVID-19 (Shahid et al., 2020). This situation may have contributed to a behavioral change in which family members living off the island refrained from returning home for visits, as they strongly felt the need to avoid spreading the novel coronavirus infection on the island. Furthermore, the family's sense of urgency about the spread of the novel coronavirus was also influenced by administrative measures (Chen et al., 2021). When administrative measures such as restrictions on activities were more lenient, family members' sense of risk for COVID-19 were correspondingly low; but when administrative measures became more stringent, family members' sense of risk toward COVID-19 became heightened. --- Impact of COVID-19 on the supra system Ten of the 14 families in this study were religious, which is a significantly higher ratio compared to the 36% of Japanese who, according to nationwide survey data, ascribe to a religion (Kobayashi, 2019). The regional nature of this study suggests that even To control the COVID-19 pandemic, it is important for individuals to acquire accurate and up-to-date knowledge and adopt correct measures (Ngwewondo et al., 2020). However, as the number of COVID-19 cases increased explosively, a feeling of resignation toward infection arose, even in the face of infection control measures. This can be regarded as a long-term negative impact of COVID-19. --- CONCLUSION In families with older adults on Japan's remote islands, impacts of COVID-19 were observed in the family internal environment system, family system unit, micro system, macro system, supra system and family chrono environment system, respectively. The CSFET is considered to be an effective method for family assessment because its --- DATA AVAILABILITY STATEMENT The data are not publicly available due to privacy or ethical restrictions. --- AUTHOR CONTRIBUTIONS --- Substantial contributions to conception, data collection, and analysis: Naohiro Hohashi, Shiho Araki, Minami Taniguchi. Writing: Naohiro Hohashi, Jaroensuk Pinyo, Shiho Araki, and Minami Taniguchi. Manuscript revisions: Naohiro Hohashi. --- CONFLICT OF INTEREST The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

impacts not only on the health of individuals, but also on family functioning and a family's well-being. Japan's remote outer islands, with their aging populations, harbor a unique culture, and it is believed that the COVID-19 pandemic has impacted on such populations in a distinct manner. This study aims to clarify the impacts of COVID-19 on families with older adults residing on remote islands, using the Concentric Sphere Family Environment Theory (CSFET) as a theoretical framework. We conducted family ethnographic research including semi-structured interviews with 14 families on Japanese islands whose total population numbers approximately 34,000, and performed directed content analysis of impacts on the families using CSFET. Forty-three categories were extracted according to the five systems of the CSFET. For example, negative impacts such as "occurrence of concerns over the scarcity of medical institutions" in the macro system; positive impacts such as "growing consideration of the life span of older adult family members" in the chrono system; and context-sensitive impacts such as "changes in family's awareness of infections arising from the contents of information on infectious diseases" in the macro system were identified. The islands' characteristics, such as vulnerabilities in terms of medical care, isolated environment and strong community ties, were considered as impacting both within and outside of the family. Accordingly families with older adults experienced negative impacts, but also found positive impacts in their difficulties.

Introduction: Sexual harassment is a pervasive issue that affects individuals across various settings, including workplaces, educational institutions, public spaces, and even online platforms. It manifests as unwanted advances, verbal abuse, physical contact, or any other behavior that creates a hostile environment and violates the dignity and rights of the survivor. In the face of this distressing social problem, social workers have emerged as key players in providing support, empowerment, advocacy, and healing to survivors. This article explores the vital role of social work interventions in addressing sexual harassment, highlighting the approaches used to empower survivors, advocate for change, and facilitate healing processes. --- About Sexual Harassment; Sexual harassment is a distressing form of misconduct and abuse that involves unwelcome sexual advances, comments, or actions directed towards an individual without their consent. It occurs across various contexts, such as workplaces, educational institutions, public spaces, and online platforms. The behavior can range from subtle and implicit to overt and explicit, but the common thread is that it violates the survivor's dignity and personal boundaries, leaving them feeling violated, humiliated, and unsafe. In the workplace, sexual harassment may manifest through inappropriate jokes, unwarranted touching, lewd comments, or persistent requests for sexual favors. This hostile behavior creates an uncomfortable and toxic environment, affecting the survivor's emotional well-being and often causing them to fear for their job security if they speak out. In educational settings, sexual harassment can occur between students, teachers, or staff members. It may involve spreading rumors, making derogatory comments, or engaging in non-consensual physical contact. These actions significantly disrupt the survivor's learning experience and may lead to feelings of shame and isolation. Sexual harassment can also manifest in public spaces, where strangers or acquaintances may subject individuals to unwanted attention, catcalling, or sexual gestures. These incidents can make individuals feel vulnerable and unsafe in places where they should feel secure. With the rise of technology, sexual harassment has extended its reach to online platforms. Cyberbullying, non-consensual sharing of explicit content, and online stalking are forms of harassment that can have severe psychological and emotional consequences for the survivor. It is important to note that sexual harassment is not about attraction or flirtation; instead, it is an abuse of power and a violation of a person's autonomy and consent. It perpetuates a culture of disrespect, inequality, and gender-based violence, reinforcing harmful stereotypes and inhibiting individuals from reaching their full potential. Addressing sexual harassment requires a multifaceted approach, involving education, policy changes, and support systems. Empowering survivors, raising awareness, and holding perpetrators accountable are vital steps in creating a society that values respect, consent, and dignity for all individuals, irrespective of their gender or identity. --- Social Work Interventions in Addressing Sexual Harassment; 1. Understanding the Impact of Sexual Harassment: Before delving into social work interventions, it is essential to comprehend the far-reaching consequences of sexual harassment on survivors. Victims often experience emotional distress, anxiety, depression, and a loss of self-esteem. These experiences may extend to their personal and professional lives, affecting their overall well-being and productivity. --- Empowerment through Trauma-Informed Care: Empowering survivors of sexual harassment is at the core of social work interventions. Social workers adopt a trauma-informed approach to care, recognizing the individual's strengths and resilience while acknowledging the trauma they have experienced. By providing a safe and supportive environment, social workers enable survivors to regain a sense of control over their lives and make informed decisions about their healing journey. --- Advocating for Policy Changes and Legal Support: Social workers play a crucial role in advocating for policy changes that address sexual harassment at systemic levels. They collaborate with policymakers, non-governmental organizations, and other stakeholders to develop comprehensive policies and legislation aimed at preventing and responding to such incidents effectively. Additionally, social workers provide survivors with information and support regarding legal avenues available to seek justice and redress. --- Community Awareness and Education: To combat sexual harassment effectively, social workers engage in community awareness and education initiatives. They conduct workshops, seminars, and training sessions to raise awareness about the issue, its impact, and ways to prevent and respond to incidents. By educating the public, social workers work towards creating a culture of respect and empathy, challenging harmful attitudes and behaviors. --- Healing and Support Services: Healing from the trauma of sexual harassment requires a supportive network. Social workers connect survivors with support services, such as counseling, therapy, and support groups. These resources aid survivors in processing their experiences, coping with emotions, and developing strategies for moving forward positively. --- Online and Digital Support: As sexual harassment has extended its reach into the digital realm, social workers have adapted their interventions to address online harassment and cyberbullying. They provide online support services, educate about digital safety, and advocate for better policies to combat cyber harassment effectively. --- Conclusion: Social work interventions in addressing sexual harassment are multifaceted, encompassing empowerment, advocacy, and healing. By providing trauma-informed care, advocating for policy changes, raising awareness, and offering support services, social workers play a critical role in assisting survivors on their path to healing and recovery. Moreover, their efforts contribute to creating a more inclusive and respectful society that challenges the perpetuation of sexual harassment. Through the collaborative efforts of social workers, survivors, communities, and policymakers, the fight against sexual harassment can be strengthened, fostering a safer and more equitable environment for everyone.

This article explores the crucial role of social work in addressing sexual harassment, a pervasive social issue with far-reaching consequences for individuals and communities. Drawing on recent research and case studies, the article highlights how social workers play a vital role in empowering survivors, advocating for change, and facilitating healing processes. By providing a comprehensive framework for intervention, social workers work towards creating safer environments, fostering awareness, and promoting social justice to combat sexual harassment effectively.

INTRODUCTION Theoretical and conceptual views on social reforms in the PRC, methodological foundations of reforms, political and ideological evolution in connection with processes have been scientifically researched. The following three periods related to the westernization of the Ching Empire are indicated in the scientific studies of the problem: the first period is the "Politics of Internal Tension" and the period of westernization (1860-1894), in which the desire to own Western weapons and equipment became the main trend; In the second period, attention was mainly focused on socio-political institutional changes (1895)(1896)(1897)(1898)(1899)(1900)(1901)(1902)(1903)(1904)(1905)(1906)(1907)(1908)(1909)(1910)(1911)(1912); the third period entered history as a movement for a new culture (1915)(1916)(1917)(1918)(1919)(1920)(1921). It emphasizes the importance of culture in changing China. However, these attempts were not effective due to various factors. It was the result of the unwillingness of China's ruling elite to accept the expected changes, the conflict of territorial interests of China's main rivals, the United States, Russia, and Japan, and finally, internal disarray, the lack of discipline of the central government, and disagreements among local leading reformers. However, those paths that have been traveled will become a decisive factor for the sociopolitical thinking of the Chinese society and the intelligentsia of the intention to build a new state. --- Research The collapse of the empire, the establishment of the Republic of China, and then the People's Republic of China at the beginning of the 20th century served as a unique foundational experience for the reformation of the ruling political powers. The influence of the Christian missionary on the world view of the Chinese leadership, intelligentsia, society, education of youth and training of modern personnel has gained significant importance. The second period of large-scale reforms is characterized by the establishment of the People's Republic of China. In essence, this period has two stages: the first stage is characterized by Mao Zedong's comprehensive reforms in the fields of political system, ideology, national economy, culture, education, foreign policy and their results related to the construction of the modern Chinese state and its development; the second stage is related to Deng Xiaoping's "open door policy", and at this stage, the "four modernizations" and the purposeful reforms based on the "four principles" in ideology, which were designed to bring the society out of the social crisis, showed their results. In fact, the PRC's forty-year reform experience and the scale of achievements achieved by the Chinese people in this process, as well as the ways and methods of implementation, have an irreversible character in world development. The chapter draws as much as possible from research on reforms abroad and in the PRC itself, so far there is a misunderstanding among non-Chinese audiences about China's successful development and promising development. Prescriptive theories take precedence over interpretations of the Chinese way. They are among the problems that overshadow the formation of a healthy environment in the PRC's relations with the world. The theoretical views of the PRC reforms by the Soviet-Russian school of sinology show that serious steps were taken in the path of reforms in the PRC in the first decades of the 21st century, and the Chinese reforms are shown as an example for development today. Research on the study of PRC reforms has been carried out by Yu Jiangjun, Mao Zedong, Zhang Weiwei, Yu Keping, Wang Huning, Li Chan'yu and Huang Jingfu, Chen Jinpei, Chen Jiagui, Lin Ifular. This research sheds light on the criticisms being made by Western schools of reform. In them, in the analysis based on the standards of traditionality and modernity, it is clearly visible that they do not deviate from their practice and that every new idea is closely related to social development in the search for the national-based aspects of the reforms. It is known that in the western society, free thinking is practiced, but in China, the weighing of thoughts is respected in the form of moral values. The split of culture will lead to the derailment of economy and politics, ideology is a difficult process for the society, and only the self-aware people will be able to act based on their national interests. The fact that the leadership of the People's Republic of China is implementing large-scale reforms based on this idea, and that the implementation of reforms based on historical experiences is a force that determines the strategy of According to the plan, the PRC should achieve leadership in the following areas: robotic technologies; new generation information technologies; aviation and space equipment; marine equipment and high-tech ships; railway transport; new energy-carrying and energy-saving vehicles; energy equipment; agricultural equipment; new materials; high-tech equipment for biopharma and medicine; China's sputnik (satellite) grouping; creation of high-speed trains is among them. China aims to lead not only in production, but also in creation. Therefore, a logical question arises as to which aspects of the reforms in the PRC are scientifically important to study. In this regard, the following three aspects of the issue are considered important: firstly, China's existing capabilities and uniqueness in terms of strategic development, attempts to make good use of the experiences of Western countries in defining the strategy of reforms in the PRC; the second, the transition processes of the PRC to the market economy; third, the implementation of PRC reforms in harmony with national values, on the basis of ensuring stability. This long-term reform led to the growth of the PRC's "image" in the outside world. A two-stage plan for the period from 2020 to the middle of the 21st century has been developed, taking into account the comprehensive assessment of the international and domestic situation and the conditions of China's development. According to him, socialist modernization is the basis of the average welfare society established during fifteen years of mobilization (2020-2035). In the next fifteen years (from 2035 to the middle of the 21st century), it is planned to transform China into a rich and powerful, democratic, highly civilized, harmonious and beautiful modernized powerful socialist state. --- CONCLUSION As a result of the analysis, the reforms of the People's Republic of China continue to develop gradually after passing the tests of time; that modern China is attracting the interest of many countries with its reform experience, that President Xi Jinping is taking steps to implement the "four modernizations" based on the ideas of the "four principles" developed by Deng Xiaoping of the Communist Party of China today; it was concluded that the strategy of reforms is being determined taking into account the socio-political trends occurring in the world during the renewal period.

The article is devoted to the study of China's development in the first half of the 19th and 20th centuries. China's confrontation with Western culture, which is more advanced than itself in the social and cultural spheres, from the 19th century, the reasons for China's involvement in the world economy, the gradual development of Chinese reforms, etc., are discussed.

Since the 1970s, providers and researchers have documented high levels of unmet health needs among the 6 million children referred to child welfare agencies annually. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] Mental health (MH) problems are identified in 23% to 80% of children, chronic health problems in 35% to 80%, growth abnormalities in up to 43%, and educational challenges in 31% to 67%. 2,3,9,[11][12][13]15 Although these problems have long been recognized, the documentation of their MH service use and its predictors is relatively recent. 18 Early information about service use came from multiple sources. 18 Medicaid analyses showed that children in foster care had higher MH services use compared with other Medicaidsupported children and that usage was related to sociodemographic characteristics and physical health status. [19][20][21][22][23][24] Single-site studies demonstrated that age, race/ethnicity, and need were usually positively associated with use. [25][26][27] San Diego-based studies found that abuse type, race/ethnicity, age, and need were related to services use. [28][29][30][31] These studies documented that need and non-need factors are related to use. The National Survey of Child and Adolescent Well-being (NSCAW I) allowed the first examination of need forand use of MH services in a nationally representative sample of children investigated by child welfare agencies. Analyses showed high MH need at entrance into child welfare (47.9%) but less service use (24.4%). 32 Longitudinal analyses established that age, race/ethnicity, placement type, and consistency of service use are all positively related to continued service use. Being reported to child welfare greatly increased the likelihood of receiving some type of MH services, although these services may be suboptimal. 18,26,[33][34][35][36][37] Much has changed since NSCAW I began in 1999. Professional groups concerned with the needs of vulnerable children and multidisciplinary groups of experts have continued to advocate quality standards for screening, assessment, and treatment. 38 The Council on Accreditation and the Child and Family Services Reviews have mandated attention to child well-being, including assessments and services. [39][40][41] Advocacy groups have brought class action lawsuits against child welfare systems in more than 32 states with settlements requiring that states implement actions in 30. Approximately 70% of the settlements require provision of services, including MH services. 42 These pushes for additional services occurred during a period of deep economic recession. Unemployment more than doubled nationally from a low of 4.6% in 2007 to 9% in 2011, diminishing states' tax revenues. 43 States cut budgets by an average of 4% in 2009 and almost 7% in 2010. 44 Since 2008, more than 45 states have reduced services including health care programs like Medicaid (31 states) and services to the disabled (29 states). 45 It is unclear what the current MH services use is for children investigated by child welfare agencies, how use is related to MH needs, and whether factors previously related to use remain important. The analyses reported in this article address these issues and compare predictors of MH services use and rates of use at 18 months post baseline between NSCAW I and the second National Survey of Child and Adolescent Well-being (NSCAW II). --- METHODS --- Design and Analytic Sample Data came from NSCAW II, a longitudinal study of 5872 youth ages 0 to 17.5 years referred to US child welfare agencies for whom an investigation of maltreatment was completed between February 2008 and April 2009. Excluded from the study were agencies in states that required first contact of caregivers by agency staff rather than study staff. 46 Initial interviews were collected within ∼4 months of completed investigations. NSCAW II, like its predecessor NSCAW I, used a national probability sampling strategy to select primary sampling units (PSUs), typically counties, from which the sample was drawn. --- Survey Design and Assessment Procedures --- Analysis Weights Analysis weights were constructed in stages corresponding to the stage of the sample design, accounting for the probability of county selection and of each child' s selection within a county. Weights were further adjusted for more or fewer population members than expected in the sampling frame, small deviations from the original plan that occurred during sampling, nonresponse patterns, and replacement PSUs. All analyses use weighting, and weighted estimates (ie, means, percentages) represent the US child welfare population. --- Measures Sociodemographics included child' s age, sex, race/ethnicity, insurance status, and placement-related information. The Vineland Adaptive Behavior Scale Screener measures personal and social skills with 4 age-specific versions consisting of 15 items in each domain. NSCAW II includes daily living skills and socialization domains. 47 Chronic conditions is a dichotomous measure indicating whether caregivers endorsed any of 9 chronic physical health problems (ie, AIDS, asthma, autism, Down syndrome, developmental delay, diabetes, cystic fibrosis, cerebral palsy, and muscular dystrophy). Family Risk Score is constructed from caseworkers' interviews at baseline. A cumulative risk score was based on the sum of 14 risk assessment items (scored 1 if present, 0 otherwise) that were part of the NSCAW I risk assessment. Child Behavior Checklist (CBCL) version 1.5-5 was administered to caregivers of young children and the CBCL 6-18 was administered to caregivers of older children. The CBCL was "designed to provide standardized descriptions of behaviors rather than diagnostic inferences." A score of $64 is considered clinically significant. 48,49 Outcome Variable: Use of MH Services Current caregivers detailed children' s MH services by using an adapted version of the Child and Adolescent Services Assessment, 50 focusing on 3 classes of services: Specialty MH services (outpatient and inpatient), school-based services, and medical MH services. 18 Children were characterized with regard to whether they had received any MH service at the time of investigation and between the baseline and 18-month interviews. At baseline, caregivers who lived with the child since birth were asked about services received "ever" and "in the last 12 months," whereas those who lived with the child for 12 months were asked about services in the last 12 months. Caregivers who lived with a child for ,12 months or those of infants ,12 months of age were asked about services "since start of living arrangements" or "since birth." The services data were augmented with reports of MH services from caseworker interviews and, at the 18-month follow-up, from interviews with children $11 years old. Changes in the structure of questions about services occurred in response to concerns that NSCAW I caregivers were asked to report on services use for periods when they had not been living with the child. Given differences in the services questions between NSCAW I and NSCAW II, rates of services use at baseline are not directly comparable. --- Analyses Descriptive statistics summarize key variables. Models predicting MH service use employ logistic regression and were tested in stages. Except where noted, significant bivariate predictors (P , .05) were included in multivariate models. Model stages included variables related to the child and the type of maltreatment, and then the family risk score. All analyses were conducted by using SAS-Callable SUDAAN version 10.0.1 (SAS Institute Inc, Cary, NC). --- RESULTS One-third of the sample was 2 to 5 years old (33.7%), half was female (50.2%), just over 50% was either black (21.8%) or Hispanic (29.3%), and 72.7% was insured by Medicaid (Table 1). Most children were in their biological homes with (22.5%) or without child welfare services (64%). Only 13.5% lived in an out-of-home placement. Many lived in families experiencing considerable psychosocial risk (33.2%, 2-3 risks; 28.4%, 4 or more risks). Children were most often placed out-of-home for supervisory neglect (25%) or other types of maltreatment (35.5%), and 61.8% of these children had a previous maltreatment report. More than 20% had one of the chronic physical conditions; 36.2% scored in the moderate to severe problem range on the Vineland Daily Living Skills and 46.3% in this range for 18 As in NSCAW I, the rates of service use were largely consistent with levels of need; however, rates of service use were considerably lower than need among the youngest children 51 and increased substantially between baseline and 18 months for children ages 2 to 5 years old. We suspect that involvement in other service sectors (eg, school, primary care) contributes to the substantial increases in service use rates among these children as their needs come to the attention of other care providers. 18 Support for the role of alternate care providers in recognizing need is provided by the relationship of chronic physical conditions and service use among young children. The increased likelihood of contact with medical care providers because of a chronic physical condition may increase the identification of and referral for emotional and behavioral concerns. Similar identification and referral may happen as children enter school. Children placed out-of-home had a higher probability of use of MH services than those remaining at home. These results are consistent with analyses of NSCAW I, which established that child welfare contact acts as a gateway to MH services for children placed out-ofhome, but not as strongly for the many children who remain in their homes subsequent to a maltreatment investigation. The high rates of socialization difficulties among children in NSCAW II suggest that children from families at risk for child welfare involvement often experience emotional/behavioral and relational difficulties. Among adolescents, use of MH services is also driven by multiple family risk factors. These associations might be a result of adolescents more actively seeking to address issues that affect their own MH in complex family environments, or a result of increased help-seeking among families with more risks. Whatever the reasons, NSCAW II clearly shows an increase in the connection between MH service use and the complexity of family issues as children age. One important non-need-related finding, also observed in NSCAW I, is the lower rate of service use among nonwhite children. Among 2-to 10-year-old children, rates of service use by children from other race/ethnic groups is significantly lower than among white children. Previous studies have documented low rates of MH and developmental service use among nonwhite children, especially during early childhood. 18,29,30 --- Dr Horwitz conceptualized the study, constructed the analysis and interpreted the data, drafted the initial manuscript, reviewed and revised the manuscript, and approved the final manuscript as submitted; Dr Hurlburt conceptualized the study, assisted with the analysis and interpreted the data, reviewed and revised the manuscript, and approved the final manuscript as submitted; Dr Goldhaber-Fiebert interpreted the data, drafted portions of the initial manuscript, reviewed and revised the manuscript, and approved the final manuscript as submitted; Dr Heneghan interpreted the data, critically reviewed and revised the manuscript, and approved the final manuscript as submitted; Ms Zhang analyzed and interpreted the data, critically reviewed and revised the manuscript, and approved the final manuscript as submitted; Ms Rolls-Reutz interpreted the data, critically reviewed and revised the manuscript, and approved the final manuscript as submitted; Ms Fisher interpreted the data, critically reviewed and revised the manuscript, and approved the final manuscript as submitted; Dr. Landsverk conceptualized the study, critically revised the manuscript for important intellectual content, and approved the final manuscript as submitted; and Dr Stein interpreted the data, critically reviewed and revised the manuscript, and approved the final manuscript as submitted.

Children investigated for alleged maltreatment have considerable physical, mental health (MH), developmental, and educational needs and often do not receive services to address these needs. The prevalence/ correlates of MH services use in the current challenging financial environment is unknown.This study demonstrates the importance of medical providers and schools for receipt of MH services for these children, but shows disparities in MH service use between white and nonwhite children. Unlike earlier findings, MH service use declined over the follow-up.

METHODOLOGY: The present study has been undertaken to assess the knowledge of adults regarding mental illness. --- Research Approach: The investigator has adopted the quantitative descriptive survey approach to assess the knowledge of adults regarding mental illness. --- Research Design: The research design selected for the study is non experimental descriptive research design. --- Setting of the Study: The study was conducted in gomti nagar at Lucknow Sample and sample size: A sample is a selected proportion or a subset of units which comprise the population. The sample for the present study included 120 adults of selected area at Lucknow Sampling Technique: Non probability purposive sampling technique was used to select the sample according to the purpose of study. Sampling Criteria: (a) Inclusion Criteria: 1. Adults of selected area at Lucknow 2. Adults who are willing to participate in the study. (b) Exclusion Criteria: 1. Who are not available during the period of data collection? 2. Adults who are mentally and physically ill. --- Description of the Tool: The tool for data collection comprised of three sections. Section A: Demographic data consisting of 12 items seeking information about the baseline data such as age, gender, religion, residential area, type of family, occupation, monthly income of the family, source of information about mental illness and any known person mentally ill. Section B: Consisted of 30 items on knowledge about mental illness like meaning of mental illness, its causes, symptoms and treatment. In knowledge aspect the items were objective type with choosing the most appropriate response for each item. The correct answer was given a score of 'one' and wrong answer 'zero' Data Collection Method: Permission was obtained from the leader to conduct the study. The investigator personally visited each respondent and introduction about the investigator and the purpose of the study was given, and nature of the study was briefly explained. The questionnaire was administered after getting the respondent's consent. Hypothesis is tested at 0.05 level of significance. --- Plan for Data Analysis and Interpretation The data collected has been analysed by using the descriptive method and inferential statistics. The plan for data analysis is as followed by the Percentage, Mean and standard deviation to assess the existing knowledge. --- RESULTS: The data obtained was analyzed in terms of the objectives of the study using descriptive and inferential statistics. Experts in the field of nursing and statistics directed the development of data analysis plan which is as follows: a) Organizing data on a master sheet. b) Tabulation of the data in terms of frequencies, percentage, to describe the data. --- Description of demographic variables of students: Result shows that the majority of respondents 40% belonged to the age group of 21-30 years whereas 38% belonged to 31-40 years and 22% adults belonged to 41-50 years. With regard to gender, majority of respondents 53% were female and 47% were male Most the adults 64% belonged to Hindu religion, 10% belonged to Muslim, 9% were Christians and others religion 17%. The majority of adults are 77% married, 23% unmarried. The majority 76% of adults were from joint family and 34% from nuclear family the majority of education of adult's 35% secondary, 34% primary, 18% higher education, 12% graduation and 1% uneducated. The majority of adults had business 35%, agriculture 34%, govt. service 17%, private service 13% and only 1% was unemployed. All of adults were residing staying in selected area. Majority 65% of adults family income was below Rs. 10,000, 27% in 10,000-20,000 and that of 8% was above Rs. 20,000 rupees per month --- C S The Genesis ISSN 2395-2164 Volume: 6 Issue: 2 April -June -2019 Majority of the adults 58% had get information from radio/television, 23% had get information from mass media, 9% had get information from newspaper, 5% had get information from books, 2% had get information from health education programme, and 3% had get information from others. Majority 93% of adults were not having mentally ill person in their family and 7% of them having mentally ill person in their family. Majority 56% of adults were seen mentally ill person and 44% not seen mentally ill person in their community Assessment of the Knowledge related to mental illness among students. The knowledge related to mental illness among of adults was assessed using structured knowledge questionnaire. Section A: Analysis of the Knowledge related to mental illness among students. In order to assess the knowledge related to mental illness among of students, percentage scores were graded arbitrarily as follows: poor ≤ 10%, average 11-20%, good 21-30% and very good 31-40. The knowledge of mental illness among adults was found 40% good knowledge, average knowledge among 26% adults, very good knowledge among 44% adults and no one with poor knowledge Association between knowledge scores with selected demographic variables regarding mental illness among adults. The knowledge of mental illness among adults was found 40% good knowledge, average knowledge among 26% adults, very good knowledge among 44% adults and no one with poor knowledge. Chi-square values indicate a significant association between the knowledge scores of adults with income i.e. calculated value 14.861 is more than table value 9.51 at 0.05 levels). But there is no significant association between the knowledge scores of adults and other demographic variables such as age, gender, religion, marital status, type of family, education, occupation, any mentally ill person in family, seen any mentally ill person in community and source of information regarding mentally illness. However, the above finding reveals that there was association between the knowledge scores of adults with income. So the hypothesis H 1 was accepted. --- CONCLUSION: The above finding reveals that there was association between the knowledge scores of adults with income. The further research related to mental illness needed to improve the awareness among the community RECOMMENDATIONS: --- C S The Genesis ISSN

Feeling stressed or having the blues is a normal response to the psychological or social challenges most people encounter at some time or another. Hence there is a need to assess the knowledge regarding mental illness in a selected area at Lucknow The objectives of the study are to assess the knowledge to assess the level of knowledge regarding mental illness among adults of Selected area and to find the association between knowledge scores regarding mental illness with selected demographic variables, on knowledge and attitude and also the correlation between knowledge and attitude scores of students among adults of selected area. The sample selected for the study includes 120 adults of selected area. Non-probability purposive sampling method was used. Data was collected by using structured knowledge questionnaire, based on demographic data, 30 items on knowledge. The knowledge of mental illness among adults was found 40% good knowledge, average knowledge among 26% adults, very good knowledge among 44% adults and no one with poor knowledge. Chi-square values indicate a significant association between the knowledge scores of adults with income i.e. calculated value 14.861 is more than table value 9.51 at 0.05 levels). . So enhancement in knowledge aspect is required.

cultural representations, and other norms work in various, often reinforcing ways to perpetuate racial group inequity" (Aspen Institute, n.p.). Structural racism is maintained through institutions. Libraries, as educational and cultural institutions, have been implicated in their role in maintaining structural racism in American society (ALA 2020). In the aftermath of the Floyd protests, the United Nations (U.N.) investigated police brutality and issued a report describing global human rights violations related to racism directed against people of African descent; they found systemic racism persisting in a culture of denial (Office of High Commissioner, United Nations Human Rights 2021). They made several recommendations to support transformative change: (1) ceasing denial of racism, (2) confronting past racist legacies, (3) dismantling systemically racist structures, and (4) attainment of reparatory justice. Library and Information Science associations have preemptively taken the first step recommended by the U.N., ceasing denial, and have issued various public statements admitting to their role in perpetuating racism (ALA 2020, PLA 2020); further actions by them leading to reparatory justice appear not to have been rigorously pursued. At the personal level and at the individual library level, more sustained work has been done. Within this context, a project to capture how LIS has promoted racial justice was conceived. Antiracist Library and Information Science: Racial Justice and Community (2023), a volume of critical, scholarly and reflective perspectives on the theory, practice and progress made towards the actualization of antiracism, edited by Kimberly Black and Bharat Mehra was published (Emerald Publishing). The volume consists of twenty chapters describing the theoretical foundations of antiracism in LIS, a discussion of the manifestations of racism in LIS and communities and strategies for actualizing an antiracist LIS. Contributors to the volume consist of noted and emerging LIS educators and scholars, librarians, and students who have a stake in the enterprise of racial justice. The editors and contributors to this volume would like to convene a public conversation about antiracism in LIS through a panel presentation and discussion. The goal of this proposed panel is to discuss the ideas presented in the book:  Confrontation of past legacies -discussion of theoretical and philosophical foundations of antiracism in LIS  Cessation of denial -discussion of the manifestations of racism in libraries, LIS associations and the profession itself  Dismantling structures/pursuit of racial justice -conversation about strategies for achieving antiracism in LIS The panel will consist of brief talks by authors about their chapters and breakout sessions designed to explore issues and develop solutions related to anti-racism in LIS. Kimberly Black will serve as panel moderator. The 90-minute session is organized as follows: By the conclusion of the panel, participants should walk away with a clearer understanding of how systemic racism is manifested in LIS as well effective strategies to support and enact antiracist practices and create racially just communities. --- Activity --- AUTHOR KEYWORDS --- Antiracism

Racial discrimination continues to be a feature of American life. In his 1881 essay, "The Color Line," Frederick Douglass describes the enduring strain of racial prejudice which he characterized as a "moral disorder" that "creates the conditions necessary to its own existence and fortifies itself by refusing all contradiction" (p. 567). W.E.B. Du Bois decried this moral disorder in The Souls of Black Folk where he famously asserted that "the problem of the Twentieth Century is the problem of the color-line" (n.p.). Despite the progress achieved through successive American racial justice movements (Abolitionism, Civil Rights Movement, Black Power Movement), the problematics of the color-line remain a defining feature of the twentyfirst century American experience. The murder of George Floyd at the hands of law enforcement in the summer of 2020 triggered mass outrage in communities across the U.S. (and the world) over the accretion of racially motivated acts of police brutality directed against individuals of African descent. Regardless of movements for social change, the U.S. has maintained a durable institutionalized and systemic structure of racial inequality -a society characterized by structural racism. Structural systemic racism is "a system in which public policies, institutional practices,

of the iceberg. Equally important are the covert manifestations of racism and bias in society and in institutions, such as white silence, denial of institutional racism, fear of people of color, and microaggressions. Indeed, these latter realities negatively affect education in the health professions, learning and work environments, the well-being of students, trainees, and colleagues, and the health of the community. Disparities in the infection and death rates due to coronavirus disease 2019 provide a current example of the interaction between structural racism, social risk factors, and inequities in health care access and quality that affect the health of Black people in the US. Structural racism encompasses the sum of the ways in which societies perpetuate racial discrimination through mutually reinforcing systems. Although racial injustice and discrimination are not new, after recent egregious incidents, many organizations issued calls to action with an eye toward addressing racism and discriminatory practices in medicine and science. Antiracism practice and training are recommended to address racism and bias and advance health equity. It is essential to respond to the moral imperative of mitigating the effects of racism, discrimination, and bias in medicine. The latter compromises the ability of health care professionals to fulfill their oaths and ethical responsibilities to treat patients, student, trainees, and colleagues with respect, justice, and equity. It is time to take bold, but measured, steps to bring antiracism training to fruition and begin to unravel the pernicious effects of systemic racism in the nation's medical schools, academic medical centers, and teaching hospitals. There also must be a commitment to move the needle by making real advances and not be satisfied with just undertaking a few time-limited, box-checking training activities that result in no improvement in antiracism competencies or in institutional measures of inclusion, equity, or health outcomes. There are several recommended strategies that medical schools, academic medical centers, and is required, not optional. Because antiracist training will be required for stakeholders from all mission areas, it must be designed with broad relevance in mind. Second, establishing a steering committee composed of institutional leaders, faculty, staff, and students and trainees to oversee and direct antiracist training initiatives is essential for success. Institutional transformation requires leadership and stakeholder engagement, sustained institutional commitment, as well as resource and incentive allocation. The diverse composition of the committee blends strengths from leadership and grassroots perspectives. It must also rely on data-driven methods to identify and monitor evidence of disparities, inequities, and bias across the institution. In so doing, the steering committee will be in a position to recommend appropriate administrative, process, or training interventions to drive improvement. Third, building an antiracism vocabulary with a glossary of terms and references is needed to create a common language with an eye toward promoting precision and consistency in communication. A common vocabulary will also promote the cultivation of a shared cognitive model by providing stakeholders with common terminology and constructs. A fourth strategy of developing a longitudinal antiracist training curriculum marked by an iterative approach supports continuous quality improvement of curricula as well as meeting stakeholder needs. Using a longitudinal approach also permits the periodic reinforcement of core A sixth strategy involves medical schools, academic medical centers, and teaching hospitals. These institutions should develop external partnerships to build trust with vulnerable communities and community organizations. Establishing an external review process will further enhance the effectiveness of antiracist training initiatives and responsiveness to community needs and concerns. Partnerships with professional associations and societies can also facilitate advocacy for the standardization of antiracism competencies and the incorporation thereof into Entrustable Professional Activities-activities that all medical students should be able to perform upon entering residency-or accreditation standards. The ability of physicians to fulfill their oaths, create inclusive learning and work environments, provide bias-free education, and deliver quality care that reduces health care disparities is undermined by bias, discrimination, racism, and systems of oppression in medicine and science. Commitment to advancing antiracism training is essential for deconstructing the effects of these pernicious elements and improve health equity. --- ARTICLE INFORMATION Open Access: This is an open access article distributed under the terms of the CC-BY License. Corresponding Author: Eli Y. Adashi, MD, MS, Brown University, 272 George St, Providence, RI 02906 (eli_adashi @brown.edu). Author Affiliations: College of Medicine, Baylor University, Houston, Texas (Monroe); Cullen Trust for Higher Education, Houston, Texas (Monroe); Medical College of Georgia, Augusta University, Augusta (Sturgis); Warren Alpert Medical School, Brown University, Providence, Rhode Island (Adashi). --- Conflict of Interest Disclosures: Dr Adashi reported receiving personal fees from Ohana Biosciences Inc. No other disclosures were reported.

Racism and bias are antithetical to the oaths, moral commitments, and ethical responsibilities upheld by health professionals who are dedicated to the missions of medicine. Accordingly, educators, healers, and role models for the next generation of physicians must redouble their efforts to work alongside leaders at medical schools, academic health centers, and teaching hospitals to address racism, bias, and other factors that negatively affect the health and well-being of students and trainees, colleagues, patients, and communities. The horrific deaths of numerous unarmed Black people-such as the killing of George Floyd in May 2020-highlight the twin traumas of racism and police brutality that affect the lives of Black people in the US. Overt acts of racism such as violence and public harassment constitute only the tip

Introduction I have personally been pressured to behave and dress in more traditionally feminine ways by my mother and sisters. This often goes against my nerdy, tomboyish nature, especially since I do not enjoy wearing things like earrings, high-heels, (most) bright colors, or frilly clothesthe types of things that are equated to femininity. I also do not often act as elegant or passive as my mother would prefer, but rather I am generally blunt, cynical, awkward, and geeky. These characteristics do not really fall under the clear-cut generalizations for females; they are somewhere in between male and female characteristics. Many people still stick to traditional ideas that men and women should behave in ways that fall into specific categories determined solely on their gender. However, male or female genderspecific identities are irrelevant in modern, civilized society. Gender roles are social constructs developed over time and are not based on natural human behavior. This is because gender roles evolved as a way to organize the necessary tasks done in early human society. Some may say that due to the fact that traditional gender roles have been practiced for so long, they should not be changed, and are now a key element in human development. Nevertheless, in many of the modern societies today, there is no need for traditional gender roles, because both men and women are able to do many of the same necessary tasks, thereby making gender-specific behaviors irrelevant. These stereotypes can be harmful because they motivate people to condemn and oppress those who do not fit the traditional gender roles. As a result of this oppression, many people struggle to reach their full potential. Therefore, it is critical that we encourage everyone to follow and express their own truth, regardless of gender norms, so that everyone is able to contribute fully to our society. Many of the gender stereotypes we know today were not always present in the past; they are relatively new trends in human society. This is because social expectations of each gender change over time, and often develop differently in cultures around the world. Sara Bobolts, a writer for The Huffington Post, stated how several common gender stereotypes changed over time. Bobolts describes how gender stereotypes, such as the color blue being for boys and the color pink being for girls, are new concepts. She explains that between the years 1918 and 1940, pink was viewed as a masculine color, while blue was seen dainty and soft, making it best suited for females. Bobolts also states that during the Middle Ages in Europe, high-heels were exclusively for men, rather than women. They were seen as a "sign of masculinity", depending on their height. This shows that the attributes people connect with "traditional" gender categories were very different only a few centuries ago, and cannot be used as a reliable basis for establishing roles today. A gender role, also known as a sex role, is a social role encompassing a range of behaviors and attitudes that are generally considered acceptable, appropriate, or desirable for a person based on that person's sex. Gender roles are usually centered on conceptions of masculinity and femininity, although there are exceptions and variations. Gender roles influence a wide range of human behavior, often including the clothing a person chooses to wear, the profession a person pursues, the personal relationships a person enters, and how they behave within those relationships. Although gender roles have evolved and expanded, they traditionally keep women in the "private" sphere, and men in the "public" sphere. --- Discussion:- This course serves as an introduction to research methods in the interdisciplinary study of gender and sexuality. We will explore a range of methods used in the qualitative social sciences and the humanities, including one-one-one interviewing, participant observation, focus groups, surveys, textual and content analysis, and archival analysis. We will discuss the relationship between research methods and other crucial aspects of research design, including formulating research questions, creating implementation plans, selecting sampling strategies, selecting analytical strategies, and writing up results. The course will include guest lectures by Gender & Sexuality Studies (GSS) faculty. We will examine the methodological sections of some of their work, as well as other key sources on GSS-related methods. Students are expected to do all assigned readings, attend class regularly, participate in class discussion, write short critical reviews and research proposal drafts, provide peer review comments, complete all readings and written assignments, receive peer review comments and incorporate them into their research proposals, and produce a complete research proposal for a planned GSS project. --- Conclusion In conclusion, gender roles tend to change over time. It is important for individuals to have a present that the world was not always as they know it today, and the future can be completely different. How the future may look depends on humanity and the way they think. In brief, roles for women and men will continue evolving.

A gender role, also known as a sex role, is a social role encompassing a range of behaviors and attitudes that are generally considered acceptable, appropriate, or desirable for a person based on that person's sex. Genders roles are culturally specific, and while most cultures distinguish only two (boy/man and girl/woman), others recognize more. Some non-Western societies have three genders: men, women, and a third gender. Buginese society has identified five genders. Androgyny has sometimes also been proposed as a third gender. An androgynies or androgynous person is someone with qualities pertaining to both the male and female gender. Some individuals identify with no gender at all. Gender role is not the same thing as gender identity, which refers to the internal sense of one's own gender, whether or not it aligns with categories offered by societal norms. The point at which these internalized gender identities become externalized into a set of expectations is the genesis of a gender role.

Sociocultural aspects of gerontology education have received growing attention in recent decades, as globalization and population aging resulted in more diverse older populations across global communities. Accordingly, gerontologists must equip with cultural and international competencies for their future careers, regardless of the fields, such as health care, long-term care, research, and education. This presentation outlines a development and case study (2023) of an international gerontology education course designed for graduate students in the U.S. After the preparation sessions, students take a faculty-led two-week trip to Japan, which is known as a super-aging society with nearly 30% of the population is age 65 years and older, and visit multiple aging-related sites including government agencies, research and education organizations, local communities, industries (e.g., robotics) and cutting-edge programs (e.g., health care research incubation program). The presentation offers three components. First, the academic objectives, such as the enhancement of cultural competencies and cross-national perspectives in gerontology, are described. Second, the practical course development process, including curriculum construction, planning trips, professional networking, student recruitment, funding source, coordination between two countries, and outcome assessment strategies, are illustrated. Finally, using the course evaluation data (n = 13 graduate students from 9 aging-related programs) and qualitative data (journals and field notes), positive outcomes (e.g., increased interest in working with socio-culturally diverse older adults) and challenges (e.g., funding international travel; scheduling difficulty; language barrier) are evaluated. Intergenerational learning strategies can increase wellness, both among students and older community members, while challenging ageism on college and university campuses. Still, existing studies on the mutual benefits and effectiveness of intergenerational learning strategies for addressing biases among college and university students are limited and as such, are continuing to emerge. Thus, a scoping review was conducted to explore current research on intergenerational learning in higher education, the potential relevance of such strategies to reduce ageism and better prepare future service providers, and to explore current implications for education, practice, policy, and research. Included in this scoping review were peer-reviewed and grey sources based on primary research on what is known about intergenerational learning strategies in higher education and their potential impacts on ageism. Excluded were sources not based on primary research or without clear implications for relevant education, practice, policy or research. In total, 313 articles were identified; 67 of these were screened in for full text reading, and 37 were initially screened in for analysis, after which another 8 were excluded, resulting in 29 cases for thematic analysis. Key themes surround intergenerational service learning and creative expression, attitudes toward older adults, perceptions

where residents can easily engage in community-based activities centered on self-help and mutual aid. It is an urgent task to create a place for activities such as lifelong education and multi-generational exchanges as well as to build a comprehensively integrated community care system that allows people to live with peace of mind when they need long-term care. Thinking about planning the 100-year life, the superaging society has had consequences for the healthcare and social care of older people in Japan, leading to societal innovations that promote health in older people. To extend the healthy life expectancy and achieve a bottom-up sense of community resilience and activity, an interdisciplinary gerontological collaboration with multi-stakeholders is indispensable, with collaborators such as municipal governments, industries, professional staffs, academic researchers (including universities, young career researchers, and students), and citizens. This session will introduce our efforts to promote gerontology education through redesigning the community with comprehensive knowledge.

Nevertheless, the ability of persons with disabilities to engage in sexual activity can to a great extent be altered by motor, sensory and autonomic dysfunction (Naphtali et al. 2009). Motor dysfunction may relate to the movement of arms and legs, sensory dysfunction to temperature and touch sensations, and autonomic dysfunction to the regulation of blood pressure. However, persons with disabilities have commonly reported that gaining or regaining sexual functioning is one of their priorities (Anderson 2004;Peta 2017a). A study carried out by Anderson (2004) in the United States revealed that recovering sexual function tops the list of priorities of persons with paraplegia. Whilst the disability movement prioritises issues such as housing and transportation, Waxman (1989:2) states that 'many people with disabilities consider sexuality to be an area of their greatest oppression: We are more concerned with being loved and finding sexual fulfilment than getting on a bus'. The irony of the matter is that compared to other rehabilitative spheres, such as occupational therapy and physiotherapy, sexual rehabilitation receives the least attention, yet a part of the United Nations Convention on the Rights of Persons with Disabilities in Article 26 (United Nations 2006), directs state parties to design and implement comprehensive rehabilitation services. Some scholars have noted that the subject of sexuality is regarded as a very sensitive topic which is difficult to discuss even among clinicians (Mall & Swartz 2012); it is therefore not surprising that the stakeholders who participated in the formulation of the APL may have found it difficult In 2016, the World Health Organization, through the Global Cooperation on Assistive Technology Initiative, issued the Priority Assistive Products List which is meant to be a guide to member states of the 50 assistive products needed for a basic health care and/or social welfare system; it is also a model from which nations can develop their national priority assistive products lists. The aim of this opinion paper is to share my views about the Priority Assistive Products List on the grounds that it makes no distinct mention of sexual assistive devices, yet research has indicated that sexuality is an area of great concern for persons with disabilities. In any case, sexuality forms a core part of being human, and it impacts on both the physical and mental well-being of all human beings. I conclude in part that, in its present format, the list perpetuates the myth that persons with disabilities are asexual beings who are innocent of sexual thoughts, feelings and experiences. The list also propagates the stereotype that sexuality is a sacred, private, bedroom matter that should be kept out of the public domain, to the detriment of the health and well-being of persons with disabilities. --- Deafening silence on a vital issue: The World Health Organization has ignored the sexuality of persons with disabilities --- Read online: Scan this QR code with your smart phone or mobile device to read online. http://www.ajod.org Open Access to advocate for the inclusion of sexual assistive devices. However, in this opinion paper, the subject of sexuality is closely linked to assistive devices; hence, the meaning of assistive devices is explained below. Under the WHO Global Cooperation on Assistive Technology (GATE) initiative, a list of 50 assistive products, namely, the APL was published. The main goal of the GATE project is to improve on the status quo, where currently only 1 person among 10 people of those in need is able to access assistive products. Assistive devices or assistive products are defined as: Any external product (including devices, equipment, instruments or software), especially produced or generally available, the primary purpose of which is to maintain or improve an individual's functioning and independence, and thereby promote their well-being. Assistive products are also used to prevent impairments and secondary health conditions. (WHO 2016:1) In line with the above definition, the significance of sexual assistive devices in preventing impairments and secondary health conditions as well as promoting the well-being of persons with disabilities is further discussed below. --- Ethical consideration The confidentiality and anonymity of persons who took part in other studies that were undertaken by the author of this opinion paper and that are referenced in this publication are upheld. --- The assistive products list is silent on sexual assistive devices The most common examples of assistive devices that have been identified by WHO include hearing aids, communication boards, wheelchairs, canes, prosthetic and orthotic devices, spectacles, low vision aids, portable ramps and incontinence products (absorbent) (AFRINEAD n.d.; WHO 2016). In Canada, Naphtali et al. (2009) illuminated examples of sexual assistive devices that may enhance the sexual expression of persons with disabilities; intimate riders, harnesses, leather cuffs, hands free kits, massagers and body bouncers. However, articulating a comprehensive list of such devices and the distinct ways in which they enhance the sexuality of persons with disabilities or promote their well-being would take this opinion paper beyond its requirements in terms of both scope and length. Nevertheless, the intimate rider, which was designed by an individual with C6-7 quadriplegia to facilitate varied positions of sexual activities (Naphtali et al. 2009), is an example of one of the sexual assistive devices that could have been included in the APL. The rider comprises accessible supports such as grab bars or counter tops; its use along with additional sexual assistive devices could promote the health and well-being of persons with disabilities as illustrated in the example below. A study carried out in Zimbabwe by Peta (2017a;2017b) revealed that women who acquire physical impairment in the course of their marriages, particularly spinal cordinduced impairment, are often deserted by their husbands who castigate them for the ways that disability alters their sexual expression, thereby withdrawing all forms of support that would have been extended to the wife before the 'arrival' of the disability. The result is untold anguish, which among other impairments results in the occurrence of psychosocial impairments that include bipolar affective disorder or the occurrence of disease and impairments among children. The women struggle to economically fend for themselves and their minor children, whilst at the same time making efforts to adjust to the social and sexual challenges that are brought about by disability (Peta 2017a;2017b). The use of the intimate rider and additional assistive sexual devices could reduce sexual frustration, save marriages and keep nuclear families together within contexts where healthy children are likely to be raised. Nevertheless, the omission of sexual assistive devices in the APL can be attributed to the fivestage strategy which guided the formulation of the APL (AFRINEAD n.d.), as further discussed below. The APL emerged from a scoping review, pilot survey, Delphi exercise, global survey and global consultation (AFRINEAD n.d.). The process was also guided by an initial proposed breakdown of 155 'important' assistive products that were from the onset solicited to fit in six pre-determined areas: (1) mobility, (2) vision, (3) hearing, (4) communication, (5) cognition and ( 6) environment. Sexuality could have been included as a seventh area, considering that all human beings including persons with disabilities are sexual beings; disability intersects with sexuality which needs to be supported by appropriate assistive sexual devices. That is not to dispute the fact that the APL is a guide, but it is to say that as evidenced by the earlier example of women with disabilities in Zimbabwe, a deafening silence about sexuality in such an original international list makes it easier to keep the subject of sexuality 'hidden' in subsequent national lists, thereby opening doors for sexuality to be used negatively in abuse, control, oppression, to cover up sexual scandals and to misinform one another (Interesting Interests 2009; Peta 2017a); disability adds a rung to the ladder of such vulnerabilities. In any case, some studies undertaken in both the Global North and the Global South have confirmed the need for people with disabilities to have appropriate sexual assistive devices that enable them to have a positive sexual life, which ultimately enhances their health and well-being (Mackelprang 2009;Naphtali et al. 2009;Peta 2017a;Taylor 2011). In the United States, Mackelprang (2009) points at vibrators and states that such sexual assistive devices are valuable because they enhance stimulation when there is reduced sensation and they can also be useful in instances where mobility is restricted. In the United Kingdom, Taylor (2011) calls upon occupational therapists to pay attention to the impact of assistive devices on sexual expression. A study carried out in Zimbabwe by Peta (2017aPeta ( , 2017b) ) revealed emotional distress among women with disabilities if something goes wrong http://www.ajod.org Open Access during intimate moments with their male partners, whilst the women are using inappropriate assistive devices or none at all owing to unavailability. The use of appropriate sexual assistive devices contributes to the promotion of safe sexual environments, safe sexual practices, keeping families together and the raising of healthy children whose survival, protection and development are prerequisites for future development and humanity. --- Conclusion There is need to bring the subject of sexuality into the discourse of assistive devices; persons with disabilities are not asexual beings. I therefore call upon the architects of the APL to come to terms with the fact that people with disabilities have a right to sexual expression, and as noted by Morris (2001) they should be allowed access to relevant entitlements (including sexual assistive devices), not only because they are human beings but also because they are equal citizens. The pledge that 'no one will be left behind' and that governments will endeavour to reach 'the furthest behind first' lies at the heart of the Sustainable Development Goals (SDGs) (United Nations Development Program 2018). To ensure that no one is left behind, architects of the APL should include sexual assistive devices that are not exclusionary but that embrace persons with disabilities of all sexual orientations, including lesbian, gay, bisexual, transgender and intersex (LGBT1). Perpetual failure to openly name assistive devices that enhance the sexual expression of persons with disabilities may result in the APL sending a potent message which may be misconstrued to mean that the subject is an unimportant side issue. Such distinct naming promises to go a long way in raising awareness of the sexual rights of persons with disabilities and to nurture receptiveness to their rights. Whether we like it or not, sexuality is a major rehabilitation priority for persons with disabilities; hence, it should be respected, celebrated and be openly talked about (Naphtali et al. 2009). Sustainable Development Goal Number 3 calls upon state parties to 'ensure healthy lives and promote wellbeing for all at all ages', but how can SDG Number 3 be attained if the APL maintains a deafening silence on assistive devices that are directly related to sexual rehabilitation? The open inclusion of sexual language in international policy documents, legal instruments and guidelines can go a long way in dismantling myths that surround the sexuality of persons with disabilities, thereby enhancing their quality of life, health and well-being. --- Acknowledgements --- Competing interests The author declares that she has no financial or personal relationships that may have inappropriately influenced her in writing this article.

Sexuality encompasses the total behaviour of who we are as human beings, from birth to death, including the growth of our bodies in relation to, among other things, puberty, menstruation and reproduction; it involves how a person feels about himself or herself, how he or she feels about others, as well as his or her interaction with society (Makinwa-Adebusoye & Tiemoko 2007). People may explore their bodies through masturbation or personal fantasies at the individual level, but they may still want to choose persons with whom they address their sexuality with. However, the World Health Organization (WHO) Assistive Products List (APL) is devoid of sexual assistive devices, thereby ignoring the sexuality of persons with disabilities and reducing complex beings to a single social life attribute of disability. Yet, the American Occupational Therapy Association asserts that sexuality is part of every person's life and therefore an activity of daily living along with eating, toileting and dressing (Naphtali, MacHattie & Elliott 2009); Gomez (2012) and McKenzie (2012) also assert that no human being is asexual.

Where do we start with prevention? Many would begin with adverse childhood experiences (ACEs). The original concept arose from a prospective study of childhood obesity, 4 but their wider predictive value merits study. Hughes et al 5 demonstrate increased relative risks in adults with four or more ACEs: doubled risks of heart disease (95% CI 1.66-2.59), alcohol misuse (1.74-2.78), and cancer (1.82-2.95); tripled rates of chest diseases (2.47-3.77) and anxiety (2.62-5.22); a four-fold increase in 'low life satisfaction' (3.72-5.10) and depression (3.54-5.46); and a 30-fold increased risk of a suicide attempt (14.73-61.67). For selective or targeted prevention, we look at the other end of the (shorter) life of someone with severe mental illness (SMI); 6 we might start with smoking, obesity, alcohol and substance misuse. All four shorten life expectancy and healthy years expectancy (life before multimorbidity begins) and make our task of improving quality of life in SMI even harder. Then there is a sixth area, fair access to medical care: current national strategies to improve physical health outcomes in people with SMI and treatment of all mental disorders focus on this. Older citizens, who began life as 'baby boomers', have acquired the nastier metaphor of a 'ticking time bomb' in terms of likely health and social care costs. The prevention of many dementias (vascular dementia, alcohol-related brain damage, head injury) is achievable. 7 Seven challenges then, maybe for seven Royal College of Psychiatrists-led intercollegiate Committees? No, there is a better way. Behind all seven of these, Michael Marmot's 'causes of the causes', prevention has one major focus: poverty-inequality. --- What are the consequences of poverty-inequality? 'Inequality exists in the stresses and strains on family life, which shape the environment in which children grow up. It is the divergence in life expectancy between deprived and affluent areas, and the growing burden of poor mental health among disadvantaged groups'. 8 In his accessible book, The Health Gap, Marmot 9 concludes that 'the (health) gradient involves everyone, rich, poor and in between' (p. 26). Poverty is not inevitable, and 'in the US, after transfers and taxes, child poverty is higher than Lithuania -23% compared with 15%despite having similar levels of poverty pre-tax' (p. 137). Life expectancy, and specifically why this is falling in the UK (and was falling before COVID-19) among older and poorer citizens, is key to understanding why we need fundamental change. Marteau and colleagues 10 studied the UK government's ambitions to reverse this rising mortality: 'the leading causes of years of life lost in England are tobacco use, unhealthy diet, alcohol consumption, and physical inactivity. All of these behaviours are socioeconomically patterned'. The scientific literature has reached a consensus on the health harms of poverty-inequality. In their study of multimorbidity in the ethnically diverse London borough of Lambeth (where a third of a million are registered with a general practitioner (GP)), Ashworth et al 11 concluded that: 'acquisition of multimorbidity is patterned by socioeconomic determinants', with depression and asthma as early drivers of poor physical health. The US and the UK have similar high levels of inequality, and their inhabitants can expect to lose 7-9 healthy years (free from physical disability) by the age of 50 if they are poor, compared with their fellow citizens at the least deprived end of the gradient. 12 All the evidence points to poor mental health, from common mental disorders through to SMI, as the means whereby poverty wrecks physical health. --- But rich people get mental disorders too Yes, they do. But they get better from depressive episodes faster and relapse less, in contrast to people on lower incomes, who have higher prevalence rates and worse outcomes. 13 We also concede that most people who grow up in poverty do not develop a life-changing episode of depression, let alone SMI. But the antecedents of SMI are complex, and our understanding of why people develop psychosis is changing, building on the seminal work of Jim Van Os on the toxic effects of urbanicity 14 with consistent evidence of the cumulative effects of social disadvantage. Work with case-control groups in south London showed odds ratios (ORs) for subsequent psychosis in people below the poverty line of 4.50 (95% CI 2.89-7.00) and 2.95 (1.89-4.61), for 1-year and 5-year pre-symptom onset, respectively. These ORs were the single highest predictors of psychosis, other than the related but confounded OR of 12.05 (7.13-20.35) for being unemployed on presentation to psychiatric services. 15 Outcomes in adults with first-episode psychosis are complex and improving slowly in our professional lifetimes (with adequately resourced early intervention services); even at 5-year follow-up, Mattsson et al 16 showed financial strain and social networks to be strong, independent predictors of outcomes. --- Lessons from history We cannot ignore poverty as a predisposing, precipitating and maintaining factor in most of our patients' disorders. Early in the neuroleptic era, we knew that poorer people had worse outcomes in schizophrenia, stayed in hospital longer, and were socially isolated even if they achieved discharge, 17 but our textbooks called this 'social drift' despite prior debunking of the drift hypothesis. 18 Hindsight is easy, certainly, but perhaps we should look to psychiatry's institutional bias. We still speak of a problem of stigma (negative societal attitudes) rather than acknowledging the reality that people with SMI have lower status conferred on them and face institutional obstacles to achieving their life goals, and calling this out as subcitizenship. 19 At the time we started writing this, we welcomed the stated intention of the UK government to reverse a decade of austerity, signalled first in October 2018 20 and often repeated during the first weeks of the spring 2020 lockdown. In advocating a broader role for busy psychiatrists in opposing regressive social policies, we are echoing the 'wake-up call' to colleagues from 2008: '[it is] fully consistent . . . to think of psychiatry as being the only specialty in which its practitioners are fully trained doctors, incorporating psychology and socialbased knowledge and skills as major components of training'. 21 Not 'social workers with stethoscopes' but clinicians with public health knowledge who understand the environments in which our patients live. And die. --- What we know about the effects of COVID-19 (so far) COVID-19 has changed how every health professional practises. Each health specialty must play its part in mitigating and preventing further adverse outcomes. The virus leaves a trail of delirium, depression and anxiety, perhaps posttraumatic stress disorder in those who survive, 22 and further misery for those bereaved. COVID-19 has revealed and exacerbated inequalities. Examination of death rates in the first 20 283 hospital deaths with proven COVID-19 in England and Wales shows major differences between the richest and poorest regions: 'people living in more deprived areas [for example, the London boroughs of Newham and Brent, in the context of an early first peak in London] have experienced COVID-19 mortality rates more than double those living in less deprived areas. General mortality rates are normally higher in more deprived areas, but so far COVID-19 appears to be taking them higher still'. 23 At the time of writing, recording of the proportions of deaths among Black, Asian and minority ethnic (BAME) groups was incomplete, but preliminary figures, not least those for deaths among our BAME colleagues working in health and social care, have shown an excess. Health gradient differences are among the lessons of the pandemic: the age-standardised mortality rate of deaths involving COVID-19 in the most deprived areas across England was 55.1 deaths per 100 000 population, compared with 25.3 deaths per 100 000 population in the least deprived areas. 23 We have yet to learn the full extent of excess deaths from COVID-19 among our patients across age groups, regions and specialties. It is too late for them, but we will not dodge the hard questions. As mental health professionals, we cannot remain as observers; we must now act on poverty-inequality. --- Solutions in this issue This issue opens with a contribution from two people with lived experience of SMI. Smoking remains a challenge in mental health services, and you will read about tobacco poverty and how to achieve more 'quits'. Housing First shows the evidence for changing how we approach this issue. We feature the Glasgow perspective on how we might progress, as well as an article on the cruelty of 'reforms' to the safety net benefits system. There is a biomedical perspective too. --- What have we left out? To name just five areas, we have not raised here the related premature mortality of people with personality disorders and intellectual disabilities, often worse even than that in people with SMI,6 nor the excellent work by patients, carers and professionals to reduce high-dose prescribing of psychoactive medications in intellectual disability. 24 Health inequalities drive the UK's obesogenic environment, which is relevant to premature mortality in general but specifically to COVID-19 deaths. Cuts to addictions services are considered elsewhere, alongside the opioid crisis that has crossed the Atlantic. 25 --- Solutions beyond this issue As we mature as clinicians, our goals of intervention adjust to realities and hard-won experience. We do not see patients as a collection of neuroreceptors (including subtype and putative phenotype); we devise complex formulations to persuade patients towards self-management and empowerment, consolidating their (real not virtual) social networks and support systems. To achieve this, we will need to practise psychosocial education. Communicating complex information about the drivers of mental disorders might be easier if our patient has just one, but aetiology (causes of the causes) is shared. Beyond your wards and clinics, other health professionals also need to know what we know. Do our GP letters communicate the individual drivers of someone's misery (inadequate housing, precarious income, indeterminate status to remain, no locally available stop smoking services, the pressures of raising children when a parent has mental health or substance issues, etc.), or is it easier to write about medications and risk? It is a great start to identify what we can do better where we work 9,26 and we cannot dispense social prescribing unless we understand our local communities. --- From public education to public engagement Do you know who leads on inequalities in your local organisations? Are there aspects of your practice where inequalities are making outcomes worse, and are you in a position to influence mitigation for these? Regional structures and local alliances have the potential to achieve results beyond the ephemeral 'levelling up' of current public discourse. Of course there will be political voices (of all shades and volumes) to keep us quiet, but we are 'following the science'. The Royal College of Psychiatrists has joined with many partners in Equally Well (www.equallywell.co.uk) to use the available evidence to reverse rising SMI mortality. We hope this special issue of the BJPsych Bulletin will get people thinking and talking. What will you do to achieve a wider societal dialogue? Our College and others are building resources to tackle poverty-inequality, but we need all the help we can get. --- Author contributions P.B. devised and wrote first drafts of this article to frame a special issue of the BJPsych Bulletin on poverty. A.J. commented on these drafts and enhanced the content on BAME inequalities and prevention. --- Declaration of interest

We examine epidemiological evidence for the central role of inequalities (principally economic) in driving the onset of mental disorders, physical ill health and premature mortality. We locate the search for solutions in current UK contexts, and include known and likely effects of the COVID-19 pandemic. Prevention of mental disorders and adverse outcomes such as premature mortality must begin with efforts to mitigate rising poverty-inequality.

The impact of fetal and early life experiences on health and developmental outcomes across the life course are increasingly well mapped (1). Physical and social exposures during sensitive periods of development are now understood to shape the development and host response to a broad array of chronic diseases, of both childhood and adult onset (2). The mounting acceptance of a life course approach to human health and well-being is conditioned by accruing biological and epidemiological evidence of gene-environment interactions in the propagation and evolution of chronic diseases (3). Heart disease is a quintessential case in point highlighting an opportunity to incorporate the role of social determinants of health, the social and economic factors that influence people's health. The aetiology of congenital heart disease (CHD) has been considered to be multifactorial, due to both genetic predisposition and environmental influences (4), profoundly influenced by conditions in fetal and early life. Recent research has shown that gene expression can be altered by chemical modifications to the Deoxyribonucleic acid (DNA) and DNA-associated proteins in the nucleus, the epigenome. These modifications occur as a natural process during development and tissue differentiation, are heritable and can be altered in response to environmental exposures or disease (4). The insight that cardiovascular health in children and adults-once viewed as the province of genetic lottery or lifestyle choice-might hinge on the milieu of early life is transformative, to both science and policy (5). It challenges received notions of the determinants of heart disease and of the emphasis placed on strategies for prevention and treatment. A life course approach has far-reaching implications for both clinical and health system approaches to congenital heart disease (6). --- FACTORS THAT AFFECT THE INTRAUTERINE LIFE STAGE Heart malformations are the most common birth defects, affecting at least 2% of all newborns (approximately 1.35 million infants) each year worldwide (7). CHD affects both high and low income countries, with attendant burden on health Paediatrics & Child Health, 2018, Vol. 23, No. 2 93 systems with disparate resources and capacities. While the overall prevalence of birth defects has remained constant over time, since the 1970's there has been an almost twofold increase in the prevalence of CHD, which may be due to changes in ascertainment and the availability of ultrasound (8). The highest overall rates of congenital heart disease are found in Asia (9.3 per 1000 live births), significantly more than in Europe (8.2 per 1000 live births) or North America (6.9 per 1000 live births) (7). The prevalence of major congenital heart disease, including hypoplastic left heart syndrome, transposition of the great arteries, truncus arteriosus, total anomalous pulmonary venous return and Tetralogy of Fallot has been reported as 1.1 per 1000 live births (9). Differential genetic and environmental risksincluding disparities in social determinants of health may play formative roles in the observed geographic variation of CHD prevalence. A recent analysis of Canadian data with universal health care access revealed that children born in low income neighbourhoods had significantly higher rates of CHD (10). The concept of childhood disease and adversity beginning in utero implicates the emerging field of epigenetics in developmental science (4). The role of epigenetics in the development of CHD is now the focus of extensive research. Most of the inherited forms of congenital heart disease are a result of mutations in cardiovascular transcription factor genes, which are regulated at the chromatin level and potentially modified by epigenetic mechanisms including environmental factors (11). Although of limited access to families of low socioeconomic status, pregnancies assisted by reproductive technology are associated with an overall increase in congenital anomalies and specific cardiac defects. Intracytoplasmic sperm injection is associated with a two-to fourfold increase in TOF occurrence (12). It is well recognized that exposure to medications, such as antiepileptic drugs, lithium and alcohol are associated with an increased risk of developing CHD in the fetus. Although evidence is limited, there is growing concern that environmental exposures may contribute to the development of CHD. Observational studies have demonstrated increased incidence in ventricular septal defects in parents exposed to pesticides and an increase in the incidence of transposition of great arteries in maternal exposure to herbicides (13). Maternal cigarette smoking in the first trimester has also been linked to an increased incidence of CHD, and some studies have linked ambient air pollution to CHD after adjusting for socioeconomic status (14,15). In addition to maternal environmental exposures, associations between maternal nutritional status and the development of CHD in offspring have been observed. The introduction of folate to reduce the prevalence of neural tube defects has been associated with reductions in CHD prevalence, particularly transposition of the great arteries (16). However, poor socioeconomic status may decrease the availability of folate containing foods and result in suboptimal folate levels to prevent defects. In addition, interactions between maternal lifestyle factors that alter folate metabolism, such as obesity and carrier rates of certain genetic polymorphisms, have been associated with increased rates of CHD (17). Similarly, studies have documented associations between maternal hyperglycemia and hyperlipidemia and increased risk of CHD (18). Maternal diabetes is strongly associated with certain cardiac defects and the increasing prevalence of glucose intolerance seen with maternal obesity and elevated body mass index is linked to socioeconomic status (4). Due to advances in cardiac surgery and interventional techniques, there are now more adults than children with congenital heart disease, with corollary repercussions across the life trajectory (19). In many cases, the impact of CHD extends far beyond the patient's diagnosis into their preoperative care, surgical management and medical therapies and follow-up, affecting the child's and their family's interaction and integration with their community. The social determinants of health have a bidirectional relationship with CHD, both contributing to aetiology and outcomes and in turn being influenced by the experience of living with congenital heart disease. --- FACTORS THAT AFFECT THE CHILD LIFE STAGE Adverse early childhood exposure is an important determinant of lifetime health setting children on a trajectory of increased risk for development of cardiometabolic risk. Children with congenital heart disease are equally susceptible. Cardiometabolic disease is a leading cause of morbidity and mortality in chronic noncommunicable disease worldwide. Stressors and toxic exposures during sensitive and critical periods of early development play critical roles in determining cardiometabolic risk over the life-course (20). This is of particular relevance as metabolic syndrome is more common in adults with CHD than in the general population (21). Barker's seminal epidemiological study demonstrated the detrimental effect of nutritional insults to the fetus and influence on later-life (20). In particular, the association of low birth weight secondary to intrauterine growth restriction, has significant association with later risk of hypertension and cardiovascular disease (4,20). Similarly, the Life Course Health Developmental Model posits that health outcomes are defined by continuous interactions between biology and developmental experiences, such as genetic, psychological, socioeconomic and cultural over the lifetime (6). Optimal health outcomes can be obtained by promoting protective factors and reducing stress (6). Psychological stressors, negative life events and low family income are associated with childhood overweight and obesity (22). Similarly, socioeconomic disadvantage at individual to neighbourhood levels and childhood obesity and cardiometabolic risk are linked (23). Time spent in low socioeconomic position, including poor hygiene, unhealthy lifestyle habits and limited access to health care, predicts cardiovascular disease and related mortality (4). Importantly, early-life cardiovascular disease risk factors, particularly childhood obesity, independently predict adult cardiovascular disease (21). --- IMPLICATIONS FOR PAEDIATRIC PRACTICE Paediatricians will need to consider a public health paradigm of preventing and promoting cardiac health across the lifespan (Figure 1). First, we will need to recognize that economic and social drivers, such as income, food security, education and access to comprehensive health care, have profound influence (24). Second, we will need to implement universal screening for social factors that identify children at risk for heart disease and connect to community resources (25,26). Finally, we will need to detect early and intervene for developmental delay in children with CHD to optimize long-term child potential (27). --- KEY MESSAGES • Cardiovascular health in children and adults is profoundly affected by the milieu of early life. • Social antecedents play a significant role in conditioning disease burden and modulating outcomes of congenital heart disease. • Wider introduction of universal screening for social factors that impact on cardiac health will help identify children and families at risk. --- Conflict of Interest: There are no conflicts of interest or financial relationships relevant to this article to disclose from all identified authors.

Congenital heart disease is a significant cause of infant mortality. Epidemiology and social context play a crucial role in conditioning disease burden and modulating outcomes, while diagnosis and treatment remain resource intensive. This review will address the role of social demographics, environmental exposure, epigenetics and nutrition in the aetiology of congenital heart disease. We then discuss the determinant effect of social factors on the provision and outcomes of care for congenital heart disease and implications for practice. It is our hope that enhanced knowledge of the intersection of social determinants of health and congenital heart disease will facilitate effective preventative strategies at the individual and population levels to optimize heart health outcomes across the life course.

Data Collection Reddit is a social media platform where users can post anonymous submissions and comments in various subreddits. We use the Pushshift Reddit API (Baumgartner et al., 2020) to collect all submissions posted to nine subreddits related to the birthing experience between April 2009 and June 2021. 1 Following Antoniak et al. (2019), we remove all posts that do not include any of the terms "birth story," "birth stories," or "graduat," guaranteeing our corpus consists of birthing narratives. We remove all posts that contain less than 500 tokens,2 resulting in a corpus of 4,484 birthing narratives before and 913 during COVID-19. 3 3 Method Topic Modeling. To discover distinct topics across our collection of birthing narratives, we apply Latent Dirichlet Allocation (Blei et al., 2003), as implemented in Mallet (McCallum, 2002). In initial experiments, k, the number of topics, ranges from 5 to 50. We choose k = 50 based on C v coherence (Röder et al., 2015). Discovered topics include induced labor, family, breastfeeding, and the first moments between a new parent and child. To determine whether the prevalence of these topics changed during COVID-19, we fit topic-specific Prophet models, an additive regression approach for forecasting time series data (Taylor and Letham, 2018), on the topic's average monthly prevalence in our corpus prior to March 2020. We then compare the topic's actual average monthly prevalence in our corpus during COVID-19 with the corresponding model's forecast. Following Biester et al. (2020), we quantify how often the actual topic's monthly probabilities fall outside the model's 95% CI and use one-tailed Z-tests to determine statistical significance. Quantifying Personas Presence. Determining the prevalence of types of characters, or personas, in a narrative can illuminate information from an author's perspective, e.g. who is most the relevant, valued, or supportive character. Following Antoniak et al. (2019), we quantify a persona's prevalence by counting how often they are mentioned, using a dictionary of terms for each persona. 4 We examine the difference in average mentions of each persona before and during COVID-19.5 --- Results Figure 1 shows how the forecasted prevalence's for the family and induction topics significantly differ with the topics' prevalence during COVID-19. The increase in the induction topic (Figure 1b) may reflect the increased recommendation of planned induction, enabling COVID-19 testing of expecting parents in advance of delivery (Goer, 2020). The decrease in the family topic (Figure 1a) might correlate with hospitals restricting visitors during the pandemic. Our experiments quantifying the personas' presence demonstrate that the healthcare providers were mentioned at similar rates before and during COVID-19, indicating that from the perspective of birthing parents, providers' roles in birthing narratives remained consistent. We notice a significant drop in the family persona's presence (22.8% , p < 1 -7 ) and significant increase in the partner persona's presence (5%, p < 0.028) during the pandemic. Figure 2 indicates that these differences were usually most apparent from periods 2 to 8 in the stories, which correlates with the time generally spent in the hospital during birthing narratives (Antoniak et al., 2019). This might suggest that partners supplemented the support missing by families that were unable to visit hospitals before and after delivery. --- Conclusion We presented a study demonstrating how parents' self-described birthing experiences significantly changed during COVID-19. Our results indicate that hospital policies may be reflected in birthing narratives. Our work presents a case study in how we can analyze patient experience from their own written narratives and perspectives.

Social media has the potential to elucidate a deeper level of understanding of COVID-19's impacts across wide ranging communities. Recent work leveraged publicly available data from social media platforms to detect emerging symptoms from COVID-19 (Santosh et al., 2020) as well as the pandemic's impacts on mental health (

INTRODUCTION Cases of sexual violence against children in Indonesia are not a new phenomenon. Children should receive protection from parents, family, society and the state. Children must receive special protection to ensure that children grow and develop well and are protected from the risk of crime in accordance with the Child Protection Law No. 35 of 2014. Cases of sexual violence against children are often carried out by people closest to them such as family, parents, friends and teachers who should being a substitute for parents at school (Joni & Surjaningrum, 2020). Based on data from the Online Information System for the Protection of Women and Children in 2023, there have been 25,342 cases of violence with 5,2261 male victims and 22,293 female victims. The highest age of victims was 13-17 years old with a total of 9,591 cases. The highest number of cases of violence based on the location of the incident occurred in the household sphere, namely 15,450 cases, with the most common type of violence experienced, namely sexual violence, amounting to 11,191 cases. Based on this data, many cases of sexual violence occur from the family environment, including parents (Online Information System for the Protection of Women and Children, 2023). Sexual violence against children is the involvement of children in all forms of sexual activity that occurs before the child reaches the age limit determined by state law and is carried out by adults or older people for sexual pleasure. Sexual violence against children is carried out by asking children to carry out inappropriate sexual activities, including non-contact sexual interactions with children carried out by adults (Solehatiet al., 2022). Forms of sexual violence can be divided into two forms, namely physical contact and nonphysical contact. Physical contact can take the form of sexual harassment or sexual abuse of a child's body, where the child is asked to hold or touch parts of the perpetrator's body to commit rape. Forms of non-physical contact sexual violence, namely showing genitals to children, showing sexually explicit images or videos, taking photos or videos of children without clothes, using terms that contain sexual elements or pornographic elements, and buying and selling photos and videos that contains elements of child pornography (Joni & Surjaningrum, 2020). Factors that cause sexual violence in children include low levels of education, economic factors, environmental and housing factors, alcohol factors, technological factors, emotional factors, social factors, lack of faith in God Almighty, prioritizing momentary desires, and unpreparedness to --- A Multidisciplinary Journal for Health Professionals Health Frontiers become parents. where this can be in the form of not being ready to care for, not being ready to educate and accompany the child at home which will later result in easy stress and emotions and then doing inappropriate things which are taken out on the child (Solehatiet al., 2022). Sexual violence can affect the growth and development of children who are victims of sexual violence. Apart from physical problems such as unwanted pregnancies, sexually transmitted infections, and reproductive disorders, they also have an impact on children's psychology, such as self-image, emotional disorders, relationships with the social environment, changes in behavior, and even deep trauma in children. Apart from that, the impact on victims of sexual violence against children can be divided into three categories, namely physical impact, psychological impact and social impact. Physical impacts include physical injury, death, pregnancy, unsafe abortion, and sexually transmitted infections. Psychological impacts such as depression, shame and trauma due to experiencing violence, loss of self-confidence and self-esteem, self-harm, and suicidal thoughts and behavior. Social impacts include isolation and rejection from family and society (Joni & Surjaningrum, 2020). Prevention of sexual violence can be done by parents at home and the role of parents in this case is very important. The role of parents in preventing sexual violence in children is as educators, parents need to understand how to prevent sexual violence and be able to provide information about what should be avoided to prevent sexual violence. As an incentive to grow self-confidence and courage in facing problems, such as what to do when a stranger disturbs you. As a role model, both in terms of religious values and norms in society and providing a good example in speaking. As supervisors, parents must properly monitor their children's interactions. As counselors, parents give consideration to children in making the best decisions (Liginaet al., 2018). Based on the explanation above, the author wants to provide information and education regarding "Sexual Violence According to Parental Aspects" so that the public, especially parents, can know about sexual violence and will not do it to their children. --- MATERIALS AND METHODS The method we use is the study literature method and quantitative methods for the results in the video, where this literature method is collected from several library reference sources as support for the research we carry out. Then the quantitative method applies to the results of uploaded TikTok videos which include total audience impressions, number of likes, number of comments, number of shares and number of people who saved the video. In the video uploaded to the Tiktok application, cases of sexual violence perpetrated by parents against children most often occur in the household. Where in making the video itself, in order to display a good appearance and be easy to understand, the video is packaged with animation and additional voice over so that the video can be conveyed well to listeners and viewers, where it is hoped that the information uploaded by the video can be received in a relevant way, which is what it is hoped that the audience will be able to do. awareness, especially for parents who have children, so that they --- A Multidisciplinary Journal for Health Professionals Health Frontiers can gain additional insight into anti-sexual violence against children. Because this video also covers the causes of sexual violence against children and how to prevent it. The process of uploading this educational video starts from November 27, 2023 to December 4, 2023 on the TikTok platform, where this educational video has a duration of 2 minutes 41 seconds. --- Results and Discussion Information and educational videos regarding "Sexual Violence According to Parents"were --- A Multidisciplinary Journal for Health Professionals Health Frontiers uploaded on the Tik Tok platform on November 27 2023, within one week. The 02 minute 41 second video shows performance and viewership with the following results: The reason for choosing to use TikTok social media as a medium for education in understanding sexual violence committed by parents against children is because currently this media has many users, is easy to use, is popular among millennials, and TikTok has a "share" feature which can optimize the distribution of content. As an innovation effort in terms of education, Tiktok can be used as a learning medium and source of information that can help increase new knowledge by displaying useful educational videos. With interesting and educational video content, so that it can be accepted and understood by all TikTok users. So that the content in the video, which is about the impact of parental sexual violence on children and the role parents should give to children, can be conveyed and implemented well. --- Video Performance The theme of our activity is PSSE: Parenting Style Sex Education, which aims to provide education through TikTok social media to discuss the issue of sexual violence according to parents. The discussion includes the number of cases of sexual violence committed by parents to children where most occur in the household. Then regarding the causes of sexual violence committed by parents due to a lack of faith in God Almighty, prioritizing momentary desires, and unpreparedness to become parents. As for discussing the impact of sexual violence committed by parents on children due to forms of betrayal, sexual trauma, powerlessness, and stigmatization. Parents should have a protective role in sexual violence. Then where should these children take refuge, if they are the main source of the cause of sexual violence. The obstacle in raising the theme of sexual violence by parents against children is that sexual --- A Multidisciplinary Journal for Health Professionals Health Frontiers violence is quite taboo to be disseminated on social media, especially sexual violence committed by parents. Then the obstacles obtained when making TikTok as a medium of delivery or education are targets that are not all parents, but this can be a provision for them prospective parents to know when our family or children will experience sexual violence from the family itself and for children, adolescents, or adults when experiencing sexual violence. Future solutions from the PSSE theme: Parenting Style Sex Education is a provision in the future for us to be able to find out about parental sexual violence committed by children because social media is eternal so it can be seen at any time. --- CONCLUSIONS The cause of sexual violence against children is the excessive sexual desire of the perpetrator of sexual violence, and one of the main factors in the emergence of this sexual desire is pornography. Another cause of sexual violence against children is abnormal (abnormal) sexual desire. It is said that the greater the difference in physical strength, the easier it is to carry out coercive deceptions against the child, so that the perpetrator leaves his desires untouched by the child. Apart from the government's role in overcoming sexual violence against children by providing stricter sanctions, the role of parents in overcoming sexual violence against children is also very important. The author advises parents to always look after their children and give them love so that they do not receive less attention from other people. Parents who abandon them are vulnerable to sexual violence due to lack of parental protection. --- Acknowledgement In completing this research, the author received a lot of help from teaching, guidance, direction, and instructions from various parties both directly and indirectly so that this research could be completed on time. Therefore, the author would like to thank: 1 As an ordinary human being, the author realizes that this article is far from perfect due to the limited knowledge possessed by the author. Therefore, the author apologizes and accepts constructive criticism and suggestions for future improvements. Finally, I hope that the writing of this article can provide benefits for anyone who reads it. --- Conflict of Interest The authors declare no conflict of interest --- A Multidisciplinary Journal for Health Professionals --- Health Frontiers Swasta Tipe C Provinsi Sulawesi Utara. Jurnal Ilmu Pendidikan Nonformal, 09(1), 421-436. http://ejurnal.pps.ung.ac.id/index.php/Aksara Sukarmo. ( 2019). Meningkatkan karakter self leadership melalui pendekatan experiential learning peserta didik kelas X SMA negeri 76 Jakarta. Improvement, 6(2), 69-89.

Child sexual abuse is the involvement of children in all forms of sexual activity that occurs before the child reaches the age limit set by state law and is carried out by adults or older people for sexual pleasure. Based on data from the Online Information System for the Protection of Women and Children in 2023, the highest number of cases of violence based on the place of occurrence occurred in the household sphere, which amounted to 15,450 cases with the most experienced type of violence being sexual violence at 11,191 cases. The purpose of this study is to provide information and education about "Sexual Violence According to the Aspects of Parents" so that people, especially parents, can find out about sexual violence and will not do this to their children. The method used is the literature review method by collecting various articles that have discussed sexual violence according to the views of parents and quantitative methods in calculating research results. The results of the study obtained that our educational video aired for a week received a total audience of 1,171 views with 24 likes, 1 comment, 8 shares and 6 accounts saved the video. 52% of the video viewers were female and 56% were in the age range of 25-34 years. With the results of the audience mentioned above, which is mostly adults, it is hoped that it can increase their insight and empathy to be more concerned about preventing sexual violence against children.

outcomes, but there has been relatively little work describing and synthesizing the merits and limitations of methods available for this purpose. We will discuss the application and limitations of popular longitudinal methods that can be applied to the study of change in multimorbidity and associated health outcomes. We will consider overarching issues in the longitudinal study of multimorbidity including operationalizing multimorbidity, data-related concerns such as measurement invariance, and choice of time scale (i.e., change in age or calendar time). We will then cover methods aligned to four specific research objectives: 1) examining individual change in multimorbidity, 2) identifying population sub-groups that follow similar trajectories of multimorbidity progression, 3) understanding when, how, and why individuals/groups shift to more advanced stages of multimorbidity, and 4) examining the co-progression of multimorbidity with key health domains over time. This work will help establish a common language for assessing longitudinal changes in multimorbidity, inform research that can fill gaps in our knowledge regarding multimorbidity progression and critical periods of change, and support the identification of groups that experience divergent rates and etiological pathways of disease progression. Sequence analysis is used in the social sciences to examine patterns of events occurring across the life course, but there are few examples of its use in multimorbidity research among older adults. We used sequence analysis to identify longitudinal patterns of cardiometabolic multimorbidity over a five-year period among participants in the National Health and Aging Trends Study (N=5,218). Multimorbidity sequences were constructed using self-reported diagnosis of diabetes, heart disease, stroke, and myocardial infarction (MI) assessed annually. Death was included as an absorbing state, yielding a total of 281 distinct sequences. We calculated sequence dissimilarity using optimal matching then used hierarchical clustering to identify seven distinct sequence clusters. The largest cluster (46.2%) was characterized by no baseline cardiometabolic disease and minimal incident disease across the 5-year period. Three clusters were characterized by stable sequences: diabetes (13.1%), heart disease (7.5%), and MI or stroke (7.3%) across the 5-year period. Two clusters exhibited a high rate of incident cardiometabolic disease during the 5-year period, one among persons with no baseline disease (9.6%) and one with rapid accumulation of cardiometabolic multimorbidity (5.3%). Finally, one cluster largely contained persons who died during the study period (11.0%). Compared to those with no baseline and minimal incident cardiometabolic disease, the odds of subsequent dementia were significantly higher among the cluster without prior disease who developed incident cardiometabolic disease (OR= 1.61, 95% CI:1.07,2.43) and the cluster with high cardiometabolic multimorbidity (OR=2.77, 95% CI:1.84,4.18). These findings contribute to our understanding of the impact of cardiometabolic multimorbidity on cognitive health. The growing burden of multiple chronic conditions documented by a U.S. Department of Health and Human Services initiative noted the importance of studies that 1) "Develop tools to identify and target population subgroups of individuals with multiple chronic conditions who are at high risk for poor health outcomes", and 2) "Improve knowledge about patient trajectories temporally in relation to changes in health status, functional status, and health services use". Expanding upon our methods for jointly modeling multiple outcomes, where each person's shared influence on concurrent outcomes can be captured by using a random intercept term, we demonstrate how to model additional heterogeneity. Based on the estimates from the joint model, the typical concurrent risk (TCR) of each outcome (i.e., probability) can be estimated at the cohort level, providing a method for identifying average longitudinal effects of risk factors useful for healthcare system policies. In contrast, a person-specific effect reflects the probability of each outcome within a defined interval of time, while currently at risk for another non-mutually exclusive outcome (i.e., personalized concurrent risk [PCR]). Chronic conditions and sociodemographic risk factors may partially account for the heterogeneity of a cohort. However, differences in the occurrences and associations among these may differ for minoritized groups. These methods identify persons above (or below) average risk. We expanded these joint models to address truncation of measurement due to death and the interdependence of outcomes at the person-level, while maintaining the Type I error rate. We have made the code publicly available. Abstract citation ID: igad104.0760 --- EMERGING COHORT DISPARITIES IN MULTIMORBIDITY IN US ADULTS ENTERING EARLY OLDER ADULTHOOD Nicholas Bishop 1 , Steven Haas 2 , and Ana Quiñones 3 , 1. University of Arizona,Tucson,Arizona,United States,2. Penn State,University Park,Pennsylvania,United States,3. Oregon Health and Science University,Portland,Oregon,United States Recent evidence of generational disparities in multimorbidity risk among older adults indicates earlier transitions into multimorbidity and greater disease burden for those born to later cohorts. As costs of managing chronic disease will rise with population aging, it is imperative to identify whether cohort effects in multimorbidity extend to cohorts just entering early older adulthood. We use representative data from the Panel Study of Income Dynamics to model cohort trends in multimorbidity from 1999-2019 in adults who were 50 years of age or older at any observational period (n = 4,975; 40,822 person-observations). Multimorbidity was assessed as a count of nine chronic conditions (stroke, hypertension, diabetes, cancer, lung disease, heart problems, emotional problems, arthritis, mental loss). Weighted Poisson mixed models were used to estimate multimorbidity trajectories adjusted for fixed effects of cohort, linear and quadratic age, and sociodemographic covariates. The model accounted for repeated measures though inclusion of a random effect for within-person error covariance across wave. After adjustment, those born to the Early and Late Baby Boom cohorts (b. 1946-1955 and b. 1956-1964, respectively), as well as those born to the early Gen X cohort (b. 1965-1972), reported significantly greater multimorbidity burden than those born to the late depression-era (b. 1931-1942). These findings extend evidence of cohort effects in multimorbidity in U.S. older adults, indicate these problematic trends apply to U.S. adults entering early older adulthood, and suggest practitioners and policymakers should prepare for an aging population with expanding disease burden. --- SESSION 2365 (SYMPOSIUM) Abstract citation ID: igad104.0761 --- MEASUREMENT MATTERS IN EPIDEMIOLOGIC STUDIES OF SENSORY HEALTH AND AGING Chair: Jennifer Deal Co-Chair: Bryan James Discussant: Alison Abraham Valid and reliable measurement is a cornerstone of epidemiologic data collection and analysis. Sensory health is important for maintaining cognitive, physical and social function with age, but multiple measures of sensory health exist, and not all are the same. For example, audiometric hearing loss reflects the cochlea's ability to process sound, while self-report captures an individual's perception of their hearing ability within their social and environmental context. How we measure sensory function has important ramifications for prevalence estimates and results from association studies, and therefore, public health and clinical decision-making. Sensory loss may also have important implications for the measurement of other factors in aging research. For example, neurocognitive tests are administered aurally or on paper, which could present a challenge for older adults with sensory loss. This session, jointly sponsored by the Sensory Health and Epidemiology of Aging Special Interest Groups, focuses on the intersection of measurement and sensory health. We will report on vison and hearing measures in a large, nationally representative study of Medicare Beneficiaries, with a focus on the recent addition of objective measures of vision and hearing loss, and their implications for sensory loss prevalence estimates, particularly for the oldest old. We will also discuss how sensory loss impacts cognitive testing, including best practices for measuring cognitive function in older adults. Finally, we will present

The growing body of longitudinal research on multimorbidity (≥ 2 chronic conditions) has identified that multimorbidity progression in mid and late life is associated with change in other health domains (e.g., mobility limitations) and can have far-reaching effects on person-centered outcomes such as health-related quality of life. Several increasingly accessible quantitative methods can be applied to the longitudinal study of multimorbidity and related health

Method This research uses the newly linked administrative database created under the "Children's Lives and Outcomes" research strand of the Scottish Centre for Administrative Data Research (SCADR). This linkage, the first of its kind in Scotland, includes data from Education Analytical Services and the Information Services Division of NHS Public Health Scotland from the period between 2007-2019, and the 2001 and 2011 Census. We adopt a Multilevel Modelling approach to ascertain the extent of the variation in the likelihood of a student being excluded across schools and council areas and its association with individual, school and area-level characteristics. --- Results Preliminary results suggest that the variation in exclusions across secondary schools in Scotland is substantial and significant in terms of size and importance. Moreover, variation across council areas is also non-negligible, and is smaller than the variation found between-schools. This suggests that the effect of policy and/or practice at the school level is greater than that at the local authority level. Our analyses continue and are currently focusing on prior exclusions in primary school, deprivation, mental health, household and demographic characteristics, as well as school and area-level indicators. We expect to be able to elucidate further the relationships and interrelationships between schools, areas and family circumstances in the likelihood of being excluded from school. --- Conclusion Our findings are pertinent to policymakers and practitioners in the context of a widening socio-economic gap exacerbated by COVID-19 restrictions and the current economic turmoil, to reduce the inequalities in exclusions and ultimately improve school experiences and outcomes. https://doi.org/10.23889/ijpds.v8i2.2194 November 2023 © The Authors. Open Access under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/deed.en)

This paper explores the patterning of educational exclusions in Scottish secondary schools by variation across schools and council areas, and by structural socioeconomic factors and demographic characteristics of the pupils, their families, their schools and the areas in which they reside.

INTRODUCTION Anxiety and depressive disorders being most common across the world 1 contribute substantially to global burden of disease (GBD) and by 2020 they are expected to be the second commonest cause of disability. 2 Anticipated early onset of these disorders in life 3 with their chronic course 4 associates them with considerable impairment consequently enhances need to use primary care services thus leads to economic burden. 5 These disorders put low income countries in a challenging situation where infectious diseases and malnutrition are rife and general population can only allocate a low proportion of gross domestic product to health care services. --- 6 . Even developed countries like United States could not exempt themselves from bearing economic consequences that anxiety disorders pose. Estimated annual cost on anxiety disorders was reported to be forty two billion dollars in 1999. 7 Some of the symptoms of depression are excessive or decreased appetite, sleep and psychomotor activity, anhedonia and fatigue. 8 Gender issues, employment problems, family setup, social status and social support influence mental wellbeing. In depressive disorder family and social support provides buffer against it, in contrast economic problems and family conflicts aggravate depression. [9][10][11] Additional associated risk factors among adolescents were identified as female sex. 12 low parental education, 14 and weak inter-parental relationship. 14 Some reviews on rural-urban differences for psychiatric disorders show urbanization as risk factor while others contradict this concept. 15 Islamabad, the capital of Pakistan has five zones among which two are designated for urban development and other three for rural development. 16 Islamabad is well developed in health care facilities and its rural population can conveniently approach these facilities in contrast to other deprived rural areas of Pakistan. Considering this, present study aims to explore rural-urban differences in prevalence of anxiety, depression and stress in Islamabad. The objective of the study was to compare the prevalence of anxiety, stress and depression in rural and urban population of Islamabad, Pakistan. --- METERIAL & METHODS --- DISCUSSION In this study more sum of participants were rated on moderate to extremely severe depression and anxiety. In comparison to rural population more participants in urban population experienced moderate, severe and extremely severe depression. Data from Canadian community survey explored more deprivation in urban population due to adverse living conditions which consequently showed increased rates of depression and anxiety in them. 18 In a meta-analytic study conducted to find urban-rural differences in prevalence of psychiatric disorders published since 1985, it was exhibited that pooled total prevalence was significantly higher in urban population as compared to rural population for psychiatric disorders. 15 In another study conducted in US no significant association was seen between urbanity and prevalence of depression. In this study no significant differences were found in adults of large metropolitan and rural areas. This study concluded that prevalence of mental disorders is not subject to urbanity suggesting that consideration of mechanistic explanations as risk factors of psychiatric illness in urban environment is still immature. 19 In another study conducted on US population, contrary to expectation, the prevalence of most psychiatric disorders was similar across rural-urban continuum which concluded rurality as not being a risk factor for any psychiatric disorder or trauma exposure. 20 Few studies link Urbanization as a risk factor for mental disorders 15 and on contrary literature also reveals high prevalence of major depressive disorders in rural areas. --- 21 Prevalence of anxiety disorders was reported to be 18% in US 1 and in European Union more than sixty million people gets affected per year. 22 GBD study projected that Disability-Adjusted Life Years (DALYs) was around 26.8 million due to anxiety disorders. 23 For past few decades anxiety disorders are getting increased attention globally for research purposes due to greater recognition of -burden they cause and their associated implications with untreated illness. Anxiety disorders contribute as a risk factor for substance abuse and mood disorders and these comorbidities makes treatment difficult thus contributes to poor prognosis, decreased remissions rate and increased risk of suicide. 24 Increased cost of untreated anxiety at personal and societal level is being associated with frequent health care visits, unemployment, declined work productivity and problems in social relationships. 25 In 2016 Pakistan was ranked as seventh most stressed country in the world. 26 Depression is the second leading cause of DALYs in both sexes across age 15 to 44 years and 47 is expected to take second place in DALYs' ranking for both sexes across all ages by 2020. --- 27 Around the world approximately one million people commit suicide annually due to depression and nearly 150 million people suffer from depression at some point in their lives. 28 Doctors in primary care setups seldom make appropriate diagnosis of depression and when they make, it often leads to inappropriate treatment recommendations. 29 --- CONCLUSION Studies that associate rurality as a risk factor of psychiatric disorders conclude it on the basis of social stratification and incapability to use appropriate skills to cope up with stress. Findings of our current study contradict rurality as risk factor might be because rural areas of a welldeveloped urban city like Islamabad have not major difficulty in accessing urban health care facilities and rural areas of Islamabad are not as deprived with health care facilities as other poor population of rural areas that one could imagine. --- LIMITATIONS AND RECOMMENDATIONS This study lacks generalizability due to small sample size and specificity of areas only to zones of Islamabad. For better generalization of results this study needs to be conducted on larger sample size. Rural-urban comparisons of Islamabad with other provincial capitals of Pakistan i.e. Lahore, Karachi, Peshawar and Quetta are recommended to study in extension of this research. Prevalence in other rural and urban areas of Pakistan should be calculated and compared with national and provincial capitals. Sociodemographic correlates also present as risk factors for depression, anxiety and stress which are not considered in this study. In further extension of this study sociodemographic correlates will be explored.

Background: Depression, anxiety and stress are most prevalent causes of disease burden in common population. Due to rapid economic and social changes same increasing trend of these disorders has also been observed in Pakistan. Objective: To compare level of depression, anxiety and stress between rural and urban population of Islamabad, Pakistan. Methodology: A cross-sectional comparative survey was administered on a sample of n=386 participants. A total of n=193 participants belonged to rural population and n=193 belonged to urban population of Islamabad. Participants were interviewed and responses were rated on Depression Anxiety Stress 21 scale (DASS). Data was analyzed by using frequency, percentages, mean and standard deviation. To compare rural and urban population independent t-test was used. Results: The mean age of study participants was 32.46±9 years and 33.75±9.98 years in urban and rural population, respectively. There was no significant difference at p≥0.05 between total scores of depression, anxiety and stress among rural and urban participants. Conclusion: Rural and urban population of Islamabad does not vary significantly on the basis of depression, anxiety and stress level.

INTRODUCTION This commentary asks anthropologists to contribute to the COVID-19 pandemic response in novel ways. As anthropologists working within health-care systems, we see firsthand the deficits and areas where improvements are desperately needed. Moreover, many have experienced mental health impacts in their own lives, among their family and social networks, their students, and their research interlocutors, This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Published 2022. This article is a U.S. Government work and is in the public domain in the USA. American Anthropologist published by Wiley Periodicals LLC on behalf of American Anthropological Association. but are in a place of privilege with access to resources to navigate behavioral health care. Here we provide examples and evidence of how anthropologists can call upon our colleagues across diverse settings inside and outside the United States to bring our training and scholarship to bear in pandemic and recovery responses. COVID-19 has had an unprecedented impact on mental health globally, with increasing rates of depression, substance use, anxiety, traumatic stress, complex grief, interpersonal violence, disordered Am. Anthropol. 2022;1-6. wileyonlinelibrary.com/journal/aman 1 eating, suicidality, burnout, etc., manifesting in all ages (Boden et al. 2021;Ehlman et al. 2022). While clinicians are trained to treat these conditions on an individual basis, the social determination of health (Spiegel, Breilh, and Yassi 2015) and the processes that contribute to the spread and exacerbation of these conditions demand higher-level local, state, national, and global responses. Multiple social and physical losses, worsened by health-system failures, social unrest, racial injustice, economic hardship, disrupted education, forced migration, and political instability have emerged. These factors have produced syndemic (Singer and Rylko-Bauer 2021) traumatic stress across populations, where persistent inequalities are amplified, and the greatest impact is endured by the most structurally marginalized (Whitacre et al. 2021). Acknowledging the limitations of the concept of trauma in Western society (Fassin and Rechtman 2009), System (VA) and in academia, all of whom work to align the social determination of health research (Spiegel, Breilh, and Yassi 2015) to address policy change to improve mental health and mental health services. anthropologists When the world transitions from pandemic/endemic response to postpandemic recovery, anthropologists are needed at the forefront of rethinking mental health and wellness both at home and globally. Several have offered important critiques of psychological and psychiatric practices, processes, and systems (Hansen and Metzl 2019;Jenkins 2018;Kleinman 2012;Luhrmann 2011) --- DEVELOP MENTAL HEALTH PROGRAMS Given the urgency and global scope of mental health distress caused by the COVID-19 pandemic (Boden et al. 2021), anthropologists can engage in critical perspectives while also working collaboratively to develop programs that center responses within community and culture (Pigg 1993). For example, in rural Wisconsin, VA psychiatrists leverage anthropological techniques vis-à-vis narrative medicine (Charon 2008;Sweet 2021) to treat veterans with traumatic stress. Narrative medicine, which incorporates patient experiences during treatment, has the capability to improve clinical engagement and empathy, a nuanced understanding of how others are feeling, in settings where participants have experienced traumatic stress compounded by isolation (Remein et al. 2020). Another application of narrative medicine is in a form of "writing therapy" or expressive writing, where instead of talking, trauma-affected individuals are instructed on how to write about their thoughts and feelings about a given traumatic experience. Working in conjunction with clinicians, anthropologists have contributed to the development of this intervention (Groleau, Young, and Kirmayer 2006;Sweet 2021) that could be done individually, in a group setting, or via telehealth, enabling greater treatment reach. Recovery from traumatic experiences often requires transformative sense-making (Lester 2013;Panter-Brick 2014) and intensive translation of events that have felt threatening (Pillen 2016). Supportive modes for healing from trauma ideally would build capacity for those experiencing trauma to reconnect to community and social worlds in ways that feel safe (Lester 2013) --- CONFRONT THE RACIALIZATION OF COVID-19 Current (Pigg 1993(Pigg , 2002)). We recognize that structural barriers may prevent such work (lack of time, institutional restrictions), and that anthropologists, in some settings, may be negatively perceived (Fletcher et al. 2022). But for so many, the unprecedented health, economic, and political impacts that have occurred because of COVID-19 will take years, perhaps decades, to undo. We encourage anthropologists to take calculated risks, leverage their expertise, and engage as public servants and intellectuals in solidarity with others working to be part of the conversations to solve the emerging realities of postpandemic life at home and abroad. Anthropologists can extend critical studies of health-policy processes and impact, such as highlighting the undervaluing of mental health care at home and globally (Dao and Nichter 2016), to actively shape new policy, broadly construed. These policy responses need to consider decreasing health and increasing health-care inequities, making mental health-care services more accessible and decreasing the social distance between services and patients (Madaras et al. 2019). Anthropologists can investigate the social, political, and economic structural factors that impact mental health and health care to help clinicians and health-care systems respond to these factors (Seymour et al. 2018). They can also inform policy to decrease structural iatrogenesis (Stonington and Coffa 2019) and its unintended consequences (Pigg 1993) and consider the social forces that directly impact diagnosis and treatment (Holmes et al. 2020). Moreover, anthropological involvement in policy can support a more realistic and nuanced understanding of racialization and racism (Amutah et al. 2021). Anthropologists in VA settings have taken up calls for increasing participation in making policy (Bernstein and Razon 2019). For rates of suicide on a national level. Similarly, anthropologists may be able to address the complexity of COVID-19 impacts, even those not directly relating to health but needed to support community well-being and recovery more actively when societies transition to an endemic phase (Metzl and Kirkland 2010). The key is to translate and communicate our expertise in a way that is more legible to public health officials, mental health clinicians, and the public at large. --- APPLY OPEN SCIENCE AND COLLABORATIVE RESEARCH METHODS Our research methods need to be adaptable, transparent, and read-

This commentary asks anthropologists to work within communities to actively address the global mental health impact of COVID-19 and contribute to the pandemic response. Multiple social and physical losses, worsened by numerous factors, have produced syndemic traumatic stress and suffering across populations, highlighting persistent inequalities further amplified by the effects of COVID-19. Specifically, anthropologists can work to contribute to the development of mental health programs; confront the racialization of COVID-19 alongside marginalized communities; support real-time policy making with community responses; and innovate transparent collaborative research methods through open science. This pandemic can serve as an opportunity to prioritize research endeavors, public service, and teaching to better align with societal needs while providing new opportunities for synergy and collaborations between anthropologists in and outside the academy. Anthropologists collaborating directly with mental health clinicians and the public can contribute to knowledge specifically through direct program development and implementation of interventions designed to improve mental well-being. Innovating to find impactful solutions in response to the unprecedented mental health challenges exacerbated by the COVID-19 pandemic has the potential to promote more equitable recovery around the world.

INTRODUCTION Neurocognitive disorders such as Alzheimer's disease (AD) are often diagnosed in later stages due to its insidious onset, and particularly in Greece, this can be explained by the fact that the general public is not able to recognize the early symptoms of this disorder, attributes the symptoms as part of the normal aging process, and shows general ignorance regarding this disease [1]. Although loss of financial capacity is a common consequence of AD [2], Parkinson's disease [3], vascular dementia [4], frontotemporal dementia [5], and amnestic mild cognitive impairment [6], only one study has investigated what caregivers of frontotemporal dementia patients believe [5]. This study found that caregivers tend to overestimate the patients' financial performance [5]. Although the general public opinion (as expressed in the attitudes of laypeople in Greece) shows doubts about financial capacity, mental capacity, and legal issues in older patients [7], so far, no research worldwide has focused on the possible predictors of the financial capacity estimations made by caregivers (adult children) for older AD patients. In the Greek society, familism values and behaviors are widespread, something that is reflected in the fact that adult children are those who mainly take care of the older adults diagnosed with neurocognitive disorders and usually (and informally) they are the ones who take financial decisions for them, even if no official power of attorney document exists [2,5,7]. Thus, the perceptions-estimates of adult child caregiver regarding financial capacity in patients with AD not only counts but is also of paramount importance in understanding the decisions that are being made, but also in cases of detecting financial abuse. This study included biological factors (such as the biological sex, age, and health status-existence of chronic disease(s) of mild AD patients and their caregivers) and social determinants (such as social engagement (social exclusion/isolation or support), rural/urban physical living environments, education and socio-economic status (based on income) of mild AD patients and their caregivers), as well as the behavioral and psychological symptoms of dementia (BPSD) as presented in mild AD patients. Here, we must note that ethnicity/race, religion, and access to health services were excluded as variables as all participants and their caregivers were Greeks, Greek Orthodox Christians, and with a state insurance that ensured access to healthcare services. In addition to that, socioeconomic status (SES) and vulnerability was not simply defined as annual income above/below the yearly Greek poverty threshold, but for this sample the following categories were presented to choose from (severe hardship, significant hardship, some hardship, fairly comfortable, comfortable, good, and very good). Patients and caregivers SES coincided, so only one variable was used in the statistical analyses. --- METHODS The participants of this study were recruited in the Memory Clinic of a local Greek Hospital and elderly day care centers of the Greek Alzheimer Association. 109 Greek older adults (61 women and 48 men ≥65 years old, all having financial experience in their prior lives as confirmed by history taking) with a diagnosis of mild AD, coming from both rural and urban areas in Northern Greece, underwent a neuropsychological evaluation with an extensive battery of neuropsychological tests administered according to the routine protocol assessing all major cognitive domains (memory, language, attention and information processing speed, visual-spatial ability, and executive functions). After the completion of the assessment, 109 caregivers (n = 68 female daughters, n = 41 sons) caring for these home-dwelling mild AD patients completed a detailed demographics questionnaire and were asked a single question 'Please indicate your estimations on this 5-point Likert scale regarding your mother's/father's financial capacity'. The caregivers did not have any knowledge of the neuropsychological test results. Caregivers had to be family members (preferably son or daughter as adult children were the target group as healthy husbands/wives were not accompanying the older patients and for the majority of this sample were not alive), 18 years or older, and able to give informed consent. In addition to that, they all had financial experience and knowledge that is real-life practice acquired on managing and making use of money. None had attended specialized education programs on financial capacity assessment issues. Procedures were approved by the local university Bioethics Committee Greece (2/27.3.2013) following the declaration of Helsinki. The patients/participants provided their written informed consent to participate in this study. Financial capacity was directly assessed with the use of the Legal Capacity for Property Law Transactions Assessment Scale (LCPLTAS) [2], which consists of seven main domains: 1) basic monetary skills, 2) cash transactions, 3) bank statement management, 4) bill payment, 5) financial conceptual knowledge, 6) financial decision making, and 7) knowledge of personal assets [2]. BPSD were measured with the use of the Neuropsychiatric Inventory (NPI), which is a questionnaire given to the caregiver, exploring 12 behavioral and neuropsychiatric domains (such as delusions, hallucinations, agitation/aggression, disphoria/depression, anxiety, apathy, irritability, euphoria, disinhibition, aberrant motor behavior, sleep behavior disturbances, besides appetite and eating abnormalities). It evaluates the frequency and severity of the symptoms and the impact of each behavior on the caregiver [8]. The domain total score is obtained by multiplying the severity of symptoms (1 = mild; 2 = moderate; 3 = severe) with their frequencies (4-point scale from 1 = occasionally to 4 = very frequently, more than once a day). A total score of NPI is obtained by summing all the domain total scores. General cognition was measured with the use of Mini-Mental State Examination (MMSE), which examines a plethora of cognitive domains such as memory, language, orientation, attention, and visualspatial skills [9]. Depression was also measured with the use of the Geriatric Depression Scale (GDS), which is widely used in the Greek older population [10]. --- Data analysis IBM SPSS Statistics for Windows (version 22, IBM Corp., Armonk, New York) was used for data analysis. Descriptive statistics were computed to describe the abovementioned variables using means (M) and standard deviations (SD) for dispersion for continuous type variables. Frequency counts were computed for categorical variables. Correlation matrices were extracted by using Pearson correlation coefficients. Dummy variables were created for the categorical variable sex. A p value < 0.05 was considered statistically significant. --- RESULTS Descriptive statistics were computed for this sample of participants using means (M) and standard deviations (SDs) for all variables (see Table 1). Pearson correlations were performed between biological factors, such as the biological sex, age, and health status-existence of chronic disease(s) of mild AD patients and their caregivers; social determinants, such as social engagement (social exclusion or isolation to complete social support) as measured by a 5-point Likert scale, education (in years), and socio-economic status (based on income) of mild AD patients and their caregivers; and BPSD, as presented in mild AD patients with the use of the NPI. Statistically significant correlations were found between financial estimations and the sex of the patients. More specifically a negative correlation was found (r = -0.247, p = 0.010). In addition to that, a negative correlation was found between financial estimations and NPI total score (r = -0.458, p < 0.001) (Table 2). In search of any possible differences between males and females, there were no differences between the group of older men and women AD patients regarding their education (t(107) = 0.581, p = 0.563), MMSE scores (t(98) = 0.451, p = 0.653), GDS (t(99) = 0.593, p = 0.554), their age (t(107) = 0.333, p = 0.740), health status (t(107) = 0.676, p = 0.500), social engagement (t(104) = 0.826, p = 0.411), actual financial capacity performance as measured by LCPLTAS (t(107) = 0.524, p = 0.601), the age of their caregivers (t(107) = 1.174, p = 0.243), the health status of their caregivers (t(107) = 0.881, p = 0.380), SES (t(105) = 1.552, p = 0.124), and sex ratio of their caregivers (χ 2 (1) = 0.439, p = 0.551) that could explain the difference found in the expressed estimations of the caregivers regarding patients' financial capacity (when grouping was based on the patient's sex) (t(107) = 2.639, p = 0.010). There was only one statistically significant difference with men showing higher scores in NPI (t(85) = 2.201, p = 0.030; Mfemale = 5.45, SD = 5.46, Mmale = 9.41, SD = 10.87). One additional interesting qualitative finding is that delusions and hallucinations were reported for all the cases of men with BPSD as measured by NPI. --- DISCUSSION This is the first study of its kind for the Greek geriatric population to show the importance of older patients' characteristics on the financial capacity estimations made by their caregivers. Caregivers seem to be biased towards older women, reporting lower estimations for them, although women are not different from men in their cognitive performance as measured by MMSE, depressive symptomatology as measured by GDS, and actual financial capacity as measured by LCPLTAS. Additionally, an interesting finding is that women did not demonstrate the same high levels of BPSD as did men, something that supports that the discovered sex-related financial capacity preconceptions are actually prejudices against women. There are many reasons which could interpret why caregivers offered lower financial capacity estimations for female AD patients. For example, two explanations could be based on lifetime financial roles and the structure of the Greek society, but it seems that this not the case as after the second World War, both men and women had to be involved in financial matters, both in rural and urban areas. Although a plethora of factors were included, one major limitation of this study is that it does not cover all possible factors. This exploratory study aims to establish what factors should be considered in future research not only in Greek cultural settings, but also in cross-cultural environments in order to support if the abovementioned findings are important in other western cultural settings. A related limitation was difficulty recruiting cognitively healthy family members (other than adult children who accompanied the patients), thus generalizations to wives/husbands is not possible and the fact that perceived gender identity was not examined, but only biological sex. Nevertheless, these findings open the debate about how accurate financial capacity estimations are and what really shapes them, and may have legal consequences as it seems that the biological sex of the older patients drives Greek family caregivers (regardless of their own sex) to consider them as financially incapable. --- CONFLICT OF INTEREST The authors have no conflict of interest to report.

This study examines the connection between biological factors, social determinants, and behavioral and psychological symptoms of dementia (BPSD) and the estimations of financial capacity made by caregivers of mild AD patients in Greece. Financial capacity estimations negatively correlated with biological sex of the patients (female), but Neuropsychiatric Inventory (NPI) scores were statistically lower for older females. BPSD (measured with NPI) was found to negatively correlate with estimates of financial capacity. The existence of delusions-hallucinations was reported in all males. No correlations were found between financial capacity estimations, actual cognitive and financial capacity performance, and all other included biological and social characteristics of the patients as well as their caregivers.

Background Policy or social norm change has been shown to be an effective tool in decreasing prevalence of tobacco use (Zhang, Cowling, & Tang, 2010). However, culturally or community competent ways to engage priority populations a using social norm-change methods in mainstream tobacco control policy initiatives have been limited with the exception of a few tobacco control policy initiatives (e.g., Praxis Project's PATH Initiative). Since the 1990s, some leadership development programs have incorporated a theory of change approach using broader comprehensive community initiatives beyond the individuallevel impact, but only recently have elements of health equity been integrated (Hannum, Martineau, & Reinelt, 2007;Leadership Learning Community, Meehan, Reinhelt, & Perry, 2009). Few studies have been documented in the literature showing the effectiveness of formalized, cross-cultural leadership programs for multiple priority populations on tobacco control. An initial scan of health leadership institutes, commissioned by ClearWay Minnesota, revealed multiple mainstream health leadership programs but few that focused primarily on priority populations (ACET, Inc., 2009). Leadership development has been defined as "the ability to move others, communities and systems toward positive social change" (Lew, 2009) and has been a mechanism for moving priority populations toward social norm change (Task Force on Advancing Parity, 2002). This article describes a cross-cultural leadership training program and its effect in training community advocates and emerging leaders to become involved in implementing and sustaining social norm change on tobacco in Minnesota. --- Overview of Laampp Institute The Leadership and Advocacy Institute to Advance Minnesota's Parity for Priority Populations (LAAMPP Institute) was designed to build the tobacco control capacity of five priority population groups in Minnesota: African/African Americans, American Indians, Asian Americans, Chicano/Latinos, and lesbian, gay, bisexual, transgender (LGBT) in a community competent manner. The LAAMPP Institute was adapted from the APPEAL Leadership Model (Lew, 2009), which has trained more than 600 fellows from priority populations. Funded by ClearWay Minnesota, the LAAMPP Institute was a year-long, innovative, cross-cultural leadership program from May 2006 to June 2007 with 32 fellows completing the program. Based on an integrative model using the comprehensive community initiative approach, social ecological and empowerment models of change, the LAAMPP Institute was designed as an interactive, experiential-based learning model and focused on the core competencies of tobacco control, facilitation, advocacy, collaboration, and cultural or community competency. Components of the LAAMPP Institute included a strategic planning process, a tobacco disparities conference, two intensive four-day leadership summits, four bimonthly theme-based trainings on policy advocacy, fund development, media and tailored topics, and a series of institute activities and meetings. In addition, each priority population group was funded to implement a culturally-tailored tobacco control project in their community. Critical elements of the LAAMPP Institute included a flexible and collaborative planning team, a skilled and community-competent training team, and a strong principle-based model. Central to the APPEAL Leadership Model and LAAMPP Institute is a philosophy that includes principles of inclusion of priority populations during all phases, creating an assetsbased model steeped in a social justice context, developing a safe, learning community, and applying the lessons learned to engage in and implement social norm change. A logic model was developed for the LAAMPP Institute to help guide the program's implementation and evaluation (Figure 1). While a core objective of the LAAMPP Institute was to increase individual fellows' tobacco control knowledge and leadership skills, other objectives focused on building capacity of the coaches to support the fellows and increasing community capacity to mobilize on tobacco control issues. In addition, this included other longer term goals such as increased advocacy efforts, institutionalization of priority population issues in mainstream health care systems, and successful policy or social norm changes (Lew, Honma, Portugal, & Baezconde-Garbanati, 2008). Following the end of the LAAMPP Institute, most fellows reported that they were involved in systems or policy change activities including organizing a letter-writing campaign to the media to support Minnesota's Freedom to Breathe Act, legislative visits at the local, state, and federal levels, working on clean indoor air policies and voluntary smoke-free apartment units, developing tribal policies on commercial tobacco, and advocating for the inclusion of questions on sexual orientation on health-related surveys. --- Lessons Learned The lessons learned from the LAAMPP Institute and other APPEAL leadership trainings include the following: 1. It is critical to involve priority populations in the initial planning stages of policy or social norm change. --- 2. Leadership development has been a way to build capacity of emerging priority population leaders in helping to advance their communities' readiness levels to engage in tobacco control policy. --- 3. Leadership trainings must incorporate a holistic, community context steeped in a social justice and racial justice framework and address issues of structural racism and homophobia. --- 4. Although the LAAMPP Institute is the most comprehensive of leadership trainings, other leadership training formats can have similar impact as long as they use a principle-based model. --- 5. Cross-cultural collaboration facilitated through leadership training can provide powerful results in advocacy, policy, and systems change. --- Conclusions The LAAMPP Institute, steeped in a strong principle-based model, is designed to be fluid and dynamic and allows for adaptation that benefits the entire community of fellows. Although the Institute initially focuses on individual knowledge and skills development, the longer term impact can be seen in social norm and policy change on multiple levels within priority population communities, mainstream institutions, and on legislative levels. For policy change to be effective, priority populations must be included from the beginning of the policy planning. Leadership programs for priority populations can be a viable training mechanism to implement and sustain social norm change in tobacco control and should be funded. Not only was the LAAMP Institute effective in increasing skills of leaders and advocates for tobacco control, but the results also showed impact in other areas of health and health equity. Leadership development, in isolation, cannot achieve elimination of tobacco disparities or health inequities, but it can provide a solid foundation for training leaders and a catalyst for mobilizing key advocates and priority population communities toward the successful implementation and sustaining of social norm or policy changes.

The development of leadership in tobacco control has been crucial in the fight against the number one most preventable cause of death and disease worldwide. Yet today, little scientific evidence exists regarding its actual impact, particularly among priority populations. This article describes the impact of the Leadership and Advocacy Institute to Advance Minnesota's Parity for Priority Populations (LAAMPP Institute), a major tobacco control leadership program for five priority populations: African/African Americans, American Indians, Asian Americans, Chicano/Latinos, and lesbian, gay, bisexual, transgender communities in Minnesota. The LAAMPP Institute, a yearlong institute with 17 days of training, focused on the core competencies of advocacy, collaboration, cultural or community competency, facilitation, and tobacco control. A logic model helped to guide and frame the institute's efforts. The LAAMPP Institute has been effective in increasing fellows' capacity to do advocacy, which in turn has led to increased involvement in implementing social norm-change activities. Leadership development can provide a solid foundation for training leaders and a catalyst for mobilizing key advocates and priority population communities toward the implementation and sustainment of social norm or policy changes.

Worldwide, about 44 million people are forcibly displaced because of conflict and persecution, including 15.4 million refugees, 27.5 million internally displaced individuals and over 800 000 awaiting resolution of their asylum application. Additionally, the number of people seeking refugee status has progressively increased in the last few years (Tol et al. 2013). It has been documented that asylum seekers and refugees are a particularly vulnerable group in relation to the development of mental illness, including posttraumatic stress disorder (PTSD) and major depression (Fazel et al. 2005;Steel et al. 2009). Torture experiences and cumulative exposure to trauma are the strongest factors associated with PTSD and depression, respectively. In addition, numerous resettlement stressors may worsen trauma-related mental health symptoms, including unemployment, unsafe housing, social isolation, discrimination, language and cultural barriers (Silove, 2012). Longitudinal studies of refugees in resettlement confirm that some populations may continue to struggle with high rates of psychiatric illness decades later (Carlsson et al. 2006). Although healthcare programmes for refugees and asylum seekers consider incorporating a mental health component, there are questions concerning the extent to which refugees are able to properly access mental health services (Crosby et al. 2013). Cultural, structural and psychological barriers to care have been identified. Cultural barriers include lack of understanding of mental health conditions related to trauma, a reluctance to initiate conversations about mental health symptoms, and mental health stigma. Structural barriers include language and interpreter difficulties, lack of insurance and cost-related issues. Furthermore, the degree and quality of collaboration between agencies such as refugee reception offices, social and mental health services may influence refugees' access to appropriate care. Psychological barriers include trauma-related symptoms, such as avoidance, that may inhibit discussions of mental health issue (Thomson et al. 2015). Culture also shapes experience and expression of symptoms, signs of mental disorders and evaluation of behaviour. In cross-cultural encounters, signs may thus be misinterpreted. A compelling issue is therefore how the mental health system responds to structural barriers, cultural norms and trauma-related symptoms of refugees and asylum seekers in need of mental health services in high-income countries. Psychotropic drug use is often used as an indicator of mental health problems in large populations (Barbui, 2015), but its use in refugees and immigrants is very rare in the international literature. Key issues related to psychotropic drug use among refugees have recently been analysed by Brendler-Lindqvist et al., who conducted a cross-sectional register study of a national cohort of 43 403 young refugees and their families from Iraq, Iran, Eritrea, Ethiopia, Somalia and Afghanistan and a comparison population of 1.1 million Swedishborn residents (Brendler-Lindqvist et al. 2014). Lower rates of dispensed psychotropic drugs among recently settled refugees, as compared with Swedish-born individuals, were found with an increase in the use with duration of residence. It is reasonable to assume that levels of drug consumption may reflect both mental health status as well as access to care, and Brendler-Lindqvist et al. noted that this pattern of drug use might suggest barriers to access mental health care: high rates of mental disorders in refugees, consistently reported in the literature, do not match with the recorded low rates of dispensed drugs (Brendler-Lindqvist et al. 2014). Thus, it seems reasonable to interpret the low rates of psychotropic drug use as related to on a lower access to care than to a better health status. Brendler-Lindqvist et al. reported that the use of antipsychotic drugs was similar between different refugee groups and the comparison group of Swedish-born residents. One explanation for this may be that antipsychotic drugs are prescribed for more severe conditions, often involving psychotic symptoms, where the need for psychiatric treatment is more obvious, and often triggered by other people rather than the patient him/herself. Poor access to psychotropic drugs might be explained by a lack of recognition of mental disorders in the refugee population. As on-going and accumulated distress is very common and expected in this population, it may not receive specific clinical attention unless it evolves into severe psychological and psychiatric problems. Furthermore, the applicability and appropriateness of western concepts of mental illnesses for use in non-western populations is not straightforward, and this may also be related to the difficulties of making a diagnosis. Finally, which measures should be employed to properly assess culturally and linguistically diverse populations is still under debate (Al-Obaidi et al. 2015). This study further expands the current knowledge on immigrants and mental health services use, and suggests that social, cultural, religious, linguistic, geographic, economic variables, as well as discrimination and stigma, contributes to lower access and use. Access to services has been defined as not only getting to service, but also getting to the right service at right time to promote improved health outcomes' (Peters et al. 2008). Barriers to services are both real and perceived obstacles that prevent or interfere with access to services. Take-home messages from this survey include the following. First, strategies aimed at improving access and rationale use of psychotropic drugs should receive specific attention, considering that one of the main challenges for mental health services is the need to flexibly adapt to constantly changing population health care needs; this flexibility should be adapted to the local organisation of health care systems, so that different countries may develop different pathways of care to meet similar needs. Second, studies are needed to further elucidate and identify current barriers to mental health care for refugees and asylum seekers hosted in high-income countries, so that effective measures can be implemented. Interventions that can lower these barriers are needed to enable newly settled refugees to access mental health care and receive correct treatment on equal terms with the native population. In particular, successful referrals to mental health professionals should be improved by better care coordination, establishing trust, resolving access barriers and providing culturally competent care. Third, epidemiological research focused on understanding current patterns and trends in health utilisation is recommended (Thomson et al. 2015), so that innovative pathways of care, integrated into the existing systems of care, may be planned and developed. It should be noted, in this regard, that several studies have already collected epidemiological and clinical data on mental disorders in refugees and asylum seekers, but most of these studies have been conducted in specific ad hoc services rather than within available systems of public health and mental health care. Lastly, inclusion of a mental health component during initial health care assessment might be seen as an optimal strategy to utilise available resources to reduce the burden of psychological distress and mental illness, as we already know that such an approach would represent a powerful aid to diagnosis (Al-Obaidi et al. 2015), and would also help reduce stigma and increase access to mental health care, including better and more rational use of psychotropic drugs. --- Conflict of Interest None. --- References

In the populations of refugees and asylum seekers hosted in high-income countries, access to mental health care and psychotropic drugs, is a major challenge. A recent Swedish cross-sectional register study has explored this phenomenon in a national cohort of 43 403 young refugees and their families from Iraq, Iran, Eritrea, Ethiopia, Somalia and Afghanistan. This register study found lower rates of dispensed psychotropic drugs among recently settled refugees, as compared with Swedish-born residents, with an increase in the use with duration of residence. In this commentary, the results of this survey are discussed in view of their global policy implications for high-income countries hosting populations of refugees and asylum seekers.

T he journey toward delivering patient-and familycentredness (PFC) healthcare can be characterized in three stages. In the "doing to" stage, healthcare administrators and clinicians decide what's best for the patient; in "doing for," although patients' needs are prominent in program design, administrators and clinicians consult patients and families late in the process. "Doing with," however, is a collaborative approach where administrators and clinicians work in full partnership with patients and families to design and deliver healthcare that is truly targeted to patients' and their families' needs. the "Doing to" Model In Canada, the United States and the United Kingdom, healthcare administrators and clinicians often hold unspoken beliefs about how services should be provided, beliefs that incorporate the organization's or health professional's viewpoint, but seldom the patient's and family's. Examples of how good care is defined when systems "do to" patients and families include determining schedules and diet and limiting family access in hospitals; creating systems in clinics that meet clinicians' but not patients' needs; holding conversations about care that exclude the patient and family; sharing incomplete or biased information in a way that patients and their loved ones cannot easily understand and act on; and holding a belief that care is primarily provided in healthcare settings. Terms such as "compliance" are used to describe the patient's ability to follow clinicians' recommendations. This collective mindset limits the potential for transformational change because we ignore a precious asset -the wisdom and experience of patients and families. patient-and Family-centredness: Growing a sustainable culture --- Barbara Balik "What patients want is not rocket science, which is really unfortunate because if it were rocket science, we would be doing it. We are great at rocket science. We love rocket science. What we're not good at are the things that are so simple and basic that we overlook them." -laura Gilpin, Griffin Hospital, planetree Hospital PaTienT-cenTred care the "Doing For" Model Gradual progress toward PFC is evident when leaders and clinicians move to "doing for" patients and families. In efforts to develop PFC care, patients are kept in mind during the design of facilities and programs; family presence replaces visiting hours; and clinicians recognize that patients and families are primarily responsible for care. However, it is still a stage of professional or organizational dominance -we design then ask, rather than partner with patients from the outset; we manage expectations about waiting or pain rather than asking what is of value to the patient and partnering to mutually set goals. the "Doing With" Model High levels of PFC performance lead to the development of true partnerships between patients/families and clinicians -a "doing with" relationship, where all involved understand that healthcare and health transcend location. The conversation recognizes that most healthcare is actually self-care (Krueger 2011). PFC provides the foundation to achieve the "Triple Aim" -better care, better health and lower costs (Berwick et al. 2008). Krueger (2011) describes this stage as recognition that in patient-centred care, the patient/family elects to determine their location within health and care. It implies that healthcare leaders need to work with patients to develop a system for the patient's needs, not the needs of professionals or organizations. Hallmarks of PFC include mutual decision making, recognizing the assets that each partner -patient/family and clinician -brings to improved health; including patients and families as design and quality improvement partners; conveying understanding through use of health literacy; and viewing all systems through the lens of the patient/family experience. For healthcare leaders, clinicians and policy makers, the question is, where to go from here to achieve PFC? Lessons from leaders in PFC provide the following guidance to create a fertile ground for the seeds of partnership to take root and flourish. --- Leadership, Partnerships and Infrastructure Leadership, partnerships and infrastructure are essential factors in the transformation from an organizational-centred focus to a patient-and-family-centred one. To begin, healthcare and policy leaders, clinicians and community members need to assess current systems in light of the Doing To, Doing For and Doing With stages. Facilitated conversations about what currently exists and is accepted or tolerated set the groundwork for moving to greater partnerships. These conversations can occur throughout the organization or the community -in an improvement team at a clinic, with patients as members; at governing boards with patient and family participation; or in regional policy committees, again with patient and family involvement. Facilitated conversations can reveal what all participants expect and what behaviours are needed to transition to partnerships. --- Leadership In their IHI Innovation Series White Paper, Balik et al. (2011) identified leadership prerequisites for an exceptional patient and family healthcare experience. In this model, governance and executive leaders demonstrate that every part of the organization's culture is focused on patient-and family-centred care, and that PFC is practised throughout. In words and actions, leaders consistently communicate that the patient's safety and well-being are the critical criteria guiding all decision making. Furthermore, patients and families are included as partners in care at every level, from policy decision-making bodies to team members providing individual care. Balik et al. (2012) found, based on learning from exemplars and others striving for PFC, that the following seven leadership actions can create fertile ground in which to establish the PFC model. • Purpose -clearly describe the purpose of PFC for everyone in the organization or community. • It's Everyone -senior leaders ensure that all leaders are clear and consistent in words and actions about the purpose of PFC. • Puzzle Maker -leaders assemble the puzzle pieces so that others can see how PFC fits in the organization's overall strategy for safety, quality and financial vitality. • Close to the Work -leaders understand firsthand the barriers to achieving PFC in their organization and strive to remove them, in partnership with those who do the work and with patients and families. High levels of PFC performance lead to the development of true partnerships between patients/families and clinicians … about PFC and links to the organization's mission. During rounds they also seek to understand the daily care environment for patients/families and staff and to actively remove barriers to effective PFC. --- Partnerships Partnerships between patients/families and clinicians are an essential component of PFC. To help forge these partnerships, three main requirements must be considered. First, knowledgeable patients and family partners must be involved in care design and improvement. Patient and family commitment to these partnerships can range from short-term participation, such as a review of patient or community education materials, to long-term, such as involvement in designing health services to better meet the needs of those with chronic conditions. If the issue at hand is about patients or healthcare delivery, consumers of healthcare should, without exception, be at the table . A second requirement for partnerships is health literacy. Clinicians carry the responsibility for health literacy, ensuring that communication -written and verbal -is clear and understandable to patients and their families. In so doing, clinicians can empower patients and families to be more informed and capable in self-management. A third requirement is family presence, as described fully by the Institute for Patient-and Family-Centered Care (www.ipfcc. org). Family presence ensures that loved ones are not separated during the course of care. --- Infrastructure Effective systems and supportive infrastructure are essential for a successful PFC environment. High-impact systems enable clinicians and others in healthcare to develop new skills and tap into the passion that led to their entering the healthcare profession. Developing partnership skills -and these are new for most clinicians, administrators, and patients and families -enables the partners to create new systems together to meet the needs of those receiving care. To realize these high-impact systems, organizations need to put structures and processes in place to ensure that patient and family partners are clear about their role, responsibilities and skills. Achieving PFC requires significant changes in existing healthcare systems, and performance improvement systems can accelerate progress toward PFC. However, performance improvement must become deeply embedded in the infrastructure of the organization; otherwise, old patterns will continue to dominate. More direct involvement with the patient experience of leaders in the organization also leads to important improvements. Leaders and clinicians who observe and learn from the patient's journey -across sites of care and into the community -will gain new insights that lead to designing high-impact systems. Role Models for Progressing to PFC Adopting these elements of leadership, partnership and infrastructure is not an instant solution, but they are important steps on the journey to PFC and true transformation in health and healthcare. The energizing story is that organizations exist that illuminate many of these essential characteristics in action. Spectrum Health, Winchester Hospital, Winchester, MA; St. Mary's Hospital, Rochester, MN; Gundersen Lutheran, LaCrosse, WI; Baylor Medical Center, Dallas, TX; Mary Hitchcock, Dartmouth, NH; and all the Planetree-designated hospitals (http://planetree.org/?page_id=260;) are among those who exemplify the best in what healthcare can become. While the organizations listed here would stress that they have far to go, they offer encouraging role models of leaders who are able to successfully grow a sustainable culture of patient-and familycentredness. --- About the Author Barbara Balik, RN, EdD, is the principal of Common Fire Healthcare Consulting, senior faculty at the Institute of Healthcare Improvement, and member of the National Patient Safety Foundation Board of Governors. She is based in Albuquerque, NM. --- High-impact systems enable clinicians and others in healthcare to develop new skills and tap into the passion that led to their entering the healthcare profession.

Elements of a sustainable culture that nourishes patient-and family-centredness (PFC) in healthcare are elegantly simple, but achieving PFC poses profound challenges for healthcare systems and policy. Healthcare organizations and policy makers often identify tactics and tools that they believe enhance PFC, but they fail to involve the very people who use healthcare services: patients, their families and community members. A way of viewing the journey to a sustainable PFC culture is by examining those elements of leadership, partnership and infrastructure that are necessary for its achievement.

INTRODUCTION Corona virus disease-2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV-2) which was declared as a pandemic on 11 th March 2020. 1 The clinical diagnosis of COVID-19 is mainly based on epidemiological history, clinical symptoms, Computed Tomography (CT) scan, and nucleic acid detection by a Real-Time Polymerase Chain Reaction technique (RT-PCR). 1 SARS-CoV-2 is an enveloped, single stranded RNA beta corona virus that belongs to the family Coronaviridae. It has four major structural proteins; Envelope (E), Membrane (M), Nucleocapsid (N), and Spike (S) protein. The S and N proteins are the principal immunogens used for the detection of anti-SARS-CoV-2 specific antibodies. 2 The S protein consists of two subunits. The first subunit (S1) mediates the attachment of the virus to human cells via its receptor-binding domain (RBD), and the second one (S2) mediates membrane fusion for viral The humoral immune response to infection or vaccination or Herd immunity has two basic outcomes: Antibody production by Antibody Secreting Cells (ASCs), which can provide rapid humoral immune response, and the development of long-lived memory B cells, which can mount recall responses. Memory B cells drive the recall response by producing new antibodies by establishing new ASCs or re-entering germinal centers for subsequent rounds of somatic hyper mutation if circulating antibodies fail to protect against a future exposure. 3,4 COVID-19 vaccination approaches aimed to generate neutralizing antibodies against S, hence preventing SARS CoV-2 infection in its early stages. Several vaccines have been demonstrated to be safe and effective in clinical studies and vaccination in huge numbers (when used in combination with other existing control measures) is recognized as one of the most important aspects of pandemic management. Although the results of clinical trials are encouraging, real-world evidence on vaccines is still lacking. Hence, this study was planned to estimate the seroprevalence of SARS-CoV-2 antibodies and to determine the association of them with the sociodemographic profile of the study subjects. --- METHODS It was a community based analytical cross-sectional study done in rural areas of Eluru district, Andhra Pradesh State for a period of 2 months (1 st October 2022 to 30 th November 2022). There were 16 villages in rural field practice area, from which 4 villages were selected by using simple random method, from each village 30 members were selected by using systematic random sampling. Sampling interval was calculated for each village separately (Figure 1). According to the study conducted by Muro et al, in Salamanca, seroprevalence of SARS-CoV-2 antibodies was found to be 8.25%, Confidence interval (CI) at 95%, alpha error (α): 5%, absolute precision 5% a sample of 120 was included. 5 People residing in rural areas who were aged 15 years and above, who were willing to participate and gave consent were included and who were absent on the day of data collection were excluded. The questionnaire used in the study was pretested among people from different areas and necessary modifications were made to make it more understandable. Prior to data collection, an elaborative briefing about the purpose of the study was done to study subjects. Data was collected from each subject by personal interview method. Permission from Institutional Ethics Committee was obtained prior to start of study. An informed consent was taken from the study subjects after thorough explanation about the purpose of the study. An assent was taken if study subject's age was between 15 years and 18 years. Blood samples from the selected individuals were taken Humoral responses (Ig G) were assessed using an ICMR approved Micro well ELISA test for the semiquantitative detection of COVID 19 (SARS-CoV-2) neutralizing antibodies in human serum samples. The antibodies titers (IgG) cut off >10 AU/ml were reactiveindicates presence of SARS CoV-2 IgG antibodies and <10AU/ml were non-reactive-indicates absence of SARS CoV-2 IgG antibodies. The collected data entered in Microsoft Excel 2019 and analysed using IBM-SPSS version 26 software, trial version. --- RESULTS Out of 120 study subjects, majority 104 (86.7 %) of them had reactive Ig G antibody titers for SARS Cov2, followed by 16 (13.3 %) had non-reactive Ig G antibody titers for SARS Cov2 (Figure 2). Sociodemographic factors were not significantly associated with antibody titers (Ig G) with (p>0.05) (Table 1). Comparison of means of antibody titers (Ig G) between period of last dose of covid vaccination by applying ANOVA test this was found to be statistically significant with F-value 3.373 and p-value= 0.02 (Table 4). --- DISCUSSION In the present study, 104 (86.7%) of them had reactive Ig G antibody titers for SARS Covid 19, followed by 16 (13.3 %) had non-reactive Ig G antibody titers for SARS Covid 19. In the study conducted by Bawa, Mukesh et al, seropositivity for SARS-Cov-2 IgG antibodies was found to be higher 84.48%. 6 In the study conducted by Carolin et al, the overall seroprevalence of IgG antibody for COVID-19 was 57.9%. 7 Study conducted by Kumar et al, the seroprevalence of Covid 19 in the S. Andaman district was found to be 39%. 8 The results were similar to the studies conducted by Bawa, Mukesh et al, and lower than the studies conducted by the Carolin et al, Deepak Kumar et al. 7,8 In the present study sociodemographic characteristics like age, gender, religion, education, occupation, type of family, Socio-economic status were found to be statistically not significant and not associated with the seroprevalence of covid 19 antibodies (p>0.05). In the study conducted by Bawa, Mukesh et al, there was no difference in seropositivity among participants as per religion, gender and SES. 6 The age group above 45 years had 91% of seropositivity, those between 18 and 44 years had 78.9%, while the age group between 6 to 18 years age had 70% seropositivity; this difference was found to be statistically significant (p = 0.001). Those participants who had confirmed COVID-19 in the past one year had 96% of seropositivity. In the study conducted by Carolin et al, age, education, occupation, presence of comorbidities and presence of self-reported symptoms were not associated with seroprevalence (p-value>0.05) whereas female gender was significantly associated with seroprevalence. 7 The present study was not similar to the studies conducted by Bawa, Mukesh et al, Carolin et al, Deepak Kumar et al. [6][7][8] In the current study, History of covid 19(p=0.02), period from recent dose of covid vaccination (p=0.04) were found to be statistically significant and associated with the seroprevalence of covid 19 antibodies. In the present study comparison of means of antibody titers (Ig G) between period of most recent dose of covid vaccination by applying ANOVA test this was found to be statistically significant with F-value 3.373 (p-value= 0.02). Study population was included only from rural population excluding the urban population. The study is limited because cellular immunity, which offers protective and long-lasting immunity against the virus, was not tested. It's been theorized that the real population level immunity to COVID-19 may be underestimated by IgG prevalence investigations. 9 --- CONCLUSION High seroprevalence in this study suggests that COVID-19 vaccination remains the best method to control the COVID-19 pandemic. It is necessary to encourage the public to take vaccination. --- Recommendations Awareness is mandatory for COVID-19 vaccination, promoting mass campaigns and encouraging public for vaccination and there is need in the development of COVID-19 vaccination for benefiting all age groups. --- Conflict of interest: None declared Ethical approval: The study was approved by the Institutional Ethics Committee

Background: SARS-CoV-2 is an enveloped, single stranded RNA beta corona virus that belongs to the family Coronaviridae. The S and N proteins are the principal immunogens used for the detection of anti -SARS-CoV-2 specific antibodies. 2 The first subunit (S1) mediates the attachment of the virus to human cells via its receptorbinding domain (RBD), and the second one (S2) mediates membrane fusion for viral entry. Antibodies that bind to the S protein can neutralize corona viruses. Methods: It was a community based analytical cross-sectional study done in rural areas of Eluru district, A.P. State. From each village 30 members were selected by using systematic random sampling. A sample of 120 was included. Blood samples from the selected individuals were taken Humoral responses (Ig G) were assessed using an ICMR approved Micro well ELISA test for the semi-quantitative detection of COVID 19 (SARS-CoV-2) neutralizing antibodies in Human serum samples. Results: In the present study 46 (28.3%) had higher education, 15 (12.5 %) belong to farmers, 84 (70%) of them belong to Hindus, 94 (78.3%) of them belong to nuclear family. History of COVID 19 (p=0.02), period from recent dose of covid vaccination (p=0.04) were found to be statistically significant. Conclusions: High seroprevalence in this study suggests that COVID-19 vaccination remains the best method to control the COVID-19 pandemic. It is necessary to encourage the public to take vaccination.

Introduction In August 2016, Amnesty International, while maintaining and reaffirming its strong condemnation of human trafficking, released a model policy that calls upon countries to decriminalize the sex trade in order to better protect the health and human rights of sex workers [1]. As Amnesty explains in the policy, decriminalization is the shift from "catchall offences that criminalize most or all aspects of sex work," including laws that target noncoercive third parties who purchase or facilitate sex work, to "laws and policies that provide protection for sex workers from acts of exploitation and abuse" [2]. The policy has been supported by the World Health Organization, UNAIDS, the Global Alliance Against Traffic in Women (GAATW), Human Rights Watch, Lambda Legal, the American Civil Liberties Union, Freedom Network USA, and numerous other organizations that focus on vulnerable populations, including victims of human trafficking [3,4]. Most importantly, it is a policy overwhelmingly supported by those trading sex-the community impacted by these laws and policies [5]. In contrast, organizations that view decriminalization as granting permission and impunity to would-be exploiters have criticized the policy, despite its insistence that anti-trafficking and physical and sexual assault laws be maintained or established [1]. These criticisms, however, fail to engage in a nuanced conversation of sex work as it relates to exploitation, poverty, discrimination, worker rights, and human trafficking [6]. More importantly, research shows the opposite to be true-that it is criminalization that creates conditions of impunity and enhances sex workers' vulnerabilities to violence and exploitation, including trafficking. --- Reasons to Oppose Criminalization of Sex Work Sex work and sex trafficking are not synonymous. Involvement in the sex trade occurs across a constantly shifting spectrum of choice, circumstance, and coercion. Victims of trafficking are at the far end of this spectrum, involved through force or coercion. While quantifying the number of persons trafficked into the sex trade is difficult, as we discuss below, we do know that criminalization of sex work increases sex workers' vulnerability to violence, exploitation, and trafficking [7]. So, here, we discuss four reasons why health care professionals should oppose the criminalization of sex work. Increased violence. First, criminalization increases opportunities for violence that's de facto unreportable [7]; that is, because the work they do is regarded as criminal activity, sex workers are easy targets for abuse and exploitation, including trafficking. Fear of arrest and other consequences means that those engaged in sex work are less likely to report instances of violence or exploitation, resulting in a "climate of impunity [that] emboldens police, health sector, and non-state groups to abuse sex workers' rights" [8]. This is true even for so-called "partial criminalization" frameworks, such as those that penalize only the buyers of sex. Although such a strategy appears at first glance to be grounded in the well-being of sex workers, implementation often means policing of the areas where sex workers conduct business. This forces those working into more isolated conditions and locations, increasing their physical vulnerability. It disrupts critical safety strategies and negotiations including harm-reduction techniques-such as the use of condoms-and peer networks [7]. According to a study published in the Lancet, partial criminalization "creates harms similar to those of full criminalisation by impeding sex workers' ability to protect their health and safety, and creating an antagonistic relationship with law enforcement resulting in a climate of impunity" [8]. Erosion of trust. Second, criminalization undermines trust in support systems, including health care. Fear of judgment, discrimination, lower quality of service, and legal consequences inhibit many from disclosing that they are involved in sex work, regardless of whether they are so engaged through choice, circumstance, or coercion [9]. One study of 783 sex workers reported that 70 percent had never disclosed the nature of their work to a health care professional [10]. In a needs assessment of sex workers who seek clients in public spaces, often referred to as street-based sex work, one woman explained, "I was raped and was afraid to be judged by the hospital and that they'd call the police" [9]. Disrupting the relationship between a health care professional and a sex worker can mean important red flags for exploitation, violence, and trafficking go unreported. Increased vulnerability. Third, involvement in the criminal justice system creates longlasting consequences, in terms of a person's health outcomes and vulnerability to trafficking and other forms of exploitation. The inability to hide an arrest and conviction for prostitution makes obtaining formal employment, housing, benefits, and community support significantly more difficult. Fines, fees, and costs associated with an arrest exacerbate poverty, which significantly increases a person's vulnerability to trafficking and other forms of exploitation. Stigma. Finally, criminalization reinforces stigma, which perpetuates sex workers' marginalization. Research supports the fact that sex workers are some of the most marginalized people in the world, subject to widespread human rights violations including homicide, physical and sexual violence, incarceration, harassment from law enforcement, and discrimination in accessing health care and other sources of support [1]. Socially, culturally, politically, and economically, sex workers are stigmatized, ignored, and actively silenced even in advocacy spaces debating the very policies that influence their lives [11]. Too often, sex workers are spoken for instead of given a platform for speaking themselves, and a result is a lack of recognition and enforcement of their basic human rights. --- Conclusion Decriminalization can motivate more prominent recognition of sex workers' human rights and is thus a critical mechanism for decreasing trafficking. When we improve the health and human rights of sex workers, we do so for those who are trafficked into sex work as well. Indeed, the United Nations Office of the High Commissioner for Human Rights "Recommended Principles and Guidelines on Human Rights and Trafficking" notes that "violations of human rights are both a cause and a consequence of trafficking in persons," and therefore it is "essential to place the protection of all human rights at the centre of any measures taken to prevent and end trafficking" [12]. By decriminalizing sex work, sex workers who experience violence can seek help from law enforcement, health care workers, or even friends with less fear of consequences to themselves or others. They can engage peer networks and employ harm-reduction techniques that help keep them safer, such that they no longer have to face the consequences of a criminal record for simply trying to survive. consultation and leadership for task forces in New England and across the country. She specializes in building organizational capacity and service collaboration through training and consultation with service providers, law enforcement, task forces, and law makers. Kate D'Adamo, MA, is a national policy advocate at the Sex Workers Project in New York City, where she works on policy and social advocacy at the state, federal, and crossregional level on issues impacting those engaged in the sex trade, including human trafficking and HIV. Prior to joining the Sex Workers Project, Kate was a lead organizer with the Sex Workers Outreach Project-NYC and Sex Workers Action New York, two constituent-led organizations supporting those trading sex in the NYC area. She has also worked on issues including human trafficking, labor rights, international solidarity, and migration at the International Commission for Labor Rights, Global Workers Justice Alliance, the Open Society Foundation, and the Freedom Network USA.

In order to decrease human trafficking, health care workers should support the full decriminalization of prostitution. Similar to trafficking in other forms of labor, preventing trafficking in the sex trade requires addressing the different forms of marginalization that create vulnerable communities. By removing punitive laws that prevent reporting of exploitation and abuse, decriminalization allows sex workers to work more safely, thereby reducing marginalization and vulnerability. Decriminalization can also help destigmatize sex work and help resist political, social, and cultural marginalization of sex workers.

A COMPARATIVE STUDY OF GRIEF SUPPORT AND BURNOUT AMONG NURSING HOME STAFF Frances Hawes 1 , and Shuangshuang Wang 2 , 1. University of Eau Claire,Wisconsin,United States,2. Southwest Jiaotong University,Chengdu,Jiangsu,China (People's Republic) A half-million older adults die in U.S. nursing homes (NHs) each year. However, only a few studies have been conducted on the experiences of the nursing home (NH) staff who provide this care. This study collected data from 555 NH workers in Fall 2022 and examined how their experiences with grief support affected burnout. Grief support was measured by the Grief Support Health Care Scale. Burnout was measured by the Maslach Burnout Inventory, which includes 3 subscales: exhaustion, depersonalization, and personal achievement. Findings indicate that 95% of sampled workers were exposed to at least one death at work; yet 31% percent of the sample never received any formal grief training. Examining the comparative dimensions of burnout, the highest percentage of workers with exhaustion and depersonalization ratings were RNs, nurse practitioners, and physicians, followed by CNAs. The lowest ratings of personal accomplishment were by direct support workers (maids/janitors housekeeping and laundry food service workers). Controlling for NH and individual characteristics, multivariate logistic regression showed that compared to workers who received low grief support, those who received high grief support were more likely to report high personal achievement and low feelings of depersonalization (i.e., impersonal response to residents). This research provides valuable information about the importance of grief support for nursing home workers to reduce feelings of burnout. In addition, findings indicate that there is a difference in grief support and burnout between different categories of nursing staff and there is a need to provide increased grief support to frontline workers. Abstract citation ID: igad104.1077 --- PERSPECTIVES OF GERIATRIC FELLOWS TOWARD SCHOLARLY ACTIVITY Sadaf Milani 1 , Adeeb Ahmed 2 , Shilpa Rajagopal 1 , and Mukaila Raji 3 , 1. University of Texas Medical Branch, Galveston, Texas, United States, 2. University of Texas Medical Branch at Galveston, Galveston, Texas, United States, 3. The University of Texas Medical Branch, Galveston, Texas, United States Previous research conducted nearly two decades ago found that almost half of geriatricians published during their fellowships. About 17% of these geriatricians also indicated a need for further training in scholarly activity. However, it is unclear what barriers and facilitators to participating in scholarly activity geriatric fellows currently face. Our objective was to assess perceived barriers, facilitators, and attitudes toward scholarly activity among current geriatric fellows in ACGME-accredited programs. We conducted a survey of current geriatric fellows from September 2022 to November 2022. An online survey was emailed to geriatric fellows and geriatric program coordinators, when geriatric fellow emails were not publicly available, to assess fellows' perceived barriers, facilitators, and attitudes toward scholarly activity. We used descriptive statistics to assess geriatric fellows' perceptions of scholarly activity. Our sample (n=36) was mostly women (61.1%). The most common scholarly activities fellows planned to participate in during fellowship included quality improvement projects (80.6%), case report/ series (44.4%), or original research studies (44.4%). The most common perceived major barriers reported were the short duration of fellowship (69.4%) and lack of training to conduct scholarly activity (58.3%). Lastly, about 44.4% of fellows reported being extremely or very enthusiastic and 50% reported being somewhat enthusiastic about participating in research during their fellowship. Most fellows reported plans for at least one type of scholarly activity and reported at least being somewhat enthusiastic about participating in research, however, barriers were identified. A follow-up email survey will be distributed at the completion of fellowship to assess changes in fellow perspectives.

shared driver of multiple conditions. This goal is the foundation of an emerging discipline, geroscience. Geroscience has fostered new research on the basic biology of aging with rapid development of biomarkers of biological age, and therapeutics that target aging biology advancing to clinical trials. This presentation will provide a translational framework for early-career investigators who seek to evaluate biological processes underlying aging, and test promising interventions targeting these processes from animal models to clinical trials. This includes: 1) developing outcomes and biomarker frameworks for aging outcomes trials, and 2) establishing functional consequences of cellular senescence in older adults; and 3) creating opportunities to grow a diverse inter-disciplinary research program in geroscience through professional organizations, scientific networks, and NIA-supported research centers.

The researchers published their findings in 2021. They showed that, while there was an increase in social mobility in many regions between the first and second cohorts, as several regional economies shifted from manufacturing and mining to services, these increases in social mobility slowed, and sometimes even stalled, for more recent cohorts. This was around the start of the 21st century -a period of socioeconomic change -with increased globalisation, the 2008 economic crash, and the start of the 'gig economy'. However, what stood out for the researchers was the patterning of regional disparities. In addition to the expected variation between large regions, they found substantial heterogeneity in social mobility within all regions as well. Indeed, all regions in England and Wales contained local districts in both the top and bottom 20th percentile of social mobility nationally. --- But what about schooling? Gorman, Buscha, and Sturgis then turned their attention to another popular perception -that selective education is an effective policy --- Changing patterns of social mobility in Britain All regions in England and Wales contained local districts in both the top and bottom 20th percentile of social mobility nationally. Social mobility refers to the link between a person's family origins and later social and economic life outcomes. Greater social mobility indicates a fairer society with more equality of opportunity. Dr Emma Gorman and Professor Franz Buscha at the University of Westminster, and Professor Patrick Sturgis at the London School of Economics, examined social mobility patterns among three birth cohorts in England and Wales. They identified substantial geographic heterogeneity in social mobility at the local level. The research team also found that selective education is not a 'silver bullet' policy solution for increasing social mobility. tool for increasing social mobility. To investigate this concept, they drew on data from a controversial period in British education. Between 1945 and the 1970s, England and Wales had a selective schooling system. This meant that primary school pupils -no matter their social background -could be selected to go to a more academically focused, state-funded grammar (secondary) school if they performed well in specific national exams. Successive governments proposed that such a system would support otherwise disadvantaged young people to achieve their full potential. The system was progressively phased out in England and Wales in favour of the current comprehensive, or mixed-ability, education system, with only a selection of UK grammar schools still being in existence today. Using census data linked to administrative records on school selectivity within local education authorities in England and Wales, the researchers examined whether patterns of intergenerational social mobility were related to selective schooling during the period of transition from the predominantly selective to the predominantly mixed-ability schooling system. While tracking cohorts across this period, they found that, accounting for local area characteristics and broader changes in the national economy, correlations between exposure to selective schooling and social mobility were small. The findings do not support the idea that either selective or comprehensive schooling improved overall social mobility outcomes, and reject the large effects which are often mooted on both sides of this debate. --- Upending perceptions Gorman, Buscha, and Sturgis have challenged popular perceptions about trends and drivers of social mobility. Their detailed, statistical analysis across generations has shown that while claims of a northsouth divide in social mobility might support political narratives -such as the current British government's 'levelling up' policy to reduce regional economic imbalances across Britain -they miss the nuanced reality. A person's local district within a region in Britain may be just as crucial for their chances of upward mobility as whether they were born in the north or south, or indeed even the generation in which they were born. --- Details Personal response --- If there is substantial heterogeneity in social mobility in all regions of Britain, what does that say about the country in terms of equity and fairness? Geography is an important dimension in debates about social mobility, and concerns about 'left-behind' towns and cities are now a persistent feature in policy discussion. While much commentary focuses on the so-called North-South divide, our study highlights that inequalities in social mobility are in fact more granular than this. Even if there is increasing upward and relative mobility at the national level, aggregates of this kind will be of little relevance to the experiences of people in local areas with markedly worse mobility prospects than the national average. Taking a localised perspective to policy is important for reducing geographic inequalities in economic opportunities. --- Where would you like to take your research next in the search for a better understanding of social mobility? Given the recent economic trends of stagnating real wages and living standards, many in the younger generations are concerned that they have been excluded from the upward mobility and economic security experienced by their predecessors. However, relatively little is known about the social mobility prospects of these cohorts. Our future research will aim to quantify the social mobility experiences of recent generations as well as shed light on the drivers of geographical patterns in social mobility. --- What would you say to those who argue for the return of selective schooling to encourage social mobility? While there is evidence that for some individuals, improved educational outcomes were indeed facilitated by attending a grammar school, we hear less about the group of people who missed out on attending a grammar school. That is, those young people who did less well in a secondary modern than they would otherwise have done in a mixed ability school. To properly assess the effect of a schooling system on social mobility, it is necessary to consider the outcomes for all affected individuals, not the beneficiaries only. This is what our research does, and it shows that selective schooling does not improve social mobility in society as a whole. Social mobility should not be used as a justification for expanding the grammar school system. --- If education is not the 'silver bullet' solution to stalling social mobility, what is? This and other research show that there is unlikely to be any one silver bullet to improve social mobility; rather, a multifaceted approach is required. --- Where would you like to see fellow researchers in your field build on your research? Further work examining these questions in Scotland and Northern Ireland would offer a more complete picture of patterns of social mobility for the United Kingdom as a whole. --- e: e.gorman@westminster.ac.uk w: www.westminster.ac.uk/about-us/ourpeople/directory/gorman-emma --- Details The findings do not support the idea that either selective or comprehensive schooling improved overall social mobility. Furthermore, neither the comprehensive state-school education nor the selective school system showed large benefits for social mobility. This would suggest that education is not a 'silver bullet' solution to the larger problems of economic inequality and stalling social mobility.

ocial mobility refers to the extent to which life outcomes are determined by the circumstances into which a person is born and raised. Greater social mobility -the ability to move through the socioeconomic 'ranks' over generations -is often seen as an indication of a fair and open society, and is therefore high on the policy agenda in Britain. Popular perceptions of social mobility are that the divisions in life outcomes are persistent and often related to geography, with those living in Wales and northern England having fewer opportunities to move up the economic and social ladder than those in more affluent areas in the south of England. However, new research suggests the picture is more nuanced than previously believed, and that previous education policies may not have the large impacts on social mobility commonly mooted by media and policy commentators.

Thalassemia, a group of genetic (autosomal recessive) blood disorders characterised by abnormal hemoglobin production in red blood cells, is a major health challenge in the United Arab Emirates (UAE) burdening the healthcare system, individuals and families. The gene carrier frequency and incidence of βthalassemia, the most severe type, are high in the indigenous Emirati population. 1 Yet, thalassemia in the UAE is underrepresented in the literature. Previous studies have focused on genetics and molecular characterisation 2 while neglecting cultural and social aspects. In this commentary, we discuss how tradition and religion in the UAE affect the prevention and management of thalassemia. Suggestions are offered on how to improve prevention of this blood disorder. Traditional marriage practices largely explain the high incidence of thalassemia in the UAE. Emirati society values closeknit families, clans and tribes, and also arranged marriages between close biological relatives (consanguinity) and between tribal members (endogamy). Cousin marriage, preferably between second or first cousins, is highly respected and is thought to support family stability and protection of assets. Consanguinity and endogamy continue to be widespread, despite rapid cultural and social changes since the 1970s, 3,4 and increase the likelihood of reproduction between thalassemia carriers and having a homozygous child. This is particularly the case in families and tribes characterised by a succession of inbreeding in previous generations and descent from a recent common ancestor. 4 A discussion in public and within families about health disorders caused by consanguinity and endogamy is needed, because many Emiratis believe in religious explanations. The discouragement of endogamy in some Islamic teachings, and the permissibility of marriage between different tribes and races in the Qur'an, should be emphasised. Information can be communicated via diverse channels including mass media, flyers and pamphlets, websites, social media and personal communication. Family and community education campaigns including distribution of educational publications such as factsheets, television programming and online videos, will help stimulate conversations within families and communities. While the curtailment of cousin marriage in the UAE might be slow-going, it is promising to note that other marriage and family traditions are in flux (e.g. family size, marriageable age, mixed marriage). These changes, and their facilitators and barriers, can be considered in attempts to combat thalassemia. Premarital screening has been funded by the Government since 2008 (which is now mandatory, unlike voluntary screening in other countries), and neonatal screening since 1995. Genetic counselling is available to couples identified as carriers, and also to their families, who are typically involved in decision making despite ethical issues such as patient confidentiality. 5 Our discussions with medical doctors confirm that carrier couples are often advised to refrain from marriage. However, while marriage and conception choices are up to the couple, the options available for those identified as carriers or given a prenatal diagnosis of thalassemia are limited. A couple is likely to continue with a marriage and starting a family because they are prized in Emirati culture, whereas separation, divorce or voluntary childlessness can © The Author(s) 2023. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/ by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com International Health be embarrassing and even stigmatising. 4 Although a significant proportion of couples in Western countries choose to terminate affected pregnancies, abortion is illegal in the UAE. New techniques such as in vitro fertilisation are also illegal. 5 Adoption is only permitted when the child is kept within the lineage of its biological parents. 5 These limited options raise questions about the effectiveness or even the logic of screening and diagnosis and genetic counselling in thalassemia prevention in the UAE, although they certainly assist couples preparing for the birth and upbringing of an affected child (and also reassure non-carrier parents). Research is needed on experiences of genetic testing and genetic counselling, and on decision making following abnormal genetic test results, because only genetics research and no sociological research has hitherto been conducted. 6 It seems untenable to try and change public attitudes towards the legality of abortion, which are based on interpretations of Islamic teachings. We advocate earlier genetic testing, for example, during matchmaking when potential spouses are considered by parents, and before unmarried people make a choice. Because social marketing campaigns in the UAE about thalassemia are currently aimed at adults and couples, 7 school-based health education and screening, perhaps as part of school curricula, can raise awareness and cultivate responsibility for thalassemia prevention from an early age. The high standard of living and generous welfare provision in the UAE mean that state-of-the-art healthcare and support are available and subsidised. Yet, treatment of thalassemia requires inordinate resources. Severe forms of thalassemia can cost an estimated AED 131 156 (US$35 713) annually per patient, of which life-long and regular iron chelation therapy (AED 78 372) and blood transfusions (AED 34 223) constitute the largest costs. 8 Diagnostic and laboratory tests, medical consultations and medications are also expensive. Living with symptoms and complications, and medical consultations and treatments, constitute a significant disruption to people's lives. Employees in the UAE with thalassemia report lost productivity and absenteeism. 9 Studies in other countries highlight emotional and social problems among those with thalassemia and also possible interventions, 10 but research in the UAE is lacking. Research is also needed on support from family and community and non-government organisations. In summary, we have highlighted pertinent cultural and social aspects of thalassemia prevention and management in the UAE. While there are no easy answers to curbing its high incidence, changing attitudes towards traditional marriage practices, health education targeting families and young people, and availability of earlier genetic testing, are culturally acceptable solutions and likely to be more effective than questioning the legality of abortion and reproductive technology. Initiatives should be supported by research on experiences of living with thalassemia (e.g. genetic testing, treatment, quality of life). --- Data availability: None. --- Authors' contributions: Both authors contributed equally and confirm responsibility for manuscript preparation. --- Funding: None. Competing interests: None. Ethical approval: Not required.

Thalassemia is a major health challenge in the United Arab Emirates (UAE), however previous studies have focused on genetics and molecular characterisation while neglecting culture and society. In this commentary, we discuss how tradition and religion in the UAE (e.g. consanguinity, endogamy, illegality of abortion and in vitro fertilisation, adoption restrictions), and limited academic research, affect the prevention and management of the blood disorder. It is suggested that changing attitudes towards traditional marriage practices, education and awareness campaigns targeting families and young people, and earlier genetic testing, are culturally acceptable solutions to curbing the high incidence of thalassemia in the UAE.

Introduction Student-Centered Learning (SCL) is a paradigm that places students in the driver's seat of the learning process, allowing them to decide for themselves what they need to learn and how they might learn it (Glasgow 1997). Around the world, SCL is adopted by many schools and education systems that promote problem-based learning, project-based learning, case-based learning, and inquiry learning (Lee and Hannafin 2016). Drawing from constructivist, constructionist, and self-determination theories, Lee and Hannafin (2016) propose that SCL cultivates student engagement through key constructs of autonomy, scaffolding, and audience. Specifically, autonomy empowers students with control over their learning (Dochy et al. 2003); scaffolding creates a strategic pathway for learning (Vygotsky 1978); and authentic audiences provide students with purpose and accountability for learning (Kearney and Schuck 2006). While these constructs are critical foundations of SCL represented in international scholarship, one limitation of Lee and Hannafin's (2016) article is to consider how autonomy, scaffolding, and audience may differ according to cultural or linguistic context. From an international, multicultural perspective, SCL is a field of educational research that is consistently studied in a variety of sociocultural contexts. Scholars and practitioners alike engage in research to better understand how motivation and self-regulationkey components of SCL-can be incorporated into diverse classrooms with the goal of empowering learners from early childhood classrooms (Nair 2019), to English as a Foreign Language classrooms (Mak and Wong 2018), to special education classrooms (Pederson and Liu 2003). In their article, Lee and Hannafin (2016) propose a design framework to enhance engagement within SCL, which they term "Own it, Learn it, Share it." With the Shift to Digital movement during COVID-19 that resulted in teaching and learning online, this proposed framework presents promising opportunities to enhance student engagement in virtual classroom spaces. Specifically, it offers timely principles that inherently promote student-centeredness when the abrupt move to digital learning resulted in predominantly teacher-centered pedagogy (Moorhouse 2020). Own It, Learn It, Share It provides a number of practical applications that educators and scholars can consider in digital learning environments. In brief, Lee and Hannafin (2016) propose to increase student engagement by enhancing student autonomy (i.e. Own it), cultivating metacognition throughout the learning process (i.e. Learn it), and empowering students to engage their work with a meaningful audience (i.e. Share it). Although technology is only explicitly referenced in the "Learn It" stage of the design framework, it can be applied to all design assumptions. To foster autonomy and "own" specific learning initiatives, the first guideline proposes that teachers facilitate student endorsement of external goals. Teachers create space for students to set specific goals with choices that are relevant and applicable to their lives. This may be done in digital environments through synchronous videoconferencing systems or asynchronous learning management systems. Adopting an international, multicultural perspective highlights a limitation of Lee and Hannafin's (2016) article whereby educators may note that "owning" a learning initiative may vary from one cultural context to the next. In education systems with high stakes assessments that strongly influence curriculum design and day-to-day instruction, student ownership or autonomy may be limited with prescribed goals for students to choose from. For example, in Hong Kong where teachers often prepare students for school-based and territory-wide assessments during classroom instruction, teachers may ask students to "own" a particular writing assignment by choosing from a select list of writing goals (Mak and Wong 2018). While this may foster autonomy among the learner, it can significantly contrast with other school systems that provide students with more freedom to "own" and develop their writing skills. To cultivate metacognition in the "Learn It" phase, design guidelines suggest that teachers provide guidance on how to engage in the learning process and provide support to students as they monitor progress. Technology plays a critical role in this phase as students need to reflect on what they know and don't know (i.e., metacognition) and seek resources-often through technology-to address their gaps in knowledge. With the shift to digital, students with access to resources at home demonstrate learning progress on asynchronous platforms or during synchronous meetings with educators. The privilege of access to educational technology, however, is not equally distributed in countries around the world. A constraint to Lee and Hannafin's (2016) framework is considering for whom SCL might easily benefit. Disparities in access to technology continue to exist both between and within nations (Flack et al. 2020), interrupting the formal education of certain communities at disproportionate rates (Gonzalez 2016). Educators, in response, have the added responsibility of providing access to materials to facilitate independent learning, or to offer explicit guidance to develop digital literacy. Future research may also consider implications for education systems in the Global South. Lastly, to enhance engagement through the "Share It" phase, Lee and Hannafin (2016) propose that educators promote dialogue among students and audiences while also facilitating peer review. Online environments provide unique opportunities and challenges for students to share work. On the one hand, students can speak to a larger audience if their learning is published in public domains. Knowing their work will be shared more broadly, in turn, affects how students own and learn activities. On the other hand, sharing work only through digital platforms limits students from skills that are more readily fostered in inperson environments (i.e., voice projection, reacting to a live audience in a room). Importantly, from an international perspective, educators must consider how different cultures value and understand the notion of sharing. For example, in countries that value saving face-the desire to maintain respect and avoid humiliation in public spaces-sharing may bring added or unnecessary stress and shame that is detrimental to the learning process. This commentary briefly examines Lee and Hannafin's (2016) framework for enhancing engagement through owning, learning, and sharing, from an international perspective. With the sudden shift to digital in classrooms around the world, future research may continue to examine how student engagement varies from context to context to understand how educators can better support all students. --- Compliance with Ethical Standards --- Conflict of interest There are no potential conflicts of interest. Research involving human participants and/or animals This research submission does not involve human participants and/or animals. Informed consent Informed consent was not required for this study. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Kevin M. Wong is an Assistant Professor in the Graduate School of Education and Psychology at Pepperdine University. He seeks educational equity for linguistically and culturally diverse students in pre-kindergarten to grade 12 international contexts. His current research investigates dual-language bilingual education programs, language policies for multilingual education, vocabulary learning through educational media, and teaching and learning during COVID-19.

This commentary is written in response to the manuscript entitled "A design framework for enhancing engagement in student-centered learning: own it, learn it, and share it" (Lee and Hannafin in 64: 707-734, 2016) and offers an international perspective. To enhance student engagement in student-centered classrooms, Lee and Hannafin (64: 707-734, 2016) argue that learners need to be empowered with autonomy, scaffolding, and authentic audiences, manifested in an "own it, learn it, share it" design framework. This commentary examines how each of these frameworks might be implemented with the "shift to digital" learning, and considers how these guidelines might be adopted in international contexts. While owning, learning, and sharing are principles that can be appreciated by systems of education around the globe, the very definitions and understandings of owning, learning, and sharing knowledge need to be carefully considered in light of cultural differences. The commentary concludes with a call for future research to closely examine what student-centered learning in online environments might look like in different contexts.

Introduction Forests are termed common property because they are naturally occurring and own by communities in which they exist. As common property, forest abuse is inevitable. The utilization of resources from forest by rustic tenants became unsustainable. In Nigeria, the scenario was not different. Inorder to regulate the behavior of mankind, laws were made. One of such law led to the creation of National Parks (NPs) for biodiversity conservation (Walpole & Goodwin, 2001). The NPs management is guided by stern laws that prevent rustic tenants where they are located from places they usually obtain resources for survival (Alkan et al., 2009;Shrestha & Alavalapati, 2006). Thus, NPs management was at variance with the need of the people (Khan & Bhagwat, 2010). Although, parks management according to Daniel (2002) consist of three approaches: Top-Down, Mixed Management and Bottom-up Management, most park officials do not involve the community in parks management. In top-down approach, control of the park is mainly by the park authorities with zero input from rustic tenants; mixed management involves the combine administration by parks officials and rustic communities while the bottom-up approach also called community participation involves full engagement of rustic tenants in parks management. In Africa and other developing world, about 90.0% of poor people rely on forest for income, thus, for survival, resorted to illegal harvesting of resources from NPs (Ohwo & Nzekwe-Ebonwu, 2021). This illegal use of NPs led to conflicts and when not properly controlled, loss of lives and properties are inevitable (Hocking et al., 2020). Over the years, poaching of NPs by rustic tenants existed but the level of trespass heightened during the lock down period as alternative sources of livelihood were stilled which resulted in excess exploitation of resources from PAs as the only means for survival (Hocking et al., 2020). In the utilization of parks resources, conflict is inevitable especially with varying interest of conservation of forest (park objective) with the livelihood sustenance of rustic tenants (stakeholders need) (Andrew-Essien & Bisong, 2012). The destruction of farms, lives and properties of rustic tenants by wildlife ensue to conflicts (Msoffe et al., 2007). For development, dialogue is essential in ensuring peaceful coexistence. Various channels and strategies exist for conflict resolution in various communal settings in Nigeria. However, dearth of information exists on the prevailing approach to park management and series of conflicts and their resolution between parks officials and rustic tenants during the lock-down period in Okomu National Park (ONP), Edo State. Examination of conflicts in utilization of resources from NPs and strategies adopted by park officials and rustic tenants in ensuring peaceful coexistence during the lockdown period of COVID-19 pandemic was studied with a view to evaluating their impacts on forest conservation. --- Materials and Methods The study area was Okomu National Park, Edo State, Nigeria. One hundred and fifty (150) respondents from 5 communities (Udo, Ora, Kolobe, Orogbon, Nikrowa) and 20 staff of ONP were randomly selected. Two sets of questionnaires (One for parks officials and the other for rustic tenants) were administered. Information gotten from park officials' included method of parks administration, relationship with rustic tenants (awareness, education, incentive (royalty), laws, penalties and threat to their job and life. Questionnaire for rustic tenants focused on awareness of laws regulating parks activities, conflicts in parks utilization and methods utilized for resolving conflicts. Data were analyzed using descriptive statistics of table, frequency and percentage occurrence. --- Results and Discussion The socioeconomic profile of rustic tenants and staff of ONP in Tables 1 and2 Awareness creation of park laws to rustic tenants shows that 75.0% of ONP staff stated a quarterly awareness education with 10.0% reporting a bi-annual education ( --- Conflicts in Park Utilization Various conflicts were evident in parks resource utilization as shown in Table 5. It shows that 63.3% of rustic tenants do not face obstacle in collections of parks resources while 36.7% encounter obstacles. Ohwo et al. ( 2023) reported an increased exploitation rate of the reserve before (1.89±0.06 and 2.15±0.13) and after (2.39±0.06 and 2.85±0.06) the lockdown period by fringe community dwellers and staff on ONP, respectively. The obstacle were bad terrain (9.3%), rangers interception (5.3%) with 1.3% stating a combine interception of rangers, distance and transportation as obstacles faced. Most (78.7%) of the respondents affirmed knowledge of ONP as protected area and explained that they utilized the forest because they have no other alternative for survival during the lockdown (19.3%). Forty seven percent (46.7%) of rustic tenants were confronted by rangers with 20.0% fighting back. However, majority (50.7%) were not confronted by rangers. Among rustic tenants, 84.7% stated a peaceful coexistence as there were no conflicts encountered in the utilization of Parks resources. Furthermore, the major form of conflict was conspiracy (8.7%) (Table 5). Emelue and Ukandu (2014) stated that rustic tenants around ONP depends on the park for survival because majority were farmers and hunters. The heightened dependence during the lockdown period corroborates the report of Hocking et al. (2020). With conservation objectives of the park on one hand, and the survival strategy of rustic tenants during the lockdown period on other hand, conflict of interest was evident (Borokini et al., 2012). The peaceful coexistence observed by rustic tenants and park officials affirms report of Kastamonu Uni., Orman Fakültesi Dergisi, 2023, 23(2) The obstacles and conflicts faced by staff of ONP are presented in Table 6. Majority (65.0%) of the staff were friendly with rustic tenants while 35.0% were strict. Ninety percent (90.0%) of ONP affirm the existence of conflict with rustic tenants while 20.0% stated that destruction of crops or farms by fauna and the inability of the park to fulfill their social responsibility to the community as the major sources of conflict. Majority (70.0%) of the staff reported the Ijaw community as the most difficult amongst the rustic communities. 2015) and Kainji Lake National Park in Nigeria (Ajayi et al., 2019). Emelue and Ukandu (2014) observed absence of expected benefit from the park as source of conflict in ONP. Education of unschooled rustic tenants by local language highlights the importance of involvement of rustic tenants in park management (Borokini et al., 2012). --- Methods of Conflicts Resolution in ONP The methods of conflicts resolution between rustic tenants and staff of ONP presented in Table 7 showed that 47.3% of rustic tenants had no conflict with the staff of ONP, 26.0% resolved conflicts by dialogue while 2.0% stated that conflicts were solved in community meeting. Majority (44.0%) of rustic tenants agreed with the various methods of conflict resolutions. Other ways suggested by rustic tenants for conflict resolution are by supply of palliative (7.3%), allow collection of minor resources (4.7%) and partial hunting (4.0%). The above methods of conflict resolution were observed by Ruschkowski (2009) The strategies adopted by staff of ONP in resolution of conflicts showed that conflict was seen as a major challenge and the strategy adopted for peaceful coexistence include; intensive support zone program (20.0%), public-private partnership (15.0%), memorandum of understanding, compounding offenses and dialogue (15.0%) (Table 8). Execution of terms on the memorandum of understanding (25.0%), provision of alternative livelihood sources (20.0%), embarking on social responsibility (15.0%) and aggressive support zone program (15.0%) were suggested as alternative ways to resolving conflicts in the park (Table 8). Provision of amenities and alternative livelihood source was proposed by Borokini et al. (2012), benefit sharing by Emelue and Ukandu, (2014) and conservation education by Kwaslema and Eivin, (2015) in Ngel Nyaki Forest Reserve, ONP and in Tanzania respectively. --- The park management techniques showed that 30.0% of staff of ONP stated that monitoring and evaluation of park resources was the most used management techniques, others included provision of alternative sources of livelihood (20.0%), enforcement of conservation laws and protection of the park (15.0%) (Table 9). The community management technique adopted by ONP focused majorly (40.0%) on local advisory committee, provision of social services (25.0%) and restriction of community folks (20.0%). The staff (100.0%) stated that rustic residents were involved in parks management plan, thus the mixed park management approach was evident in ONP. Various ways of community involvement were in decision making (45.0%), sensitization exercise (15.0%), training (15.0%), while the least (5.0%) was recruiting native. With regards to decision on land, the communities were considered with creation of buffer zone (25.0%), random selection and allocation of land for agroforestry (25.0%), recruitment of community natives (15.0%) and educating members of the communities on the importance of adoption of agro-forestry practices ( --- Conclusion The creation of National Parks for conservation of biodiversity is needed for earths' survival. However, with the good intention of parks objectives, conflict existed in its administration especially with rustic tenants. Administration of parks objectives are guided by laws which were affirmed by rustic residents but majority were adamant to these laws causing conflicts. The outbreak of Covid-19 virus and lock down measures left rustic tenants with no alternative for survival but the park, regardless of conservation awareness creation by park officials. Destruction of crops by fauna and lack of sharing of benefit from the park to communities were the major sources of conflicts in the park. The suggested methods of conflict resolution were; supply of palliative/benefit from the park to communities, employment of natives, aggressive support zone programme and provision of alternative means of livelihood. Inclusion of all cadre of rustic tenants in park management, education of unschooled community members in local language were recommended for successful attainment of Kastamonu Uni., Orman Fakültesi Dergisi, 2023, 23(2) Research, 5(3), 56-63 Msoffe, F., Mturi, F. A., Galanti, V., Tosi, W., Wauters, L. A. et al. (2007)

Material and methods: One hundred and fifty respondents from host communities and 20 staff of Okomu National Park were randomly selected and structured questionnaire administered to them. Data were analyzed using descriptive statistics. Main results: Most (86.0%) of community member were aware of law guiding park but were adamant (40.0%) regardless of awareness creation by park officers (80.0%). Destruction of farms by fauna and inability of park managers to fulfill their social responsibilities (20.0%) (Staff) and inability of park to carry out social responsibility (20.0%) (communities) were the major conflict sources. Dialog (26.0%) and intensive support zone programme (20.0%) were suggested by community and staff respectively for peaceful coexistence. Highlights: Conflicts were evident between host communities and park management. The underlying cause is deprivation of host communities from accessing resources and parks manager inability to fulfill their social responsibilities. Conflict resolution method of supply of palliative/benefit from park to communities will aid parks conservation.

INTRODUCTION There has been an active debate regarding the socioeconomic determinants contributing to the pandemic, several studies highlighting that the SARS-CoV-2 virus disproportionately affects socioeconomically disadvantaged individuals (1)(2)(3). Recent evidence has suggested that neighborhood environmental and socioeconomic factors including poor housing quality, overcrowding and inability to work from home may influence SARS-CoV-2 transmission (4). However, the association between neighborhood socioeconomic deprivation and SARS-CoV-2 transmission dynamics remains to be examined. SARS-CoV-2 spreads via close contact during daily activities which results in geographic clustering of cases (5). The location and duration of persistence of these clusters-monitored using spatiotemporal cluster detection techniques-can provide unique insights into the determinants of transmission (6). We hypothesized that the increased risk of infection within disadvantaged communities is the result of conditions favoring sustained and persistent community transmission. Hence, socioeconomically deprived neighborhoods would have longerlasting SARS-COV-2 transmission clusters than less deprived neighborhoods. We investigated this hypothesis by combining spatiotemporal cluster detection with cluster survival analysis, an approach similar to the one applied to cancer data by Huang et al. (7). --- MATERIALS AND METHODS We analyzed data from 3,355 SARS-CoV-2 RT-PCR positive test results among 17,698 individuals tested in the state of Geneva, Switzerland, covering the first phase of the pandemic (February 26 to April 30, 2020). All included patients were confirmed to be infected with SARS-CoV-2 by RT-PCR assays. The Virology Laboratory at Geneva University Hospitals did the tests and provided anonymized data, including residential addresses. Only individuals who provided a valid residential address and who resided state of Geneva were included. Residential addresses were geocoded by address matching on the reference dataset of Swiss addresses (www.housing-stat.ch). SARS-CoV-2 transmission patterns were monitored through space and time using the modified space-time density-based spatial clustering of application with noise (6) (MST-DBSCAN) algorithm available in the Python package pysda. The MST-DBSCAN algorithm was run with a maximum spatial distance of 600 m, a minimum time-distance value of 1 day, and a maximum time-distance value of 14 days. We then replicated the analysis using different spatial windows (200, 400, 800, and 1,000 m) and observed similar results. The MST-DBSCAN algorithm is one among various density-based clustering methods to detect disease clusters. This modified version of the spatiotemporal DBSCAN presents the advantage of incorporating the effect of the incubation period. The MST-DBSCAN detects clusters of cases but also identifies the daily evolution type of each cluster (6). We projected the daily evolution type of spacetime clusters onto the 2,830 Swiss Areas (SA) neighborhoods (www.microgis.ch) of the state of Geneva. This approach allowed to record the kind of cluster evolution each SA neighborhood underwent each day (i.e., increase, keep, decrease, no cluster). The SA neighborhood was used as it constitutes the smallest spatial unit characterized by aggregated census socioeconomic data in Switzerland. An index of socioeconomic deprivation was calculated at the SA neighborhood-level using a method developed Principal component analysis was used to synthesize the information from these data. To obtain a single index for all neighborhoods, the inertia of the first component was maximized by discarding variables only weakly correlated with the first component and variables contributing lower than the average (8). We defined spatial cluster persistence as the time in days from emergence to disappearance, and censored clusters remaining on the last day of the study period. Using spatial cluster persistence as the measured outcome, we estimated survival functions stratified by terciles of neighborhood-level socioeconomic deprivation with the Kaplan-Meier estimator. The contribution of the neighborhood-level socioeconomic deprivation to spatial cluster persistence was estimated in a Cox proportional hazards (PH) regression model (7) with robust standard errors. We then estimated the contribution of each individual component of the socioeconomic deprivation index [i.e., median income, foreigners (%), median rent, unemployment (%), occupation and education] as continuous independent variables in a separate Cox PH model (Table 1). Models were adjusted for neighborhood-level population density, and covariates were standardized. --- RESULTS We identified 1,079 spatial clusters over the 65 days study period, which, once projected covered, 1,931 neighborhoods of the state of Geneva (Figure 1). The median neighborhood-level SARS-CoV-2 incidence rate ranged from 0 cases per 100,000 (interquartile range, IQR = 650) in the least deprived tercile to 465 (IQR = 866) in the most deprived tercile. Clusters emerged on average 4 days earlier in the most deprived tercile compared to the moderately deprived and 6 days compared to the least deprived terciles (Supplementary Table 1). The persistence of clusters varied substantially across terciles of the neighborhood-level deprivation index (Figure 2). Two months after the emergence of SARS-CoV-2 clusters, almost 85% of the spatial clusters remained in the most deprived areas, compared to around 70% in the moderately deprived areas and around 30% in the least deprived areas. This trend was confirmed by the Cox PH model adjusted for neighborhood-level population density in which the standardized deprivation index was associated with an increased spatial cluster persistence (hazard ratio, HR = 1.43 [95% confidence interval, CI = 1.28-1.59], P < 0.005) and the adjusted tercile-specific deprivation index HR was 1.82 [95% CI, 1.56-2.17]. Hazard ratios and confidence intervals of the Cox PH model including the individual components of the socioeconomic deprivation index are presented in Table 1. Low median income, low median rent, high percentage of foreigners and high unemployment were associated with spatial cluster persistence to varying, but statistically significant, degrees (Table 1). There was no statistically significant association between spatial cluster persistence and tertiary education and the percentage of actives in the primary sector (Table 1). The MST-DBSCAN algorithm was run with a maximum spatial distance of 600 m, a minimum time-distance value of 1 day, and a maximum time distance value of 14 days. Similar results were observed using different spatial windows (200, 400, 800, and 1,000 m). --- DISCUSSION We combined spatiotemporal cluster detection with survival analysis and found that neighborhood-level socioeconomic deprivation was associated with persistent spatial clustering of SARS-CoV-2. This result supports our hypothesis, suggesting that the increased risk of infection of disadvantaged communities may also be due to the persistence of community transmission. This suggestion is of importance, considering that socioeconomically disadvantaged individuals are also at risk of worse COVID-19 outcomes due to a greater burden of obesity and other chronic diseases (9). Moreover, digital COVID-19 public health tools, such as contact tracing apps, have been developed and deployed since the first phase of the pandemic. While data remain scarce, evidence suggests that socioeconomic status is a determinant of attitudes toward these technologies (10). Public health attention and locally tailored interventions are required in socioeconomically disadvantaged communities to prevent the intersectionality of these multiple aspects of disadvantage further compounding the risk of infection, the risk of serious illness and thus, of mortality (3,11,12). --- Limitations The place of infection being unknown, we were not able to differentiate between persistence of spatial clusters driven by an increased local transmission or by an increased importation of cases in the community (e.g., from the workplace) or by a coalescence of both. We cannot exclude that the contact tracing strategy-which consisted in tracing and testing close contacts of positive cases-and socioeconomic variations in testing rate influenced spatial cluster persistence. --- CONCLUSIONS These findings bring unique insights into the determinants of transmission and suggest that the increased risk of infection of disadvantaged individuals may also be due to the persistence of community transmission. The persistence of transmission in disadvantaged populations further highlights the pressing need for public health interventions preventing an exacerbation of inequalities in the risk of SARS-CoV-2 infection, of serious illness and thus, of mortality. data. Requests to access these datasets should be directed to Idris Guessous, idris.guessous@hcuge.ch. --- DATA AVAILABILITY STATEMENT The dataset analyzed during the current study is available from the corresponding author upon reasonable request. The dataset could not be made publicly available due to the sensitivity of individual georeferenced SARS-CoV-2 testing --- AUTHOR CONTRIBUTIONS DD performed the data analyses and drafted the manuscript. DD, IG, and SJ conceived the study and completed the manuscript. JS, NV, AA, and SS participated in the design of the study and helped to draft the manuscript. All authors read and approved the final manuscript. --- SUPPLEMENTARY MATERIAL The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh. 2020.626090/full#supplementary-material --- Conflict of Interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Objective: To investigate the association between socioeconomic deprivation and the persistence of SARS-CoV-2 clusters. Methods: We analyzed 3,355 SARS-CoV-2 positive test results in the state of Geneva (Switzerland) from February 26 to April 30, 2020. We used a spatiotemporal cluster detection algorithm to monitor SARS-CoV-2 transmission dynamics and defined spatial cluster persistence as the time in days from emergence to disappearance. Using spatial cluster persistence measured outcome and a deprivation index based on neighborhood-level census socioeconomic data, stratified survival functions were estimated using the Kaplan-Meier estimator. Population density adjusted Cox proportional hazards (PH) regression models were then used to examine the association between neighborhood socioeconomic deprivation and persistence of SARS-CoV-2 clusters. Results: SARS-CoV-2 clusters persisted significantly longer in socioeconomically disadvantaged neighborhoods. In the Cox PH model, the standardized deprivation index was associated with an increased spatial cluster persistence (hazard ratio [HR], 1.43 [95% CI, 1.28-1.59]). The adjusted tercile-specific deprivation index HR was 1.82 [95% CI, 1.56-2.17].The increased risk of infection of disadvantaged individuals may also be due to the persistence of community transmission. These findings further highlight the need for interventions mitigating inequalities in the risk of SARS-CoV-2 infection and thus, of serious illness and mortality.

WHAT IS COMMUNITY AND COMMUNITY ENGAGEMENT? Current literature defines community and community engagement in different ways. What the term "community" encompasses can differ depending on a project's objective, and its scope ranges from geographic contexts to shared interests and social and political networks. In practice, "engagement" can be defined as a "two-way dialogue between crisis-affected communities, humanitarian organizations, and (...within and between communities (enabling) affected people to meet their different needs, address their vulnerabilities, and build on their pre-existing capacities" [7]. The UNICEF Minimum Quality Standards for CE frames "communities" as wider networks that influence "the transfer of health, educational, social, informational, economic, cultural and political resources" and often include "unequal distributions of authority, access, and power over decision-making and resources" [6]. "Community engagement" is "foundational (…) for working with traditional, community, civil society, government, and opinion groups and leaders." It is supposed to "empower(s) social groups and social networks" by building upon "local strengths and capacities" and improving "local participation, ownership, adaptation, and communication" [6]. CE strategies ideally allow all stakeholders "access to processes for assessing, analyzing, planning, leading, implementing, monitoring, and evaluating actions, programs, and policies that will promote survival, development, protection, and participation" [6]. We consider these definitions of community and CE as a practical working basis, as they "offer a common language for understanding community engagement and framing the engagement process in the context of global public health priorities" [8]. --- Exploring existing engagement structures in three countries As a SoNAR-Global partner, the Medical University of Vienna coordinated data collection during March and June 2019 with partner organisations in three countries: BRAC University of Dhaka, Bangladesh, Makerere University of Kampala, Uganda, and the Public Health Centre of the Ministry of Health of Ukraine, Kyiv. We broadly searched for health-related interventions, programmes, or projects on AMR or infectious diseases involving communities and seeking community feedback for programme interventions [9] to gather online resources and information on CE activities that were solely available locally. The aim was to understand the nature of these interventions: e.g. who initiated the campaign? What was the purpose of the CE project? Who was the involved public? Additionally, we looked at the form of inclusion and participation, the projected outcomes, and how monitoring and evaluation instruments were integrated into the CE. Regular online meetings were held for a continuous feedback and reflection process. The final step was a consultation meeting in June 2019, additionally involving experts from the World Health Organization (WHO), Global Research Collaboration for Infectious Disease Preparedness (GloPID-R), and the Social Science in Humanitarian Action Platform (SSHAP). --- LOCAL CHOICES Bangladesh, Uganda, and Ukraine were chosen for the exercise because they faced multiple health challenges listed among the WHO-identified threats to global health [10] and witnessed epidemic outbreaks before and during the data collection period. In Bangladesh, antimicrobial resistance (AMR) is a significant health issue resulting from the misuse of antibiotics in the animal farming industry and improper environmental practices [11]. In humans, the abuse of antimicrobials is associated with a weak regulatory regime, the economic interests of the pharmaceutical industry, and the demand by patients to avoid doctors' fees [12]. In Uganda, we focused on projects tackling AMR or common viral haemorrhagic fevers (VHF) outbreaks, especially the EVD, inside the country and in the neighbouring Democratic Republic of Congo. In Ukraine, we focused on infectious-disease-related CE projects, In 2018, the country struggled with a measles outbreak including more than 54 000 cases. A lack of vaccination coverage for preventable diseases coincides with vaccine hesitancy among parents and health workers, fuelled by media anti-vaccination campaigns [13]. The SARS-CoV-2 virus was still unknown during the data collection period in 2019. However, numerous successful COVID-19-related CE activities in Uganda or Bangladesh were later conducted [14][15][16] (see also EU project SoNAR-global deliverables, not yet published). We collected information on 41 projects; eleven aligned with the UNICEF Minimum Standards for CE -four in Bangladesh, four in Uganda, and three in Ukraine. Nevertheless, all projects lacked some elements of par-ticipation and two-way communication or did not conclusively define "community". Here we present one example for each country. In Bangladesh, the project Community Dialogue to address antibiotic resistance explored the potential of the community dialogue approach (CDA), strongly reliant on social and behaviour change theories, to improve antibiotic use on a community level [17]: the results of a qualitative study on perceptions about antibiotics and a household knowledge, attitude, and practices (KAP) survey were used for developing critical messages on antibiotics for CE activities. Community volunteers were trained in appropriate antibiotic use and AMR facts and later performed community meetings on these topics. The project sought to understand the local context by involving community members. The CDA approach included community volunteers on all project levels to facilitate community meetings and transfer knowledge. Furthermore, the study highlighted the need to hold regular feedback meetings with community volunteers to reinforce key messages and continuously document progress and setbacks for monitoring and evaluation purposes. In Uganda, the Emergency Plan of Action for EVD Preparedness stood out [18]. It involved CE through risk communication and sensitisation. Community-based surveillance and feedback mechanisms (including a rumour-tracking system) were established. Community-based volunteers were trained in risk communication, social mobilisation, and psychological first aid techniques and carried out interpersonal communications and hygiene promotion at household and community levels, reaching almost 700 000 individuals with critical messages on EVD prevention [18]. Communities were included in all preparedness-and response pillars; however, the CE interventions in Uganda provided limited possibilities for a two-way dialogue with communities, instead relying primarily on top-down communication. Monitoring, evaluation, and learning components also played a subordinate role -certainly owed to the emergency context of these EVD projects. In Ukraine, the CE method of Public consultations on health policy formation and implementation, which became legally binding for new legislation in 2010, was used to address growing vaccine hesitancy and the resulting measles outbreak [19][20][21][22]. Stakeholders consider the public consultation procedures transparent and sustainable, as the state statutorily funds them. The processes can be initiated by community requests or government and public institutions and should facilitate national decision-making, collaboration, and community participation on multiple levels. The consultations can occur via face-to-face meetings, electronically, or as social research. For instance, drafts of public health-related bills need to be published on a government webpage so that community members can comment on them and add suggestions for improvement. The drafts are modified only if experts endorse these suggestions, meaning public opinion is not always adopted. Systematic, formative evaluation processes have yet to be established. --- CONCLUSIONS On a positive note, social science instruments are already used in various ways in infectious disease and AMR issues projects. Qualitative surveys, perception studies, and community dialogues were deployed in projects across our partner countries. There is a fundamental disposition to cooperate and communicate with people affected by infectious threats and an apparent effort to build on local capacities for data collection and disease sensitisation. However, at the design level, most projects deviated from the inclusion and ownership standards formulated in the UNICEF Minimum Quality Standards guidelines [6]; two-way communication models were rarely used, and projects lacked evaluation or transparency. One fundamental challenge in applying UNICEF quality standards is its broad definition of "community". While societal inequalities are acknowledged, it does not guide how to tackle diversity, fragmentation, or dissent within communities. We argue that this diversity becomes particularly relevant during a health crisis: outbreaks of infectious diseases can create new communities of vulnerable individuals or vulnerable stakeholders such as caregivers, mentally challenged individuals, or parents of children suffering from illness [23]. These groups do not coincide with the UNICEF guidelines' definition of community; they are not necessarily organised in networks but represent communities of interest, often without structures or representation, especially in the early phases of infectious disease outbreaks. In our view, and considering the recent research experiences on COVID-19 of the SoNAR-Global network [24], CE should be informed by thorough assessments of vulnerabilities, considering a community's "history and situatedness" and inherent "systems and structures" [8]. Furthermore, monitoring and evaluation of infectious diseases must be done despite the related challenge -as in all disaster and humanitarian crisis intervention contexts. Even in health emergencies, two-way communication models with affected communities and evaluation or transparency measures must be ensured. --- Authorship contributions: The study was designed and conceptualized by RK and EJ. EJ wrote the first draft and contributed to data analysis and final revisions. PG contributed to the draft versions and organized the review process among contributors. NN, SMA, RR, CN, and DKM contributed research data from their respective countries, supported data analysis, and reviewed the final draft. RK, TGV, MD, and JO reviewed and critically commented on the study design and manuscript. All authors reviewed and approved the final version. All authors are partners in the research consortium SoNAR Global, and each contributed to the research (data collection, data analysis) in their respective countries (Bangladesh, Uganda, and Ukraine). In addition, all partners contributed to the review of the manuscript (3 rounds of commented reading). --- Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests. Communities of all sorts could profit from additions to the well-developed UNICEF document, which was written for community engagement in general. Considering the recent experiences of the COVID-19 pandemic, more attention should be paid to the specific circumstances in connection with infectious threats. Refining the UNICEF Minimum Quality Standards for CE accordingly would increase its impact in practice.

T he SoNAR-Global Social Science Network for Infectious Threats and Antimicrobial Resistance [1] connects social scientists from Europe, South East Asia, and West and Central Africa in their interest in epidemics and infectious diseases. Ebola virus disease (EVD) outbreaks in the Democratic Republic of Congo (DRC) and West Africa and the COVID-19 pandemic highlight the importance of understanding community reactions to infectious disease outbreaks [2][3][4][5]. Preparedness and response activities must suit people's demands and cultural needs. One approach that allows integrating social sciences into antimicrobial resistance (AMR) or infectious disease research is community engagement (CE). Developing appropriate models for multi-layered, multi-sectored, dialoguebased engagement represents one pillar of SoNAR-Global. Consequently, we performed a mapping and assessment exercise in 2019 as part of the project's first steps, searching for existing models of CE targeting infectious threats and AMR. We compared the identified examples with the UNICEF Communication for Development (C4D) Minimum Quality Standards for Community Engagement [6], which defines and narrows down the various understandings of CE and provides practical guidance for CE-based research and response activities, stressing that CE needs to be specific, localised, responsive, and bi-directional, and that top-down approaches must be avoided.

Colleagues remember that Ann's knowledge and decision-making skills were instrumental in the development of the library's monograph and serial collections. While maintaining a firm commitment to the traditional roles of librarianship, Ann also helped guide the library through its early progression into the world of automation. She once said, ''It's wonderful to have mechanical devices to transmit information, but in my day chips meant wood, and hardware meant hammers and nails.'' In her final years with LSU, Ann was a key force in planning the library's design and relocation to the resource center. Much of what the library is today is based on the foundations laid by Ann Macomber [1]. Ann's dedication to the library profession is evidenced by her very active participation in the Medical Library Association (MLA), at both the national and the regional levels. She was a leader in the Southern Regional Group. While opposing the split of the Southern Regional Group into what would become the South Central Chapter and the Southern Chapter in 1973, Ann continued to maintain close ties with both chapters. In a 1993 interview about the history of the Southern Chapter, she recollected the formality of the regional meetings when ''all the ladies wore gloves and some wore hats'' [2]. Her advice to new medical librarian colleagues was to take time out from all the meetings, continuing education courses, and committee work to ''have social intercourse with your colleagues and peers [and to] share thoughts about what's going on in your libraries. That's how you grow'' [3]. In 1989, Ann was named a Fellow of MLA. Though she highly valued her professional memberships, Ann firmly believed that the key to personal and professional growth was found in the ''one-on-one'' sharing of ideas between colleagues. She maintained and promoted this philosophy throughout her professional career. At the time of her death, a colleague from Charleston, South Carolina, noted that ''a long time ago, Ann was most kind and thoughtful when I was just starting my professional life. It made a huge difference in my ability to get involved and make an impact. She was a model of not only what to do-but how to do it right'' [4]. Ann also devoted much of her private life to civic affairs. She served on the board of directors for various organizations and was interested in the work of the Poydras Home, a nonprofit retirement community providing services for the elderly of New Orleans. She was president of the Poydras Home Auxiliary from 1997 through 2000. She also held memberships in the Orleans Club, the Phi Mu sorority, the Plimsoll Club, and the Fine Arts Club. She endowed a fund at her undergraduate alma mater for the printing of Under the Oaks, a publication for Newcomb College alumnae. In her spare time, Ann was an avid reader and crossword puzzle enthusiast. Ann was preceded in death by her husband, Donald Macomber Jr., a marine paleontologist with the Shell Oil Company. She is survived by a sister, two stepchil-dren, nieces and nephews, and many colleagues and friends.

returned to New Orleans and resumed her career at LSUHSC as its acquisitions librarian. In addition to her role in collection development, Ann also served as the library's associate

INTRODUCTION Krishi Vigyan Kendra, Belipar Gorakhpur established for technology dissemination though various agricultural extension activities. Participatory Rural Appraisal survey is an important mean to identify the problem constraints and need of the farmers through their own involvement. Though this Krishi Vigyan Kendra comes under scarcity zone of Kanpur village Bhitaha. Hence Krishi Vigyan Kendra has to focus on technologies. Village Bhitaha, Block-Khaijani, Tehsil-Bansgaon, District-Gorakhpur situated at distance of 16 Km from District head quarter and 28 Km from KVK Belipar. It comes under agriculture sub division Khajani. The Village Bhitaha popularly grown of Vegetables and Paddy along with cereals like Maize, Sorghum, Wheat etc [1,2]. Pulses and oilseeds are grown to some extent. There is opportunity for enhancing crop production. Participatory Rural Appraisal (PRA) is the process of involving local people in the analysis and interpretation of their own situation of a given rural area [3][4][5]. The local people i.e. the participants take a leadership role in collecting, analyzing, interpreting and presenting information and in this process impart knowledge and development insight to the specialists and extension agents. PRA approach embodies a whole range of techniques which when used reveal valuable information/data on the resources and skills existing in the village, wealth structure and dynamics of caste and class [6][7][8]. For management of natural resources, participatory Rural Appraisal is conducted to establish rapport with the village community as well as to identify and define problems for prioritization in the village itself. It is a way of learning from and with community members to investigate their need assessment, analyze and evaluate constraints and opportunities and find out priorities in the area of agriculture, small scale rural enterprises and any other social and economic development programs addressed to village development [9][10][11][12]. Based on the principle of listening and learning, PRA is the technique of immediate analysis and survey of village resources for participatory micro-planning and development [13][14][15]. Participatory Rural Appraisal is a way of enabling rural people to analyze their living conditions, share the outcomes and plan their activities. --- METHODOLOGY The present study was conducted in Village Bhitaha, Block-Khaijani, Tehsil-Bansgaon, District-Gorakhpur situated at distance of 16 Km from District head quarter and 28 Km from KVK Belipar. The Data Collection based on Participatory Rural Appraisal (PRA) exercise, a meeting of thevillagers along with the Sarpanch, Niab Sarpanch and Lamardar was conducted in the villagefor rapport building. While conducting the meeting, they were made aware of the exercise tobe conducted for the development of a plan for the village,farmers' contribution in theexercise and the objectives to be achieved. The key informants were identified who helped toinform villagers to facilitate participation. --- RESULT AND DISCUSSION TheTable 1 shows the demographic information and literacy rate of the village. The total population is 2160, with 1098 males and 1062 females. The literacy rate is 82.68%. The Table 3 shows the distribution of farming families in the village based on the size of their land holdings. The majority of families (95%) are marginal farmers, with less than 1 hectare of land. There are no large (over 4 hectares) farms in the village. TheTable4 shows the area under different agricultural crops in the village, as well as their productivity. Paddy is the main kharif crop, while wheat is the main rabi crop. There is also a small area of zaid crops, such as barseem and cucurbits.Paddy is the most cultivated crop in the village, followed by wheat and fodder crops. The productivity of cucurbits is high compared to other crops. The Zaid season has a limited variety of crops compared to Kharif and Rabi. The Table 6 shows the livestock population in the village. There are a total of 98 buffaloes, 178 goat, and no poultry birds. The Table 7 also shows the productivity of the livestock in terms of milk and meat. This Table 8 shows the availability of various ICT tools in Bhitaha, including TVs, mobiles, computers/laptops, and internet access. There are 295 TVs and 1385 mobiles in the village. Internet access is also available. This Table 9 shows the number of different transportation vehicles available in Bhitaha, such as cars, motorcycles, cycles, and other forms of transport, there are 186 motorcycles and 240 cycles in the village. This Table 10 --- Animal Problem identified --- Suggested solution Strategies Poultry --- CONCLUSION In conclusion, has explored the socioeconomic status of Bhitaha Village in Gorakhpur, using data collected through a PRA Under KVK Belipar Gorakhpur. The study has provided valuable insights into the village's demographic profile, land use patterns, sources of irrigation, and occupational distribution. The study found that the majority of the population had a High level of education, with.literacy rate is 82.68%.Marginal and small farmers dominated the agricultural landscape, with a prevalence of small-scale agriculture. The study also highlighted the importance of non-farming occupations such as skilled laborers and rural artisans. The findings of this study have significant implications for policy interventions and rural development initiatives in the region. The dominance of small-scale agriculture highlights the need for interventions that promote sustainable farming practices and provide access to modern agricultural technologies and techniques. Moreover, the presence of rural artisans in the village suggests the potential for developing cultural tourism in the region, which could serve as a source of income diversification for the local population. --- COMPETING INTERESTS Authors have declared that no competing interests exist.

The present study was conducted in Village Bhitaha, Block Khaijani, Tehsil Bansgaon, District Gorakhpur. The Data Collection based on Participatory Rural Appraisal (PRA) exercise, a meeting of the villagers along with the Sarpanch, Niab Sarpanch and Lamardar was conducted in the village for rapport building. In this research paper an attempt has been made to find out the actual socioeconomic status of rural population in different groups. Study shows that literacy rate in this area is 82.68 per cent, majority of the population belong to the schedule caste (218) and families (95 per cent) are marginal farmers, Paddy is the main kharif crop, while wheat is the main rabi crop and it shows the availability of various ICT tools in Bhitaha, including TVs, mobiles, computers/laptops, internet access and where productivity of meat and milk is very well, the number of different transportation vehicles available such as cars, motorcycles, cycles, and other forms of transport, shows different Farm machinery available such as Sprayer 286, Tractor 09, Cultivator 09, Disc Harrow 07, Thresher 07 and Seedcum Fertdrill 01,s it shows that irrigation facilities are available in the village. The findings of this study have significant implications for policy interventions and rural development initiatives in the region.

Editorial Three separate yet complementary sections comprise this concluding issue of the first volume of the Journal of Learning Analytics (JLA). As the journal concludes its first year of publishing, the papers presented in this issue demonstrate how the learning analytics (LA) research has grown and diversified alongside the substantial advancements in the application of LA initiatives within higher education institutions. As the field was developing the LA research largely focused on how analytics can help predict attrition and academic performance to inform institutional strategies for improving student retention. As evident in this latest issue, many researchers and practitioners are now focusing their efforts on using LA methodologies, often through inter-disciplinary teams, for better understanding how students learn in order to guide and inform pedagogical practice, course design, curriculum, learning support, and the development of effective learning communities to fundamentally improve their academic experience. While research on student learning is not novel nor a unique discipline, the rapid adoption of online technologies by academic staff either by their own volition or due to blended, online, flexible, and personalised learning strategies that are being encouraged in many higher education institutions has given rise to massive datasets that allows for more sophisticated analysis of a variety of objective data (and in many cases, triangulated with self-informed data as well) providing insight into how students actually experience learning. As the availability of data on students' engagement with online technologies continues to grow and LA researchers continue to push the box in terms of the application of methodologies previously not applied to research on student learning, our collective understanding of how, when, why, and with whom students learn will only flourish. A part of the rapid evolution of the discipline can be attributed to the growth in the number of established researchers coming together from various disciplines (e.g. education, computer science, statistics, etc.) to investigate the breadth of learning and teaching related data. However the future expansion and research directions will be in the hands of a growing number of post-graduate and doctoral students. While the LA field continues to better understand the student learning process and raise awareness of learning and teaching issues, its capacity for future research is fostered through the development of such postgraduate and doctoral students who not only develop new and innovative methodologies and uncover answers to challenging questions, but their research motivates and attracts the investigation of further research questions. Hence, developing the research capacity and interest in the field will further fuel the longer term development, of the discipline. Finally, critical to the discipline and for sustaining its impact on the education sector (K-12 or higher education), is the articulation of LA research into day to day practice. As well noted in this issue, whether it is to inform course redesign, curriculum reform, student support strategies, or early alert dashboards or intervention mechanisms, as research in the discipline diversifies and matures, its application in real-world settings through institutional or faculty adoption, is paramount. While, the application of LA is often fraught with challenges, institutions are beginning to identify solutions that can lead to wide-scale application. However, as a LA community, we need to share how institutional challenges can be overcome in order to advance LA practice alongside the continued surge and progression of new discoveries through research. --- Selected and Invited Papers Presented at LAK'14 This issue begins with a special issue led by the guest editors, Abelardo Pardo and Stephanie Teasley, who have compiled a selection of representative papers from the 4th International Learning Analytics and Knowledge Conference (LAK'14). The research presented in the five papers demonstrates the diversification of LA research and the move towards greater investigation into student learning and making sense of the 'data exhaust' for actionable insight that can transfer to practice impacting students, instructors, programs, and institutions (Pardo & Teasley, 2014). The papers cover various themes such as discourse analysis of discussion forums, students' use and engagement with e-portfolios and course resources, curriculum issues, and large-scale adoption of LA strategies. Collectively, they showcase the current breadth of LA research and how it can inform pedagogical practice, course and curriculum redesign, and institutional adoption. We thank Abelardo and Stephanie for their hard work and dedication for bringing this special issue to fruition. --- Sparks of the Learning Analytics Future A central aim established by the Socioety for Learning Analytics Research (SoLAR) relates to the building of research capacity in learning analytics. To achieve this aim, SoLAR has held numerous events specifically for Doctoral and Post-graduate students. The Learning Analytics Summer Institute (LASI) is one such. The second segment of this issue, led by Dragan Gasevic and Mykola Pechenizkiy, presents the current or recent work of doctoral students conducting their research in the LA discipline who attended the 2nd Learning Analytics Summer Institute (LASI'14). While the students had an opportunity to discuss their research with each other and LA researchers through lightening talks and poster presentations at LASI'14, they were invited to submit a brief article to this issue sharing their research with the wider community. As the sixteen articles in this section demonstrate, doctoral research in LA has built momentum and the diversity of research questions, datasets, and novel methodologies continues to grow. This section provides the unique opportunity to glimpse into the future of LA research as reveals what the community can expect to see and learn in the near future from these rising researchers. We thank Dragan and Mykola for compiling this special issue and encouraging the doctoral students for sharing their work with the JLA readership. --- Hot Spots The third and final segment of this issue includes two papers that discuss the application of LA research to practice. With one paper focusing on the challenges institutions face with establishing data governance models for LA initiatives and the other reporting on a tool that marries analytics with design to help teaching staff readily access the relevant data to inform their course design decisions, these papers illustrate the growing adoption of LA practice in higher education institutions and the strategies that can best support it. The first paper, Critical Factors in Data Governance for LA by Elouazizi, discusses the challenges facing institutions who are grappling with developing data governance models for LA initiatives. Overlaps between the various types of LA data, data sources, and stakeholder groups are explored and three main challenges are identified with seven key suggestions for how institutions can overcome them. The second paper by Dunbar, Dingel, Prat-Resina, reports on the Browser of Student and Course Objects (BoSCO), a LA tool that bridges the analytics and course design areas by providing teaching staff with access to data that is most relevant and useful for informing their course and curricular design decisions.

This issue of the Journal of Learning Analytics comprises two special issue sections. The first of which presents five papers from the 4th International Learning Analytics and Knowledge conference held in Indianapolis. The second showcases the current or recent work of doctoral students who attended the 2nd Learning Analytics Summer Institute at Harvard University, Boston. The issue also includes two articles in the Hot Spots section, discussing the application of learning analytics initiatives in higher education institutions from different perspectives -broad-scale initiatives to individual course design. The breadth and diversity of the articles covered in this issue demonstrate how the discipline has matured and moved towards understanding student learning to inform pedagogical practice and curricular redesign coupled with strategies for the application and adoption of LA strategies across institutions

Role adjustment of social governance of new government media in alleviating social workers' mania from the perspective of media convergence Zhuo Zhu Yancheng Broadcasting Television, Yancheng 224000, China Background. In today's media environment, the role of new government media in social governance is becoming increasingly important. However, many scholars have studied and discussed how to adjust its role in the perspective of media convergence to alleviate the mania of social personnel. Subjects and Methods. A randomized controlled trial selected two communities as the intervention and control groups. Residents in the intervention group received relevant social governance information and services through new government media, while residents in the control group received conventional social governance services. The study period was one year, and data collection included baseline and follow-up data during and after the intervention. SPSS23.0 software was used for data analysis. Results. The improvement rate of mania symptoms in the intervention group was 72%, significantly higher than in the control group (48%). The proportion of improved quality of life (68%) was considerably higher than that of the control group (45%). The rate of social function recovery was 65%, significantly higher than 42% in the control group. Conclusions. New government media can effectively help mania patients improve their symptoms and quality of life and restore social function in social governance. Therefore, we should make full use of the new media of government affairs and incorporate it into the social governance system to better serve the social personnel, especially the patients with mania. --- Civic education integrating Marxist theory on college students' social anxiety disorder Yuheng Wu Zhengzhou University of Light Industry, Zhengzhou 450001, China Background. College students face multiple challenges, such as information explosion, popularity of social media, and increased competitive pressure, which leads to social anxiety disorder in some of them. Marxist theory, as the guiding ideology of China, provides a perspective on the comprehensive development and self-realization of human beings. In recent years, the exploratory attempts of colleges and universities for Civic Education have become a focus of attention in the education sector as to whether they can effectively alleviate the social anxiety disorder of college students after incorporating Marxist theory. Subjects and Methods. Five hundred college students were selected as research subjects for the study. The experimental group was subjected to Civics education incorporating Marxist theory, while the control group received conventional Civics education. The research cycle was one academic year, using the SAS-A scale (Symptom Assessment Scale-adolescent), Negative Appraisal Fear Scale, and Comprehensive Interpersonal Relationship Diagnostic Scale. Pre-intervention, mid-intervention, and post-intervention tests were conducted to examine the subjects' dynamic changes in social anxiety. Results. The study proved that after one academic year of education, in the experimental group, college students' adaptability to social situations increased, and their confidence in interacting with others significantly improved. Conclusions. Through the integration of Marxist theory, civic education in colleges and universities can effectively help college students overcome social anxiety and enhance interpersonal communication skills. This kind of education helps students form a healthy outlook on life and values and deepens their understanding and identification with Marxist theory. --- Aesthetic education integrating traditional culture into modern ceramic design on anxiety recipients Wensong Zhang1 * and Linlin Zhang2

Results. The average MDQ score decreased by 35% in the intervention group, while the average MDQ score decreased by only 10% in the control group. Learning satisfaction increased by 25% in the intervention group, while there was no significant change in learning joy in the control group. Conclusions. The synergistic development of ideological and political education and management in colleges and universities can alleviate students' mood disorders and improve their learning satisfaction. This provides a practical way for colleges and universities to strengthen students' mental state and learning efficiency. Acknowledgement. The Second Batch of Teaching Reform Projects in the 13th Five-Year Plan of Zhejiang Province' Higher Education (Grant No.jg20190965). Background. With the accelerated pace of life in modern society, people face increased psychological pressure, leading to a gradual increase in the incidence of psychological disorders such as S58 Abstracts

INTRODUCTION This research is essential to do related with the characteristics found in the pattern of news text to explore how the participants in the news express their complex thinking. The clause can express the complex thinking as it is the logical reality in language. The major clause is divided into two kinds, namely: the simplex clause and the complex clause. In complex clause, the logical meaning is developed through two relations in interdependency and in logical semantic. The interdependency differs clause into paratactic and hypotactic. The paratactic form has parallel dependent relation. The conjunction used is the external conjunction, namely: and, but, or, so thar, both and, not only but also. The hypotactic does not have parallel relation. The conjunction used is the external conjunction, namely: after, before, since, when. Seeing from the logical semantic, the complex clause can be elaborated in two ways, namely: projection and expansion. The projection can be seen in the clauses stated in reported speech, in mental cognitive process and perceptive process. The expansion can be seen in three forms, namely: elaboration, expansion, and enhancement (Santosa, 2003). The previous studies that have conducted research in the same field in discussing the juvenile delinquency mostly still seen in sociology, law and psychology perspective are (Ariyanik & Suhartini (2012) about theory of socialization to solve juvenile delinquency; (Palupi, Purwanto & Noviyani, 2013) about the influence of religious influence in juvenile delinquency; (Sumara, Humaedi & Santoso, 2017) about juvenile delinquency handling; (Oktawati, 2017), (Artini, 2018), (Andrianto,2019), (Een, Tagela & Irawan, 2020), (Hidayah, 2020), (Karlina, 2020), (Lasnita & Utama, 2020) This research fills the gap that has not been done by the previous researchers in analyzing in linguistic perspective to see how the government officials express the solution to solve the problem of juvenile delinquency through words in news text, especially with systemic functional linguistics. The news text is explored to find out the pattern of the clauses used to see complex thinking expressed in the form of simplex clause and complex clause. --- METHOD This research is a kind of textual analysis in descriptive qualitative. The data source is the news text and the data are in the form of clauses. The purposive sampling is used by finding the news text that has given information about the solution in solving juvenile delinquency taken from https://www.detik.com/jateng/jogja/d-6030236/a-z-soal-sekolah-khusus-anak-nakal-di-jogja-usai-marakklithih. The text is analyzed by finding the simplex clause as well as the complex clauses in the form of interdependence (paratactic and hypotactic) and in the form of logical semantics (projection and elaboration). The data validation used is expert validation. --- FINDINGS AND DISCUSSION The result shows that the news text is dominant to use the projection that is included in the complex clause pattern. The analysis of clause can be seen in table 1 below. 1 above shows that the participants in the news tend to use projection as much as 79% in the form of noun clause as much as 17%, in the form of direct speech as much as 50%, in the form of indirect speech as much as 8% and in the form of preposition as much as 4%. The form of expansion is also used as much as 17% and interdependence: paratactic is used as much as 4%. The finding shows that the participants express their complex thinking through the complex clauses they use. It confirms that what Santosa (2003) states about the complex clause can express the complex thinking that the participants give the information through more than one clause. It also reveals that the complex clause can also convince the valid information given by stating the information through the form of projection (Martin & Rose, 2007). The result shows that the news text is less in using simplex clause. The table 2 below shows the examples of minor simplex pattern applied. The finding in table 2 shows that the participants limit the use of simplex pattern in giving information. It emphasizes that the participants prefer showing the complex thinking to showing the simplex thinking which is represented in the form of clauses they use in delivering information through text (Santosa, 2003;Martin & Rose, 2007) --- CONCLUSION The news text that delivers information about the solution given by the government officials related with the juvenile delinquency in Jogjakarta Indonesia tend to use the complex clause in various types, such as in noun clause, direct speech, indirect speech, and preposition although the direct speech form is dominant to be used in delivering the information and less use in noun clause, indirect speech and preposition. The expansion and interdependence patterns are seldom to use that shows the pattern of the information is less delivered by elaborating, by extending or by enhancing the utterances. The objectivity of the information delivered tend to be in high level when the complex clauses in the form of projection are dominant to be applied DAFTAR PUSTAKA Aebi, M., Haynes, M., Bessler, C., & Hasler, G. (2022) --- Halaman 43 Sharma, R., Malik, P., Dudi, J & Sharma, M. (2020)

This study is conducted to perceive the pattern of complex thinking in Indonesian news text about solving juvenile delinquency 'KLITHIH' occurred in Jogjakarta Indonesia as one of special areas in Indonesia in culture and in education. The data are explored by using systemic functional linguistics related with the rhetorical meaning in major clause in simplex clause and in complex clause. The findings are reported that the news is dominant to use complex clause as much as 92%. The complex clauses consist of 17% written in expansion, 4% written in interdependence, and 79% written in projection. The study gives contribution in linguistics in seeing social and education problem solving to see the complex thinking uttered by the government officials. Originality of this study is to show the pattern of complex thinking in news text about solving juvenile delinquency that can give impact to the society. This study has lack that it only analyzes in textual analysis. It recommends to observe the data about juvenile delinquency in the direct field for the future research in different point of view.

Objective: People whose parents had dementia or memory impairment are at higher risk for later-life cognitive impairment themselves. One goal of our research is to identify factors that either increase the risk of or protect against family history of dementia over the life course. External locus of control has been associated with lower cognitive function in middle-aged and older adults. Previous findings have shown that adults racialized as Black have relatively high levels of external locus of control due to inequity and racism. We hypothesized that lower parental memory would be associated with lower offspring memory among Non-Latinx Black and Non-Latinx White (hereafter Black and White, respectively) adults; and associations would be stronger among participants with higher levels of external locus of control. Participants and Methods: Participants comprised 594 adults racialized as Black or White (60.3% Black; 62% women; aged 56.1 ± 10.4; 15.3 ± 2.7 years of education) from the Offspring Study who are the adult children of participants in the Washington Heights Inwood Columbia Aging Project (WHICAP). Parental memory was residualized for age (74.3 ± 6.0) and education (13.7 ± 3.1). Self-reported external locus of control was assessed using 8 items from the the perceived control questionnaire. Memory was assessed with the Selective Reminding Test, and a composite of total and delayed recall scores were computed. Linear regression quantified the interaction between parental memory and external locus of control on memory in models stratified by race, and adjusted for age, sex/gender, and number of chronic health diseases. Results: Among Black participants (n=358), there were no main effects of parental memory or locus of control on offspring memory. However, lower parental memory was associated with lower offspring memory among Black participants with high levels of external locus of control (standardized estimate=0.36,p=0.02,95%CI [0.05,0.67]). Associations were attenuated and non-significant at lower levels of control. Among White participants (n=236), there was a main effect of parental memory on offspring memory, and this association did not vary by levels of external locus of control. Conclusions: Poor parental memory, which reflects risk for later-life cognitive impairment and dementia, was associated with lower memory performance among White middle-aged participants. Among Black participants, this association was observed among those with high levels of external locus of control only. Economic and social constraints shape levels of external locus of control and are disproportionately experienced by Black adults. In the face of greater external locus of control, a cascade of psychological and biological stressrelated processes may be triggered and make Black adults' memory function more vulnerable to the detrimental impact of parent-related dementia risk. Longitudinal analyses are needed to clarify temporal associations. Nonetheless, these findings suggest that reducing social and economic inequities disproportionately experienced by Black adults may dampen the effect of intergenerational transmission of dementia risk on cognition. Objective: Higher levels of inflammation are associated with risk factors for Alzheimer's disease and related dementias (ADRD) in older Black adults including psychosocial stressors (e.g., discrimination and early life adversity) and white matter alterations. Yet, limited work has investigated these risk factors together in a longitudinal neuroimaging study, despite the well-known ADRD disparity in older Black adults. Using data from the Minority Aging Research Study and African American Clinical Core of the Rush Alzheimer's Disease Center, we examined interactions of psychosocial stressors and change in inflammation on changes in white matter integrity as measured via diffusion tensor imaging (DTI). Participants and Methods: Older Black adults (n=102) without known dementia at baseline (age=75.8±6.1 years; 87.3% female; education=15.4±2.7 years) completed blood draws at two time points (follow-up=2.4±0.7 years), neuroimaging at two or more time points (follow-up=3.7±1.8 years), and psychosocial questionnaires at one time point coinciding with the first blood draw/neuroimaging. Blood serum was assayed using highly-sensitive multiplexed sandwich ELISA for interleukin-6, c-reactive protein (CRP), and tumor necrosis factor-alpha (TNF-α) and a change score was calculated for each inflammatory marker (T2 -T1). The Williams Everyday Discrimination Scale quantified experiences of discrimination in all participants and a 16-item questionnaire of emotional and physical trauma from age 0-18 assessed early life adversity in a participant subset (n=63). DTI-derived tract-based spatial statistics (TBSS) slope change measures for trace of the diffusion tensor, fractional anisotropy (FA), axial diffusivity (AD), and radial diffusivity (RD) were calculated, with the first two scans matched in time to blood assays. Linear regression models investigated interactions of each inflammatory marker change score (separately) and either discrimination or early life adversity (separately) on trace, FA, AD, and RD slopes as individual outcomes adjusting for age, sex, education, white matter hyperintensities (total volume and voxelwise), cardiovascular risk factors, statin and analgesic medications, thyroid conditions, and depression. Statistical significance was determined at p<0.05 using family wise error correction and threshold free cluster enhancement. Results: Discrimination moderated the relationship between TNF-α and AD whereby those with increasing TNF-α and higher levels of discrimination had increasing levels of AD over time in white matter tracts connecting the left and right cerebellum, the left pallidum and medulla, and the left superior frontal gyrus and left thalamus. Both discrimination and early life adversity moderated associations between CRP and AD, where increases in CRP and higher psychosocial stressors (of either type) resulted in decreasing AD over time in tracts involving cingulate, frontal, and parietal regions. Discrimination and early life adversity also moderated associations between CRP and RD, where increasing CRP combined with greater psychosocial stressors resulted in decreasing RD in right hemisphere association and projection tracts connecting frontal, parietal, central, and subcortical regions. Conclusions: TNF-α and CRP interacted with measures of psychosocial stress to associate with DTI-derived TBSS slope change measures of AD and RD in differential, and at times, paradoxical ways. Findings suggest that both risk and resilience as related to brain connectivity may be co-occurring in the

Results: Significant education by cognitive activity effects were observed for Digit Span Backward and Size Judgment Span, but not for Digit Span Forward. The interactions reflected a positive association between cognitive activity and cognitive functioning in people with at least a high school education, but not in people with less than a high school education. Conclusions: Our results support previous findings that education level and engagement in cognitive activity may serve as protective factors against cognitive decline in later life. The finding that cognitive activity was not associated with better cognitive functioning at lower levels of education suggest that earlier life experiences may moderate the benefit of lifestyle interventions later in life. Future studies should examine whether other lifestyle interventions, such as exercise, are more beneficial for people with less cognitive reserve from earlier life experiences.

ISSN-2455-6580 (Vol. V & Issue I (April-2020) www.thecreativelaucher.com --- The Creative Launcher An International, Peer Reviewed, Refereed, E-Journal in English Editor-in-Chief: Dr Ram Avadh Prajapati Disclaimer: For Any kind of confirmation and Authentication visit the website of the journal. those components would be focused along with the festival Día De Muertos on which this paper focusses. Dia de los Muertos, also known as Day of the Dead, is a Mexican holiday celebrated on November 1st and 2nd. It is a time when families and friends gather to honour and remember their loved ones who have passed away. The holiday has pre-Columbian roots and was traditionally celebrated in the Aztec empire. When the Spanish arrived in Mexico in the 16th century, they incorporated some of their own traditions into the holiday, including the use of Catholic symbols such as crosses and candles. Dia de los Muertos is celebrated with various traditions and customs, including creating ofrendas (altars) in honour of the deceased, decorating gravesites with flowers and offerings, and preparing special foods and drinks. During the festival, it is thought that the spirits of the dead visit their loved ones in the living world. Dia de los Muertos is a joyous and vibrant celebration of life and the connections between the living and the deceased, despite its association with death. It is a time to reflect on the cycle of life and death, and to honour the memories of those who have passed away. Today's Día De Muertos festivity is a mash-up of pre-Hispanic religious rites and Christian beliefs. Stanley Brands in his paper "Is There a Mexican View of Death" says, "It is said that Mexicans live side by side with death and are therefore able to confront death honestly and directly. They scorn death, they mock death, they are disdainful and irreverent in face of death" (Ethos,128). The Book of Life is an animated musical movie that tells the story of a young man named Manolo, who is torn between fulfilling his family's expectations of becoming a bullfighter and pursuing his true passion of playing the guitar and singing. The movie takes place during the Mexican holiday Dia de los Muertos and explores themes of love, death, and the power of storytelling. When Manolo and his childhood friend Joaquin both fall in love with the same woman, Maria, they embark on a journey through the Land of the Remembered and the Land of the Forgotten to prove their love for her. They meet different mythical creatures and impediments along the way, and Manolo learns that he has been designated by the rulers of the eternal to complete a hazardous mission. The movie features vibrant and colourful animation, --- ISSN-2455-6580 (Vol. V & Issue I (April-2020) www.thecreativelaucher.com --- The Creative Launcher An International, Peer Reviewed, Refereed, E-Journal in English Editor-in-Chief: Dr Ram Avadh Prajapati Disclaimer: For Any kind of confirmation and Authentication visit the website of the journal. as well as a mix of contemporary and traditional music. Ultimately, The Book of Life is a heartwarming tale about finding one's true identity and following one's dreams. On other hand Coco is an animated movie that tells the story of a young boy named Miguel who dreams of becoming a musician, despite his family's generations-old ban on music. The movie takes place during the Mexican holiday Dia de los Muertos and explores themes of family, memory, and the power of music. Desperate to prove his talent, Miguel finds himself magically transported to the Land of the Dead, where he meets his ancestors and sets out to uncover the truth behind his family's mysterious history. With the help of a charming trickster named Hector, Miguel embarks on an extraordinary journey to the Land of the Dead and discovers the importance of honouring one's ancestors and following one's dreams. Coco features stunning animation, heart-warming characters, and an unforgettable soundtrack that includes original songs and traditional Mexican music. The movie is a celebration of Mexican culture and a beautiful tribute to the importance of family and memory. It is a touching and uplifting story that will resonate with audiences of all ages. --- Día De Muertos and its significance in Mexican Culture The concept of life, death and afterlife is deeply rooted in Mexican Culture, and the selected movies best convey these ideas. Octavio Paz in The Labyrinth of Solitude expresses his view on Mexican culture's acceptance of death and how life, death and afterlife are linked: Mexicans accept death stoically; Europeans, by contrast, cannot easily or bravely confront the prospect of dying… For Paz, loneliness and solitude conspire to make the Mexican unfeeling, guarded, and defended in matters of death and life (Ethos, 129). Día De Muertos is celebrated all over Mexico and now also in different parts of USA. The rituals are performed for two days, and there is a hidden message or prayer in both the days. On the 1 st of November souls of young children or angels are remembered and this day is called Día de los Angelitos, whereas on the second day, that is, the 2 nd of November at 12:00 A.M. souls of adults are remembered and this ceremony Día de los Difuntos and on the same day at noon all the dead are collectively remembered which is known as Día de los Muertos. Marigold, sugar skulls, gifts, belongings of the dead and their favourite things are kept and people enjoy by dancing, singing, and playing games. --- The Creative Launcher An International, Peer Reviewed, Refereed, E-Journal in English Editor-in-Chief: Dr Ram Avadh Prajapati Disclaimer: For Any kind of confirmation and Authentication visit the website of the journal. The idea of Día De Los Muertos is represented in both the movies but in different ways. In Coco it could be witnessed that, when a person dies s/he is sent to the Land of Dead, where their souls are kept in form of skeleton and are allowed to travel to the Land of Living during the festival. In this movie two different concepts of "the remembered" and "the forgotten" can be traced, and those who are still being remembered by their family members are allowed to go to the Land of Living. In the movie, the character Héctor is not allowed to travel through the Marigold Bridge, whereas "the remembered" are permitted. --- The Creative Launcher An International, Peer Reviewed, Refereed, E-Journal in English Editor-in-Chief: Dr Ram Avadh Prajapati Disclaimer: For Any kind of confirmation and Authentication visit the website of the journal. The two pictures shown above are from the movie Coco; the first one shows happy dead who are permitted to move, suggesting that the "Remembered" can easily cross the "Marigold Bridge," while the second shows Héctor getting stuck among marigold petals, suggesting that he has been abandoned by his family. Marigold has its key importance in Mexican culture, and distinctively in Día De Los Muertos. Coco shows us different aspects of the festival. In the movie people are found celebrating happily the festival at the cemetery of their ancestors, face painting as done during the festival can be noticed, skull candies and other food items are seen and pierced paper which is an important part of the festival has been used in the movie. Another important element is marigold and the petal of marigold and love from the family is an integral part of the movie and helps Miguel return back to the Land of Livings and helped Héctor to be remembered by his family members. --- The Creative Launcher An International, Peer Reviewed, Refereed, E-Journal in English Editor-in-Chief: Dr Ram Avadh Prajapati Disclaimer: For Any kind of confirmation and Authentication visit the website of the journal. from life to death and afterlife is shown along with the interference of supernatural elements and a mythological story. --- The Creative Launcher An International, Peer Reviewed, Refereed, E-Journal in English Editor-in-Chief: Dr Ram Avadh Prajapati Disclaimer: For Any kind of confirmation and Authentication visit the website of the journal. The finding of offerings that more profoundly excites the imagination, as the custom seems to support the belief in the continuation of the daily needs of man even after his death. Accepting the continuing need for human essentials, an acknowledgment of the permanence of life, seems also to suggest that whatever follows death must be explained in accordance with familiar experiences. (1974, American Quarterly) As in Mexican concept of life death and afterlife is found, in the same way these movies have done justice with this concept. Though contact with death may seem unsettling but it helps in reducing feelings of anxiety regarding death. In a paper "Death in Mexican Folk Culture" Patricia Fernandez Kelly depicts her idea about death as: It is of central importance to realize that far from defining an objective reality, categories of time shape the way in which human beings organize reality. The idea of death in the pre-Hispanic civilizations of Mexico and in the contemporary folk culture cannot be fully comprehended without some mention of the peculiarities that timenotions have in specific contexts. For the natives of Mexico, time was a never-ending succession of cycles separated from one another by death and the destruction of the world, the order of which could only be restored through sacrifice. (1974, American Quarterly) The movies The Book of Life, and Coco, productions of two different studios convey very similar ideas on the concept of life, death and afterlife. They predominantly depict the Mexican culture and the famous festival Día de Muertos or The Day of Death, which is celebrated in the remembrance of the dead people of the family. Also the festival of Día de Muertos is quite different from Haloween and should not be mixed up just because of the timing of celebrations and the characters celebrated in the truest spirit of multiculturalism. While the one tries to do away with ghosts and reminisces of death the other celebrates it making it more acceptable. To show the relativity of the findings about the movie, figures have been used to show the dialogues or the conversation in between the characters.

Mexican culture has a unique and rich tradition of representing life, death, and the afterlife in art and storytelling. This is particularly evident in the animated movies The Book of Life (2014) and Coco (2017), both of which draw heavily on Mexican folklore and mythology to explore these themes. In The Book of Life, the afterlife is depicted as a colourful and vibrant world, full of music, dancing, and celebration. The movie emphasizes the importance of honouring one's ancestors and remembering those who have passed away, while also acknowledging the pain and grief that comes with loss. Similarly, in Coco, the afterlife is depicted as a beautiful and mystical world, full of music and wonder. The movie explores the idea that death is not the end, but rather a continuation of life in a different form, and emphasizes the importance of maintaining a connection with one's ancestors and family history. Both movies also highlight the cultural significance of Dia de los Muertos, the Mexican holiday that celebrates the dead. The movies depict various traditions associated with the holiday, such as creating ofrendas (altars) to honour the deceased, decorating grave-sites with flowers and offerings, and preparing special foods and drinks. These traditions serve as a way to remember and connect with loved ones who have passed away, and to celebrate the cycle of life and death. The Book

BACKGROUND Youth engagement in substance use research is critical to the understanding of correlates that lead to detrimental health and social outcomes for adolescents. Challenges to engaging historically marginalized youth, including youth of color and immigrant youth, as participants for research include housing and transportation instability, low socioeconomic status, race/ethnicity, cultural norms, and safety and legal concerns (Bradley et al., 2019). Latinx youth in high-risk settings may be difficult for researchers to engage in substance use research because they could face retributory harm if they identify their experiences to any entity perceived as an authority (e.g., researchers). Latinx youth living on the U.S.-Mexico border may experience perceived disordered neighborhood stress, drug trafficking, militarized border security, disproportionately punitive drug and immigration enforcement, and racial profiling (Valdez et al., 2019;Valdez et al., 2021). Thus, Latinx youth living on the border may be unwilling to engage in substance use research that elicits information of personal substance use history or sharing knowledge of personal or familial experience in the drug trade due to substantial fear for their personal safety or social repercussions. Empirical findings that posit viable strategies to engage marginalized youth in substance use research are lacking. Participatory approaches show promise in increasing participation of historically underrepresented youth in research (Ozer, 2016). This article discusses the youth-led participatory approach used to (a) develop and pilot test a culturally, regionally, and linguistically tailored substance use instrument and (b) engage 445 Latinx youth to participate in a cross-sectional study to assess epidemiological patterns of youth substance use on the U.S.-Mexico border. --- METHOD Partnership Development A local youth health coalition and the principal investigator (PI) engaged in a youth participatory action research (YPAR) project to examine the environmental factors that influence substance use among youth in a community on the U.S.-Mexico border. YPAR is a form of participatory research whereby youth learn how to conduct research and use their findings to engage in social action at the local community and policy levels (Ozer, 2016). The research team consisted of the PI, the youth coalition, and the youth coalition coordinator. Faculty from the University of Arizona and mentors of the PI, a doctoral candidate, had fostered a long-standing relationship with this specific border community and the youth coalition. Because the PI was a white academic outsider, it was important to work closely with the youth coalition coordinator, who was a bicultural, bilingual, and civically engaged member of the community. The youth coalition's primary focus was tobacco prevention policy in the border community, and a focus on substance use in general, therefore, fell within the scope of their purview. The coalition consisted of 25 Latinx youth aged 14 to 18 years from the community, who provided parental consent and assent to participate in the study. The research team met several times to build rapport; develop bilateral goals of the project outcomes, processes for accountability; and establish data ownership agreements prior to the study (Minkler & Wallerstein, 2011). This study received human subjects approval from the University of Arizona's Human Subjects Protection Program. --- Study Design In Stage 1, the academic-community collaborative team used a photovoice process to examine the perceived environmental factors that increase risk of, or protect against, substance use among adolescents living at the border. The youth were responsible for data collection, analysis and parts of the dissemination for the photovoice phase of the research (Valdez et al., 2019). In Stage 2, the academic-community research team developed and pilot-tested the Border Adolescent Substance Use Survey (BASUS). We used the overarching themes, relevant terms, and definitions identified in the photovoice process to identify existing validated instruments to measure select variables. For those novel variables not represented in the literature, the research team developed new questions for the BASUS. The PI crafted the questions and presented the questions to the youth coalition for approval. Finally, the PI pilot tested the BASUS with the youth coalition. In Stage 3, we developed a recruitment strategy to recruit students from the local high school to participate in the cross-sectional study using the BASUS. One week prior to data collection, the lead author described the study to 10 math classes composed of freshmen, sophomores, juniors, and seniors in order to get a representative sample of youth aged 14 to 18 years in the community. Students provided parental consent and assent prior to participation. The research team delivered the BASUS during math class at the school computer lab. As an incentive to participate, BASUS participants received 10 student dollars (to be used in the high school's student store) for submission of the parental consent and participant assent forms, and five student dollars for completion of the BASUS. A total of 597 students received invitations to participate, and 445 eligible consented participants completed the BASUS. We achieved 100% of our recruitment goal (n = 400) and a 75% response rate overall out of 597 youth (Valdez et al., 2021). --- KEY LESSONS LEARNED --- Youth-Led Instrument Design The youth coalition provided critical insights on the design of the BASUS (Stage 2), particularly the phrasing of the questions. They expanded the definition for youth involvement in drug trafficking to include store, sell, or transport drugs. They also identified a theme that was not adequately queried by existing questions and proposed additional questions, including, "In my community, music that glorifies drug trafficking or the narco lifestyle, like corridos, hip-hop, reggae, and bachata, influences adolescents to get involved in moving, selling or storing drugs." Youth contributed their regional, cultural, and linguistic expertise to develop a community-tailored substance use instrument. --- Youth-Led Recruitment Strategy The youth coalition suggested that the BASUS data collection should be at the local high school (Stage 3). The PI met with the school board, the principal, and the school superintendent to determine their level of interest and engagement with the study. All parties agreed that the data collected would be owned by the community and used to better understand the youth in the community, develop tailored prevention strategies, and apply for grants to support prevention initiatives. The youth coalition advocated that the recruitment messaging should frame the data as being beneficial to the youth (i.e., data could be used to apply for grants, allocate local resources to a youth center). The youth coalition also provided unique insight regarding the general culture of the student body, who to partner with, and how to incentivize participation. We determined that more students would return parental consent forms and participate in the study with student store dollars as an incentive, paid for with grant funds. Student store dollars are used to purchase snacks and other school promotional items (e.g., T-shirts) from the student store. The decision to use student store dollars resulted in an 83% submission rate for consent/assent forms. This particular success illustrates the importance of partnering with the youth coalition to enhance recruitment. --- Assure Participant Confidentiality The youth coalition determined that students might not want to participate in the study due to legal and personal safety concerns. Illustrating the youth coalition's concerns, during one class presentation a student declared, "I'm not doing that. I ain't no snitch." Thus, we took a number of steps to emphasize participant confidentiality. We obtained a Certificate of Confidentiality from the National Institutes of Health. Furthermore, we assured students that their responses would be deidentified, locked in a safe place, and would not be released to school officials or parents. As an additional security measure, the research team use the online REDCap (Research Electronic Data Capture) platform, which guarantees data safety and participant confidentiality. The team carefully conveyed this information to participants both verbally and written at two time points. We believe that by emphasizing participant confidentiality and safety, as suggested by the youth coalition, students felt sufficiently safe and comfortable to respond to the BASUS. --- CONCLUSIONS Our lessons learned illuminates that using participatory methods (e.g., YPAR) can enhance instrument design and recruitment efforts to increase underrepresented youth engagement in in substance use research. Future substance research should prioritize more fully engaging youth in the research process, particularly when trying to reach historically marginalized populations.

Youth engagement in substance use research is critical to the understanding of correlates that lead to detrimental health and social outcomes for adolescents. In addition to the documented challenges related to youth recruitment for substance use research, Latinx youth living on the U.S.-Mexico border may be difficult for researchers to engage in substance use research because they could face retributory harm if they identify their experiences to any entity perceived as an authority (e.g., researchers). Empirical findings that posit viable strategies to engage marginalized youth in substance use research are lacking. Participatory approaches show promise in increasing participation of historically underrepresented youth in research. Building on previously published work on our youth participatory action research mixed-methods study, this article discusses the youth-led participatory approach used to (1) develop and pilot test a culturally, regionally, and linguistically tailored substance use instrument and (2) engage 445 Latinx youth to participate in a cross-sectional study to assess epidemiological patterns of youth substance use on the U.S.-Mexico border. We share lessons learned related to the youth-led instrument design, youth-led recruitment strategy, and assuring participant confidentiality.

PRESIDENTIAL SYMPOSIUM: IMPACT OF DISCRIMINATORY POLICIES ON LGBTQ+ OLDER ADULTS' HEALTH AND WELL-BEING AND HOW TO COMBAT THEM Chair: Jung Kwak Discussant: Karen Fredriksen-Goldsen Despite some advances in LGBTQ+ rights over the past few decades, many states lack legal protections against discrimination based on sexual orientation or gender identity, and the current political climate raises concerns about future challenges to LGBTQ+ rights. This symposium explores the implications of discriminatory policies on the health, housing, and economic well-being of LGBTQ+ older adults, and solutions for promoting empowerment, equity, and inclusion throughout the care continuum, from long-term services and supports to end-of-life care. The first presentation describes a complex paradox in which sexual and gender minority (SGM) older adults avoid formal services due to fear of discrimination and poor treatment despite significant health disparities and a lack of informal support, discusses opportunities to improve access and health through education and awareness, and elucidates implications for policy and research. The second presentation describes geographic variations in access to, and receipt of gender-affirming surgery among transgender and gender-diverse Medicare beneficiaries using national Medicare data and discusses policy implications. The third paper focuses the role of spirituality and faith in the lives of LGBTQ+ older adults and reports findings from a mixed-methods study on how involvement in faith communities shape their end-of-life care perceptions and preparation. The fourth presentation describes barriers and facilitators to communicating with SGM hospice patients and caregivers about their sexual orientation and gender identity and recommendations for developing communication training to promote authentic end-of-life care for this population. Karen Frederickson-Goldsen as discussant will provide policy and practice implications of these important works.

The caloric content and manipulations of nutrient composition have defined our research focus over decades, leading to the formulation of ideal diets and supplements for every phase of life. In the last few years, the control of meal size, frequency, and timing have become a powerful strategy to ameliorate and postpone disease onset and delay aging. Emerging evidence highlights the importance of prolonged fasting periods for the health and survival benefits of calorie restriction (CR) and time-restricted feeding (TRF) across multiple species. Furthermore, there is new evidence of the potential combinatorial use of these dietary interventions with established therapeutical approaches to enhance outcomes, particularly in anticancer treatments.

Introduction According to the World Health Organization (WHO, 2016), Healthy as a condition of well-being that includes Physical, Mental and Social well-being that is not free from disturbance and mental health as an integral part of public health and an individual that is not free from mental disturbance, but in the quality therapy that makes life healthy that mental health as a condition that emotional, psychology and social relationship that can see from interpersonal satisfaction, behavior, effective coping, positive concept and emotional stability (Rosmalina, 2022) Every year the mental disorder phenomenon increases more in the world until now (Puspita, 2019). According to the WHO report (2018), people with a mental disorder register a total of 1,108 million, with a total of 21.2 % of the percentage of men with 9.3 % and women with 11.9 % in the world. Of this number more people with total anxiety disorder 284 million with 7.6 %, people with total depression disorder 264 million with 6.9 %, with bipolar disorder 46 million with 0.5 %, people suffering from drug use total 71 million with 1.8 %, person who affects total alcohol consumption 107 million with 2.8 % and affects total food consumption 16 million with 0.4 %. And with this mental disturbance number more happens to women than men. And, according to this data mental wellness in Asia (MWA, 2020). The problem that increases in mental health is a problem second each year it affects for mental deficiency in mainland Asia (Bodeker, 2020). In Asia the prevalence rate increases each year more affects for people adult majority mental disorder with 4 % (reports from Singapore) and 20 % (Vietnam, Thailand, New Zeland and Australia) (Gruber et al., 2021) According to statistics from the Ministry of Health Timor-Leste (MdS-TL, 2021), said that in Timor-Leste mental disorder will be the main problem in public health, from the beginning of March 2020 to March 2021, people with mental disorders mental register with total case 2.231. Of this total number 2.021 case undergo external treatment and a total of 210 cases are discharged from the Guido Valadares National Hospital (HNGV), comprising 92 men and 118 women. Of this number mental disorder is more with Schizophrenia and depression disorder that causes suicide (Andri et al., 2019) According to the prevalence data of the Municipal Health Liquiça Report (SSM Liquiça, 2021), reports that mental disorders in the municipality of Liquiça register a total of cases (337 men and 484 women). So also, people with mental disorders, who have already received treatment in the health facility total 399 cases (174 of men and 225 of women). In 2022, from beginning of January to the month of May, a total of 197 cases of mental disorders were registered (90 of men and 107 of women). And they who have already received the treatment the total 58 cases (31 of men and 27 of women), of this case mental disturbance most happens to women than to men. According to the report by Dato Village, Liquiça Vila Administrative Post, Liquiça Municipality (2022), from January to July 2022, a total of 62 cases of mental disorders were registered (22 of men and 40 of women). And people with mental disorders who have already received treatment total 16 cases (6 of men and 10 of women). This case most happens to the women than the men. --- Method This research uses the quantitative method with a cross-sectional correlational approach that is carried out in the Dato Village, Liquiça Municipality, Timor-Leste. Population is the family that the family member with mental disorder, in Dato Village with a total sample of 62 people (Abubakar, 2021). Non probability sampling technique with proportional sampling type. Data collection technique uses questionnaire, Data analysis uses Formula Pearson Product Moment. According to the results of the table above based on the characteristic respondent concludes as the family that the family member with mental disorder is mostly aged 18 -29 with frequency 23 (43,4 %) and minority aged 45 -69 respondent 12 (22,6 %). All religion is Catholic religion with total 53 (100 %). Secondary education level majority with respondent 23 ( 43.4 %) and minority education level is university with frequency 5 (9.4 %). Most profession that unemployment frequently 35 (66 %), and minority that Goverment employed with respondent 5 ( 9.4 %). Based on table 1 of the result respondent 53 is a respondent to the family that the family member with a mental disorder is mostly profession average with respondent 21 ( 39.6 %) and mostly mental disorder average with frequency 26 ( 49.1%) and medium profession good total 15 ( 28.3 %) and minority average mental disorder with respondent 12 ( 22.6 %). The Pearson Product Moment Statistical Test Result interval Coefficient Correlation 0.858** and significance level P-value 0.000 < a 0.05 means that Ha receives and relationship between family profession and mental disturbance. Based on table 3. of the result respondent 53 shows the family respondent that with family member with mental disorder majority knowledge with average profession with frequency 28 (52.8 %) and majority mental disorder average with respondent 26 (49.1 %) and minority knowledge with less profession total 17 people (32.1 %) and minority mental disorder maximum with respondent 12 ( 22.6 %). The Pearson Product Moment Statistical test result interval coefficient correlation 0.825** and significance level Pvalue 0.000 <a 0.05, means that Ha receives and relationship between knowledge, family profession and mental disorder. --- Result and Discussion --- Discussion --- Respondent Characteristic Related to the sample result 53, based on the table above shows that respondent family that the family member with mental disorder, is majority aged 18 -29 with frequency 23 (43.4%), all family religion is Catholic Religion a total of 53 (100%), Secondary education level family respondent most secondary education level respondent 23 (43.4%) and most profession family respondent total unemployment 35 (66%). According to Notoatmodjo (2005), said that education is like a need that is a priority to increase capacity, when good knowledge is easy to adapt with modern technology and increases productivity will be mature. According to Luluk (2005) in (Rifi, Nauli, and Utomo, 2014), said that the family's profession is related to daily activity, the unemployed family has more time to accompany It is based on the result of current research in the past on top of the researches concludes that crosstabulation between knowledge and mental disturbance shows that strong positive correlation, from this result finds a questionnaire with questions for the respondent to answer even strong correlation but needs stronger so that the community can have the good knowledge to care for family member. --- b. Family Profession on Caring for The Family Member with Mental Disorder Based on table 2, the result of a survey that measures the family profession with a sample of 53, shows that the family profession has 65.1 % with an average profession category. From this statistical result Pearson Product Moment Test, Family profession on providing care to the family member with mental disorder, with a result of significance level P-value 0.000 < 0.05 and interval coefficient correlation 0.825** 0r rxy = 0.858**, from this result, there is a relationship between the profession and family variable and mental disorder, it is related to the interval correlation 0.858** in table 3.1. Shows that positive correlation is strongest with the value between 0.800 -1.000. This research is similar to research already carried out by researcher (Kasim, 2018), who researches the topic of the relationship between profession, family and personal hygiene for people with mental disorders in Medan Sunggal City of Medan. The test statistic with value P-value = 0.151 compares with a = 0.05 so P-value < a = 0.05 means Ha receives. It is based on the result of the current research and passed on above, the researcher concludes that crosstabulation between profession, family and mental disorder shows a stronger correlation, from this result finds a questionnaire with questions for the response of the respondents even is this correlation is stronger but needs stronger so that the community can have the good profession to take care of the family member. --- c. Family Knowledge and Profession about Caring for the Family Member with Mental Disorder It is based on table 3. The result of the survey to measure the knowledge and profession of the family that causes mental disorders to occur with a sample of 53, shows that knowledge with the profession has a 66.9 % average category of knowledge and profession, From this Pearson Product Moment Test Statistical Result, the family's knowledge and profession about providing care to the family member with mental disorder, with a result of significance level P-value 0.000 < 0.05 and interval coefficient correlation 0.825** or rxy = 0.825, from this result, in the relationship between the variable knowledge, profession, family and mental disorder, correlates with interval correlation 0.825** in table 3.1. Shows that positive correlation is strongest with the value between 0.800 -1.000. From this research already carried out by researcher (Sari, 2019), on the relationship between knowledge and family attitude with the level of anxiety to care for the family member who has a mental disorder at the Sijunjung Health Center. From this relationship that is significant between family knowledge with anxiety to care for the family member who has a mental disorder with result P-value = 0.000 compares with a = 0.01 so P-value a < 0.01 means Ha receives. Based on the current result and passed on above the researcher concludes that crosstabulation between knowledge, family profession and mental disorder shows positive correlation is stronger, from this result finds a questionnaire with questions for respondents to answer even correlation is strong but needs stronger to that so the community may have the strongest knowledge and expertise to provide care for the family member. But while the researcher is doing the research, he observes that the patient's family needs a level of education, information, experience, decrease the culture and needs an economy that is sufficient to increase and improve the level of knowledge of the family. --- Conclusion The writer already mentioned the result about the cause of mental disturbance, which influence of knowledge and profession of the family on caring the family member. The family knowledge with a sample of 53, knowledge that has 66.83 % average knowledge category to provide care for the family member with mental disorder. Family profession with a sample 53, family profession which has 65.06 % average family profession category to provide care for family member with mental disorder. Knowledge and Profession family with a sample 53, Knowledge and Profession which has 66.95 % knowledge and profession category average to provide care for family member with mental disorder. Principle knowledge is how you create the environment that supports family and effective communication, encourages creativity and motivation for the family and community. The activity of this research aimed to give the motivation and opportunity for the family to realize the relationship that is good in the family to provide care for their family. Alexandra Maria Pires, Maximiano Oqui, Eurico Amaral, Meriana Barreto Amaral, Áureo Frutalegio da Costa Freitas, Hermínio Noronha/KESANS Relationship Knowledge and Profession of The Family and Mental Disorder in Municipality of Liquica, Timor-Leste

Introduction: Mental health as an integral part of public and individual health, which is not free from mental disorders, but also has quality treatment for a healthy life. Mental health as an emotional, psychological condition and social relationship that can see interpersonal satisfaction, behavior, effective coping, positive concept, and emotional stability. Objective: The purpose of observing and doing a case study with the research process that submits this research, with the result want to know more in the scope of relating knowledge and family profession about giving care to the family member with a mental disorder. Method: This research uses the quantitative method and cross-sectional approach, which will be carried out in the Dato Village, Liquica Municipality, Timor-Leste. Result and Discussion: The result proves that it has stronger positive correlation than the value between 0.800 -1.000. Conclusion: knowledge result which has 68.8 % and family profession has 65.1 % with average knowledge and profession category which provide care for family member with mental disorder, Pearson Product Moment Test value proves that P-value 0.000, and R-value calculation 0.825**

Whereas higher fast food prices have been linked to increased fruit and vegetable consumption, decreased body mass index (BMI), and decreased probability of overweight, 8 an increase in fruit and vegetable prices corresponded to an increase in child BMI, particularly among low-income participants. 8,9 Moreover, children living in high-poverty neighborhoods, which have a lower density of grocery stores, consume fewer servings of fruits and vegetables. 10 This literature implies lower-income neighborhoods, characterized by a higher density of unhealthy food outlets and lower density of grocery stores, are climates in which children consume fewer servings of fruits and vegetables and have higher BMI. 11,12 Yet research has not considered the impact of parental perceptions of the availability, affordability, and acceptability of foods on children's nutrition, despite evidence from adult populations that such perceptions affect diet. 6,13,14 Furthermore, there is limited literature on the associations between the food built environment and produce consumption in Latino families with young children, a population with higher rates of obesity. 1 Thus, this study sought to understand the relationships between objective and subjective (i.e., parentperceived) availability, affordability, and acceptability of food, and child produce consumption among urban, Latino families. --- Methods Data were collected from August to November 2013, prior to randomization, in a controlled trial of a parent-child intervention designed to prevent childhood obesity, which was approved by the Institutional Review Board of Vanderbilt University Medical Center. 15 --- Study sample Parent-child dyads were eligible to participate if they received at least one form of government assistance, spoke English or Spanish, parent was over 18 years old, child was three to five years old and normal weight or overweight (based on body mass index percentile ≥50 th and <95 th ), 16 and both parent and child were healthy enough to participate in physical activity. The first 115 dyads recruited constituted the sample for this study. The principle site for the trial was local community recreation centers in Nashville, Tennessee. --- Measures Subjective measure of food environment-Because there are no psychometrically tested subjective measures of food built environment, the authors developed the Built Environment Perception for Nutrition (BEP-N) survey based on prior literature and clinical judgment. 14 The interviewer-administered survey included six items answered on a fourpoint scale. All items were translated to Spanish by the first author and checked by a native Spanish-speaking researcher with extensive experience with the target population. Objective measure of food environment-Participants gave the name and location of the grocery store where they most frequently shopped, and the Nutrition Environment Measures Survey for Stores (NEMS-S) was conducted by a single, trained rater in the four most frequently cited grocery stores (n=70, 61% of participants, next most commonly cited stores were different locations of the same chain) on weekdays during normal store business hours. The NEMS-S is a validated objective audit tool used to assess availability, affordability, and acceptability of healthy food in grocery stores. 17 Produce consumption: Parents were asked, "How many of the last seven days did your child consume five servings of fruits and vegetables?" --- Analysis Data analysis occurred from April to August 2014. Descriptive statistics were calculated for demographic characteristics, BEP-N, NEMS-S, and parent-reported child produce consumption. Pearson correlations and two-sided Fisher's exact tests were conducted to detect significant bivariate associations. Stata/IC 12.1 was used to conduct analyses. 18 --- Results --- Descriptive statistics The mean age of the children was four years, with the majority in the normal weight range and about a third who were overweight, consistent with study design eligibility criteria. Two-thirds of the sample received supplemental nutrition assistance by participating in Women, Infants and Children (WIC) or the Supplemental Nutrition Assistance Program (SNAP). The majority of participating parents (97% mothers) were from Mexico and had lived in the U.S. for a mean of 10.7 years. On average, children consumed the recommended daily servings of fruits and vegetables four days per week (see Table 1). Participants reported driving an average of 3.9 miles to their primary location for food shopping. The most commonly cited primary grocery outlets were two large, chain stores-three Walmart locations and an Aldi, and there was little variability in the NEM-S scores for availability, affordability, and acceptability. Total scores ranged from 30-31 (scale between -8 to 50) (Table 2). Parent perceptions of the food built environment are summarized in Table 3. Due to strong within-construct correlations, the two items for affordability (r=.76) were added together and the two items for acceptability (r=.43) were added together for further analysis. --- How are the objective and subjective food built environment measures associated? The objective and subjective ratings of the food built environment were not significantly correlated. Fisher's exact tests comparing subjective scores from participants who primarily shopped at Walmart locations versus those who shopped at Aldi were not significant (results available upon request). Socio-demographic correlates of subjective food built environment were explored based on a-priori rationale that household income and WIC/SNAP would influence perceptions of availability and affordability, and that education and years in the U.S may influence perceptions of food acceptability (Table 4). Household income (n=82) was positively correlated with perceived food affordability (r=.22, p=.04) and acceptability (r=.33, p=.003). Participating in WIC or SNAP (n=114) was significantly associated with perceptions of greater produce availability (p=.001) and disagreement with the statement that fast food is more accessible than fresh produce (p=.03). There were no significant associations with level of education or years in the U.S. --- How are the objective and subjective food built environment independently associated with children's produce consumption? None of the objective measures of the food built environment were significantly correlated with number of days children ate the recommended servings of produce. Participantperceived affordability of food was correlated with more frequent child fruit and vegetable consumption (r=.21, p=.03). --- Discussion Literature reviews suggest a complex relationship between subjective and objective measures of the food built environment and child nutrition. [19][20][21] Thus, the current study assessed links between objective and subjective availability, affordability, and acceptability of food and child fruit/vegetable consumption among Latino families at high risk for childhood obesity. Despite recent attention to food deserts, this study's results align with others indicating that families in low-income communities will travel outside their neighborhoods to access supermarkets with healthy food. 22 Families drove an average of 3.9 miles to their grocery store of choice, which was almost always a large, chain store with NEMS-S scores indicating acceptability, affordability and accessibility of healthy foods. Participants generally rated their food built environments positively; 81.7% and 78.3% of participants "strongly agreed" with statements about the availability and acceptability of produce. However, only 47.4% and 38.1% of participants strongly agreed that healthy food and food in general were affordable, a perception significantly associated with household income. Moreover, perception of food affordability significantly predicted more frequent child fruit and vegetable consumption. Multiple studies have linked subjective food availability and accessibility but not perceived affordability to healthy food intake; 14,23,24 however, these studies did not examine Latino families with young children. 13,25 Cash transfer programs (conditional and unconditional) have been shown to improve child nutritional status in a variety of contexts, although with variable significance. 26,27,28 Despite this variability, the fact that higher-income participants within this relatively low-income population reported more child fruit and vegetable intake suggests that cash transfers may be a promising option. --- Limitations No assessment was conducted on the frequency with which participants shopped at the stores they identified. The questions on subjective perception were newly developed, and the number of items on this instrument is intended as a brief screen rather than a comprehensive survey; further psychometric testing is needed. --- Availability "I can easily find fresh fruits and vegetables in my community." --- Conclusions In this sample of urban, Latino families with young children, perceived rather than objective food affordability was significantly associated with parent-reported child fruit and vegetable consumption. Strategies to overcome parents' perceived financial barriers to produce consumption could enhance obesity prevention efforts in this high-risk population. --- Author Manuscript Mathieu et al. Page 9

This study explored the association between objective and subjective ratings of the food environment and child produce consumption for Latino preschoolers at-risk for obesity. Parental surveys (N=115) assessed perceptions of food availability, affordability, and acceptability. Comparable factors were objectively rated by a trained observer, using the Nutrition Environment Measures Survey for Stores (NEMS-S), in commonly frequented grocery stores cited by participants. There were no significant correlations between objective and subjective measures of food availability, affordability, and acceptability. Greater household income was associated with higher participant perceptions of food acceptability (r=.33, p=.003) and affordability (r=.22, p=. 04). Participant-perceived affordability of food was correlated with more frequent child fruit and vegetable consumption (r=.21, p=.03). These findings support that parental subjective ratings of the food environment affects their child's eating behaviors more than objective ratings.

Introduction Social media have emerged as the fora of choice for users on the Web to express their opinion about issues they deem important. These fora provide a way to interact with other users who wish to discuss the same issues. Due to their widespread adoption, and the fact that much of the activity they host is publicly available, they offer a unique opportunity to study social phenomena such as peer influence, framing, bias, and controversy. Our work, in particular, is motivated by interest in observing controversies at societal level, monitoring their evolution, and possibly understanding which issues become controversial and why. The system that we demonstrate focuses on the exploration of controversy on Twitter, currently the most popular microblogging platform. 1 The back-end of the system processes the messages generated on the platform on a daily basis in order to (i) identify different topics of discussion, (ii) assign a controversy score to each topic, and (iii) produce visual renderings of the activity surrounding each topic in a way that clarifies whether the topic is controversial. The front-end provides a web interface 2 that allows to explore the identified topics according to various views (e.g., ordered by time or magnitude of controversy) and obtain more information about each topic (e.g., by providing a keyword summary of the topic, representative tweets, or a visualization of the activity). The system is designed to identify controversy on topics in any domain, i.e., without any prior domain-specific knowledge about the topic in question. Specifically, topics are defined by hashtags, special keywords conventionally employed by Twitter users to signal that their messages belong 1 With 320 million monthly active users as of 30 September 2015 according to https://about.twitter.com/company. 2 http://users.ics.aalto.fi/kiran/controversy to a particular topic. As an example,"#beefban" is a hashtag that was employed to convey that a post referred to a decision of the Indian government, in March 2015, about the consumption of beef meat in India. The system leverages this convention and treats each hashtag as a different topic. Given a hashtag, we represent the activity on the corresponding topic by a retweet graph. In this graph, vertices represent Twitter users who have used the hashtag at least once on a given day, and edges represent retweets between users. To quantify the controversy of each topic, we rely on the hypothesis that the structure of the retweet graph reveals how controversial the topic is. This hypothesis is based on the fact that a controversial topic entails different sides with opposing points of view, as well as on previous evidence that individuals on the same side tend to endorse and amplify each other's arguments [1,2,3]. We studied this hypothesis in previous work [4], and found strong evidence that the retweet graph of a controversial topic presents a clustered structure that reveals the opposing sides of the debate. Moreover, in the same work, we developed a random-walk-based measure that quantifies accurately how controversial a topic is by taking into account the structure of its retweet graph. In light of these findings, for each topic identified, the system computes a controversy score, and produces a rendering of the retweet graph that highlights its clustering structure. --- Related Work Previous studies aim at identifying controversial issues, mostly around political debates [1,3,8,9] but also other topics [5]. While most recent papers focus on Twitter [3,5,8,9], controversy in other social-media platforms, such as blogs [1] and opinion fora [2], has also been analyzed. The main limitation of previous work is that the majority of studies have focused on known, long-lasting debates, such as elections [1,3]. Our system is the first one to attempt controversy detection in the wild, on any topic, and without human data curation [4]. Our approach to measuring controversy follows a pipeline with three stages, namely graph building, graph partitioning, and measuring controversy, as depicted in Figure 1. The input to the pipeline is a single hashtag, which defines a topic of discussion. The final output of the pipeline is a value between zero and one that measures how controversial a topic is, with higher values corresponding to higher degree of controversy. We provide a high-level description of each stage here, for further details refer to the original work [4]. --- Quantifying Controversy --- Graph Building --- Graph Partitioning Controversy Measure --- Building the Graph The purpose of this stage is to build the retweet graph associated with a single topic of discussion. For a given day, each tweet that contains the hashtag that defines the topic is associated with one user who generated it, and we build a graph where each user who contributed to the topic is assigned to one vertex. In this graph, an edge between two vertices signifies that there was one retweet between the corresponding users. We take a retweet as a signal of endorsement of opinion between the users. --- Partitioning the Graph In the second stage, the resulting retweet graph is fed into METIS [7] a graph partitioning algorithm to extract two partitions. Intuitively, the two partitions correspond to two disjoint sets of users who possibly belong to different sides in the discussion. In other words, the output of this stage answers the following question: "assuming that users are split into two sides according to their point of view on the topic, which are these two sides?". If indeed there are two sides which do not agree with each other -a controversy-then the two partitions should be only loosely connected to each other, given the semantic of edges. --- Measuring Controversy The third and last stage takes as input the retweet graph built by the first stage and partitioned by the second stage, and computes the value of a random-walk-based controversy measure [4] that characterizes how controversial the topic is. Intuitively, the controversy measure captures how separated the two partitions are. --- Visualizing controversy As explained in the previous section, we use METIS [7] to produce two partitions on the retweet graph. Given a retweet graph and its two partitions, we produce a visualization of the graph, as in the cases of Figures 2 and. The figures display the two partitions for two topics (#rus-sia_march and #sxsw) in blue and red color on their corresponding retweet graphs. The graph layout is produced by Gephi's ForceAtlas2 algorithm [6], and is based solely on the structure of the graph, not on the partitioning by METIS. It is easy to see that the retweet graph of the first topic is characterized by a bi-modal clustering structure, indicating a controversy. In contrast, the retweet graph of the second topic is characterized by a uni-modal clustering structure, indicating lack of controversy. --- Exploration Session The demonstration will allow the attendees to explore the set of trending topics discussed on Twitter during Jun-Sep 2015. The attendees will be able to interact with a web interface to select one topic and retrieve its summary, and organize the set of topics according to different views. Topic Summary. The summary of each topic consists of its hashtag, together with the most related keywords, which convey the main idea behind the topic itself. To further help in understanding the topic, the system provides representative tweets from either side of the controversy. These tweets come from authoritative vertices in the graph, as measured by the number of endorsement received. Finally, the summary also includes a visualization of the retweet graph. Topic Views. Attendees will have the option to browse the topics in chronological order, or sorting them by controversy score, to find the most controversial ones. The system offers also a search functionality, by which the user can specify a text query and obtain a set of relevant topics. Figure 4 is a screenshot of the system while showing some examples of the most controversial topics.

Among the topics discussed on social media, some spark more heated debate than others. For example, experience suggests that major political events, such as a vote for healthcare law in the US, would spark more debate between opposing sides than other events, such as a concert of a popular music band. Exploring the topics of discussion on Twitter and understanding which ones are controversial is extremely useful for a variety of purposes, such as for journalists to understand what issues divide the public, or for social scientists to understand how controversy is manifested in social interactions. The system we present processes the daily trending topics discussed on the platform, and assigns to each topic a controversy score, which is computed based on the interactions among Twitter users, and a visualization of these interactions, which provides an intuitive visual cue regarding the controversy of the topic. The system also allows users to explore the messages (tweets) associated with each topic, and sort and explore the topics by different criteria (e.g., by controversy score, time, or related keywords).

What kind of substance use issues affect LGBTQ+ populations? LGBTQ+ people have worse health outcomes than the general population across a variety of areas including substance use. The literature in the field found disproportionate levels of substance use, including harmful substance use and dependency syndromes. This includes generally higher levels of alcohol use, particularly risky long-and short-term alcohol consumption, such as binge drinking. Similar, there is a higher smoking prevalence and increased use of other drugsboth licit and illicit. Particularly interesting is that research overall suggests that LGBTQ+ communities are not only more likely to use substances but also use them more frequently and start using substances at an earlier age. A more recent phenomenon, particularly in gay and bisexual men, is chemsex, the act of intentionally engaging in sexual activities under the influence of substances such as methamphetamine, mephedrone and GHB that can lead to significant mental and physical harm to some engaged in these activities. What are the harmsboth in terms of physical and mental healthassociated with substance use in LGBTQ+ people? The harms and consequences of substance use do not differ from the harms they cause in other populations in most instances. It is also important to differentiate between substance use and harmful substance use as not all instances of substance use, including so-called 'hard drugs', will result in meaningful harm to a person or their community. However, prolonged harmful substance use can result in a range of negative consequences for a person's physical and mental health. In the case of LGBTQ+ communities, not only the higher prevalence of risky substance use itself but also the earlier onset is of concern. Several issues are intersecting here with an earlier age of onset coinciding with one of the most critical developmental periods, adolescence, during which people form their identities, while also reporting strong levels of perceived discrimination and marginalisation due to their sexual orientation or gender identity. Chemsex has been subject to multiple studies over the past couple of years and can result in serious consequences including dependence, overdosing, hospitalisation and death. It is also related to an increase in 'highrisk' sexual activity and needle sharing, with those engaging in chemsex reporting a higher likelihood of being diagnosed with sexually transmissible infections and other blood-borne viruses, such as hepatitis C, than those not engaging in chemsex. --- What do we understand about the reasons underlying these issues with substance use? There is no single unique factor that can fully explain the disparities in substance use LGBTQ+ communities experience. Unfortunately, much of the discourse in this area is centred around the concept of suffering to explain substance use. However, substance use is not always the result of negative factors or experiences. Of course, some or even a lot of these disparities can be explained by looking at substance use as a mechanism to cope with discrimination, marginalisation and oppression, but there are a variety of factors involved with some more unique to LGBTQ+ communities, and others also affecting other communities. These include cultural factors, limited access to appropriate healthcare and community services or even targeted marketing. Chemsex is a great example, with LGBTQ+ communities and individuals showing generally very high levels of openmindedness when it comes to sexuality and experimenting with sexual practices. This lower inhibition threshold makes it more likely they will also engage or experiment with risky practices such as chemsex. Research has shown that, while chemsex can be used as a coping mechanism, users report strong positive outcomes, such as enhanced sexual confidence, increased sex drive and sexual stamina and a more intense sexual experience in general. What research is needed to further understand substance use and how it impacts the LGBTQ+ community? The body of literature has developed a lot over the past ten years but more and different research is not only possible but also required. There is some evidence suggesting that the disparities in substance use are not equally distributed across LGBTQ+ populations, with some groups showing higher disparities than others. Research often still assumes that we are looking at a monolith block of identities when researching in LGBTQ+ communities. However, the reality is more complex than that and research needs to acknowledge and accommodate this reality. This means to ensure a good representation of different communities, particularly sex-and gender-diverse people and to look at these issues through an intersectional lensthat is, one that takes into account the interconnected nature of social categories and identities -as LGBTQ+ people do not exist in isolation from other groups. Furthermore, it is important to create more research with communities rather than about communities. Research too often focuses on aspects that are not a priority for LGBTQ+ communities. Community-driven research has the potential to be more valuable and useful to the lived experiences and structures of LGBTQ+ communities. --- How does your own research further these goals? My research is community-driven and community-informed. I consult with community organisations and community members about each idea I have, ensuring that my research is relevant and useful for them. To further my engagement, I volunteer for community organisations in my area and I'm involved as an active member. Being both a researcher in this area and a community member, this might be easier for me than for other researchers. My research also does not end with the publication of its results. I find it important to report my results back to the community, explain the findings, get their input into their interpretation, and assist them in using research findings to inform their services. What else is important for our readers to understand about substance use in LGBTQ+ populations? It is really important that we acknowledge the complexity of substance use and stop to pathologize the use of substances per se. The current lens used to understand, investigate and treat substance use and substance users is unlikely to reach those most in need of assistance. The public perception of substance use has changed dramatically over the past decade and research and practice need to ensure they are keeping up with community sentiments and cultures.

His research focuses on health in disadvantaged populations and he has a particular interest in sexual health and substance use in LGBTQ+ populations. In this Q&A, we ask Dr. Demant a series of questions on disparities in substance use in LGBTQ+ people, the potential reasons underlying such disparities and harms associated with them, and the direction of research in this area.

INTRODUCTION On October 26, 2017, the U.S. Department of Health and Human Services (HHS) declared the opioid crisis a public health emergency [1] and soon after announced the 5-Point Strategy to End the Opioid Crisis [2]. The National Institutes of Health (NIH), a component of HHS, mounted efforts to advance scientific breakthroughs aimed discovering new and better ways to prevent opioid misuse, treat opioid use disorders, and manage pain [3]. A major coordinated effort through the NIH Office of the Director, the Helping to End Addiction Long-Term (HEAL) Initiative, was launched in April 2018. This trans-agency effort builds on well-established NIH research to speed scientific solutions to stem the national opioid public health crisis [4]. In addition to HEAL Initiative efforts, individual NIH institutes, centers and offices have also taken action through collaborative activities and innovative funding opportunities. This Commentary will take a closer look at the NIH efforts related to opioid misuse and pain that have behavioral and social sciences research components. --- BACKGROUND According to the National Institute on Drug Abuse, drug overdoses killed more than 72,000 people in 2017, of which 49,000 deaths involved a prescription or illicit opioid [5]. The severity of the opioid crisis is often reported in drug overdose deaths; however, the number of overdoses does not convey the full scope of tragedy. This crisis reaches across practically every domain of family and community life, from lost productivity and economic opportunity to inter-generational and childhood trauma, to extreme strain on community resources, including first responders, emergency rooms, hospitals, and treatment centers [6]. Rising from two sizable public health challenges, namely the suffering of tens of millions of people living with chronic pain and the widespread diversion and misuse of prescribed opioid medications [7], this epidemic is worsened by poor implementation of evidence-based strategies to better treat addiction and to improve management of chronic pain. A public health approach to improving pain care is needed to address the biopsychosocial nature of pain through integrated care that reduces reliance on opioids. Such an approach would recognize the variability in individual experience and burden of pain that often requires an interdisciplinary, biosocial perspective approach; social and behavioral determinants that contribute to risk of both opioid misuse and for developing chronic pain are often overlooked [8]. --- HEAL INITIATIVE To speed scientific solutions to curb the national opioid crisis, Congress added $500 million to the base appropriation of the NIH starting in fiscal year 2018 [9], which nearly doubled support for research on opioid use disorder and pain from approximately $600 million in fiscal year 2016 to $1.1 billion in fiscal year 2018 [10] through the HEAL Initiative [11]. This increase will help bolster research aimed at improving treatments for opioid misuse and addiction and enhancing pain management, including research to integrate behavioral interventions with medication-assisted treatment (MAT) and implementation science to develop and test treatment models [12]. This "all hands on deck" approach provides numerous research opportunities to expedite effective strategies for opioid misuse and addiction, and accelerate development and evaluation of pharmacological and nonpharmacological interventions for pain management. As part of a government-wide effort to address the opioid crisis and the public health challenge of chronic pain, the NIH initiated a series of cuttingedge science meetings to build the inventory of top priorities for HEAL research [13]. The initial set of meetings produced recommendations for advancing the addiction and pain research agenda and focused on accelerating development of safe and effective interventions for pain, addiction, and overdose. To enhance these efforts, the Office of Behavioral and Social Sciences Research (OBSSR), in collaboration with the National Institute on Drug Abuse (NIDA), the National Institute of Neurological Disorders and Stroke (NINDS), the National Center for Complementary and Integrative Health (NCCIH) and the National Institute on Minority Health and Health Disparities (NIMHD) hosted a meeting highlighting behavioral and social science strategies and interventions for the prevention and treatment of opioid use disorder and for pain management. The meeting, Contributions of Social and Behavioral Research in Addressing the Opioid Crisis (CSBR-AOC), was held on March 5-6, 2018. A diverse panel of researchers, academics, clinicians, patients, and advocacy groups presented and discussed the most recent and relevant behavioral and social scientific data and identified the greatest needs and areas of opportunity related to the current crises. Their input helped contribute to the major research priorities within the NIH HEAL Initiative (see report for presentations and specific citation contact information). According to the panel [14,15], key issues, actionable social and behavioral science priorities and recommendations that have the potential to improve the response to the opioid crisis and alleviate the burden of pain include: --- OFFICE OF BEHAVIORAL AND SOCIAL SCIENCES RESEARCH In a follow-up to the HEAL meeting on social and behavioral research, OBSSR developed a trans-NIH --- Contributions of Social and Behavioral Research in Addressing the Opioid Crisis (CSBR-AOC) Strategic Planning Committee made up of senior-level staff from 23 NIH institutes and centers. This Committee has been charged with integrating appropriate behavioral and social science research priority recommendations from the CSBR-AOC meeting into current and future NIH activities. This includes identification and integration of social and behavioral research questions into relevant NIH funding opportunity announcements focusing on a range of topics to address opioid use disorder and pain. In December 2018, 36 funding opportunity announcements were published and are currently listed on the HEAL website [16] and include small business innovation research awards, cooperative agreements, and exploratory research grants. --- TRANS-NIH ACTIVITIES In addition to the HEAL program and OBSSR-led efforts, there are complementary activities ongoing across the NIH. For example, 25 NIH institutes, centers, and offices actively participate in the NIH Pain Consortium [17]. This group identifies, coordinates, and supports pain research initiatives and activities at NIH and is actively engaged in the NIH HEAL-related opioid and pain research efforts and other pain research activities. At the 2018 NIH Pain Consortium Symposium, From Science to Society: At the Intersection of Chronic Pain Management and the Opioid Crisis, the NIH Director, Dr. Francis Collins, engaged in a fireside chat with the U.S. Surgeon General, Jerome Adams [18]. During their discussion, the need for rapid dissemination of proven clinical practices and prevention strategies was emphasized, as well as collaborative care management between acute pain and chronic pain. Vice Admiral Adams acknowledged that current research tends to focus on creating new modalities to treat pain despite the fact that clinicians are not using 90% of the effective modalities currently available, and stigma creates taboos around some forms of therapy (e.g., mindfulness) regardless of the proven benefit and potential to decrease a patients' reliance on opioids. Dr. Collins reported that NIH is engaged in conversations with the Center for Medicaid and Medicare Services to build a stronger evidence base for pain interventions that are not based on a pill but rather built on evidence-based interventions such as acupuncture, cognitive behavioral therapy, and mindfulness [19]. --- TRANS-UNITED STATES DEPARTMENT ACTIVITIES In addition to collaborative activities between the institutes, centers, and offices, numerous cooperative efforts span across federal agencies to take advantage of opportunities to merge shared interests. The combined expertise that each partner brings to the table helps to ensure greater impact when addressing the complexities surrounding the epidemic. For example, the NIH partnered with the Department of Defense and Department of Veterans Affairs to establish the NIH-DoD-VA Pain Management Collaboratory. This multicomponent research program has awarded over $81 million to explore nonpharmacologic approaches to pain management [20]. Supported research projects focus on nonpharmacologic approaches to pain and related conditions within the health care systems serving active duty military and/or veterans. Research results include data that nearly half of soldiers and veterans experience pain on a regular basis and that there is significant overlap among chronic pain, post-traumatic stress disorder, and persistent post concussive symptoms [21]. Lessons learnt will provide evidence-based approaches to treating through nonopioid management strategies, which can be disseminated and translated across other populations. --- NEXT STEPS Efforts led and supported by the HEAL Initiative, along with activities within and across individual NIH institutes, centers and offices, reflect an ambitious vision and continued investment to address America's opioid public health emergency. Information release about funding opportunities began in summer 2018, and many included behavioral and social science. For example, through the NIDA Justice Community Opioid Innovation Network (JCOIN), the NIH will establish a network of research investigators to rapidly conduct studies on quality care for opioid misuse and opioid use disorder in justice populations by facilitating partnerships between local and state justice systems and community-based treatment providers [RFA-DA-19-023]. Funding opportunities were also available to assess the role of complementary behavioral interventions for primary and secondary prevention of opioid use disorder and to examine if these complementary approaches enhanced adherence to MAT [RFA-AT-19-007]. For a comprehensive list of opportunities, please refer to the NIH HEAL website [22] and NIH guide [23] for current funding announcements. Although it may not appear from all titles that there is relevance to the behavioral and social sciences, there are opportunities for integration of biopsychosocial frameworks and perspectives. There remains much to learn to prevent and treat opioid abuse and better manage both acute and chronic pain, and the NIH continues to support research that address these public health issues.

This commentary highlights current NIH efforts aimed at addressing the opioid crisis, specifically activities related to behavioral and social science research. Implications for this commentary will inform researchers, practitioners, and policymakers on current endeavors and future funding opportunities.

Introduction The changing socio-economic scenario of our traditional society has changed the nature and dimension of the needs of different groups particularly of the aged. It is not only the destitute who need economic support and care through institutionalisation today. But a large portion of the economically sound and physically fit aged also require social support. Emotional and psychological security and community support for whole some existence. India government starts so many services to serve old aged and sent different directives to maintain them in the stats in our constitution Article 41 of the constitution enjoins upon the Bihar to mark effective provision within the limits of its economic capacity and development for public assistance in old age, sickness disablement and in other areas of undeserved want. The government arrange to help old age persons in different ways ministry of welfare has a scheme of assistance to voluntary organisations for programs relating to the aged. The scheme aims of providing physical, social, emotional, psychological and economic support to the aged (60 year and above) with a view to help them to continue to be usefully active members of the community. There are four organisations of central government and two of Bihar govt. The programme represent a significant step towards the fulfilment of the directive principle in Articles 41 and of the constitution recognising the concurrent responsibility of the central and Bihar Government in the matter. --- Objective The present research work was carried out to find the problem in the vicinity ¼ vkl ikl ½ of Muzaffarpur. One of the important aspects of these problem is related to their status in society. The objectives of the present research are: 1. To find out the levels of social status of the old-aged persons. 2. To find out social economic that correlates of social status of aged. 3. To analyse sex distribution amongst the aged. 4. To analyse the demographic pattern and companionship among the aged with particular reference to Bihar. Accordingly separates lists of the aged males from each village was drawn through random-sampling technique for a total of 100 respondents the distribution of respondents are: --- Methodology The methodology adopted in conducting the study is interview method with random sampling technique. The study was conducted in the colonies of Shiho and Chandan patti where most of the old persons have settled after their retirement. We have randomly selected 100 respondents. Choosing 30 from the rank of offices and 70 from other ranks. The information was collected from the help of interview schedules, observations and in formal discussions. The respondents were very honest and frank in their discussions thus it is easy to have a comprehensive picture of the problems and the status of these persons in their civilian life. --- Conclusion The In this way these organisations promoting the all-round status of old age people psychological and social also. --- Findings The finding about the absence of any relationship between adjustment and strength of religious beliefs. Demonstrates that these beliefs have no important role to play regarding adjustment in old age. This finding does not encourage religion. But it is essential to believe in the religion of self. The findings regarding the relationship of various behavioural factors on the hand and the level of adjustment on the other show that the active type of life is more desirable for good adjustment. Old people do not want to disengage themselves from society. They like to remain fully integrated in the social network and enjoy association and interaction with various groups of people or their friends. Therefore, when they are forced to lead a disengaged life, initially due to retirement and them due to physical weakness they become frustrated from their life. Though in eth present study the theories of successful aging have not been tested through controlled observation still it can be said that our finding support theory. All the behavioural factors which indicate the activeness and social interaction of the respondents are found to have a positive association with their adjustment whereas the involvement in religious activities. Which shows the with drawl of an aging individual of the world is found to have relationship with the adjustment. Our finding show the lack of interest of the retirees in voluntary organizations but those who are interested in voluntary organizations are certainly better adjusted that those who are not. --- Suggestions a) The Government must support to the old age Home and in the improvement the facilities of old aged. b) The younger generation should be made aware of the love and care needed by the old people. c) The community should be facilitate economic respective and mental support also to help their old aged members of the family.

The problem of old age is becoming a social problem in every country as well as in Indian society also. Consequently, the need for finding out the correlates of good Adjustment in old age in the Indian background is being increasingly felt. The present investigation is a step in this direction. Keywords: Integrated programme for old persons (IPOP), rastriya vayoshri yojana (RVY), indira gandhi national old Age pension scheme (IGNOAPS), varisth pension bima yojana (VPBY), the pradhan Mantry vay-bandana yojana (PMVBY), chief minister vridhajan pension yojana (CMVPY).

Background: The Roma or Gipsy population is the largest ethnic minority both in Europe and Hungary with 10-15 years lower life expectancy and worse health indicators than majority populations. The aim of our study was to investigate a sensitive and controversial issue: the perspectives of Hungarian health professionals about the presence and impacts of prejudice towards Roma patients. Methods: Semi-structured interviews were conducted between June 2017 and May 2018 involving 19 healthcare professionals. Qualitative methods were applied to analyse the transcripts. --- Results: The presence and occasional manifestation of prejudices against the Romas were confirmed by the interviewees, most commonly in the form of longer waiting time, comments or other meta-communicative tools. Prejudicial attitudes and discriminatory behaviour are less common in wards where the prevalence of disadvantaged patients (HIV-positive, homeless) is higher (e.g. infectology). Prejudice is not specifically directed at the Roma ethnic minority, but also extends to populations living in poor socio-economic conditions, or with underlying self-destructive behaviour (alcoholism, drug use). In the opinion of our interviewees, occasional prejudicial behaviour does not lead directly to sub-standard care and poorer health, but it cannot be ruled out that it may indirectly contribute to it, in case the patient does not seek medical attention due to a former negative experience within healthcare. In terms of prevention, the education of both parties and the prevention of burnout of health providers are essential tasks for the future as this latter may also enhance the manifestation of prejudices. --- Conclusions: Our study includes the investigation of a highly sensitive and understudied area of research. Our findings may provide a better understanding of Hungarian health professionals' views on the effects of prejudice towards the Roma patients in healthcare, as well as about the need and strategies of prevention. --- Key messages: Direct relationship between healthcare providers' prejudices and the lower quality of healthcare services or the worse health status of Roma patients may be excluded. Indirect negative effects of prejudices may occur in cases where a patient refrains from seeking care due to previous perceived or experienced discrimination.

Implementation and use of ICT-based coordination mechanisms differed across the three ACs and could be related to differences in contextual and organizational factors in each context. It is necessary to explore factors and difficulties related to the use of these mechanisms to develop more effective strategies to improve their use and hence impact on clinical coordination.

Prevalência do padrão de comportamento de risco para a saúde sexual e reprodutiva em estudantes adolescentes O objetivo desta pesquisa foi estimar a prevalência e alguns fatores associados ao padrão de comportamento de risco para a saúde sexual e reprodutiva (PCRSSR), em estudantes do segundo grau de Santa Marta, Colômbia. É um estudo transversal. O PCRSSR foi definido como a soma de dois ou mais, de quatro possíveis comportamentos sexuais de risco, durante a vida. Foi usada a regressão logística para controlar as variáveis de confusão. Do estudo participaram 804 estudantes, os quais relataram relações sexuais, 36,1% apresentaram padrão de comportamento de risco para a saúde sexual e reprodutiva. Foram relacionados ao PCRSSR o consumo de uma sustância ilegal (OR=11,4), o consumo de álcool (OR=2,5), ser estudante de educação de segundo grau vocacional (OR=1,7) e ter nível de renda média ou alta (1,4). Aproximadamente um de cada três estudantes adolescentes possuía alto risco de infecção para HIV, ou gravidez não planejada. Recomenda-se promover práticas sexuais seguras. Descritores: Comportamento Sexual; Adolescente; Estudantes; Estudos Transversais. --- Prevalencia de patrón de comportamiento de riesgo para la salud sexual y reproductiva en estudiantes adolescentes El objetivo de esta investigación fue establecer la prevalencia y factores asociados al patrón de comportamiento de riesgo para la salud sexual y reproductiva (PCRSSR) en estudiantes de secundaria de Santa Marta, Colombia. Se realizó un estudio transversal. Se definió como PCRSSR la suma de dos o más, de cuatro posibles, comportamientos sexuales de riesgo durante la vida. Se usó la regresión logística para controlar variables de confusión. Un grupo de 804 estudiantes informó haber tenido relaciones sexuales. El 36,1% mostró el estándar de comportamiento de riesgo para la salud sexual y reproductiva. Se relacionaron con el PCRSSR el consumo de una sustancia ilegal --- Introduction In Colombia, approximately 25% of secondary education students inform previous sexual relations. Also, these sexually active adolescents mention many unsafe sexual behaviors, including inconsistent condom use, sexual intercourse under the effect of alcohol, sexual relations after consuming illicit drugs and little or recently known sexual partners (1) . To date, research information on risky sexual behaviors has been isolated (2)(3)(4) . However, the existence of a pattern of risky behavior for reproductive and sexual health (PRBRSH) has been proposed. This means that several sexual behaviors that represent risks for sexually transmitted infections or unplanned pregnancies are more frequent in the same group of adolescents. Two decades ago, the concept of pattern of risky behaviors for health was proposed, which means that different behaviors that can undermine sexual and physical health are present in the same group of adolescents (5) . Likewise, this group displays multiple risky behaviors, such as: cigarette consumption, antisocial behaviors and consumption of several possibly abuse substances (6) . www.eerp.usp.br/rlae Rev. Latino-Am. Enfermagem 2010 Mar-Apr; 18(2):170-4. The PRBRSH may be related with individual, family, social and cultural variables that influence the personality characteristics that are being consolidated (5) . It is assumed that personality characteristics basically result from the interwoven search for novelty, search for pleasure and avoidance of pain (7) . Despite the existence After a pilot study and the adjustments needed, this instrument was used in another Colombian research (8) . This type of questionnaire has shown excellent reliability in research around the world (9) . Appropriate statistical measures were used for each type of variable (qualitative or quantitative), with confidence intervals set at 95% (CI95%) when necessary. In bivariate analysis, odds ratios (OR) were determined with CI at 95%. Logistic regression was used for multivariate analysis, following common recommendations. In the final model, goodness of fit was estimated. Probabilities under 5% were accepted as significant differences. Data were analyzed using Statistical Package for the Social Sciences software (SPSS 13.0). --- Results In total, 3,575 adolescents participated in this research. A group of 804 (22.5%) informed previous sexual relations. Ages ranged between 14 and 20 years, with mean for age of 14.8 years (SD=1.7) and 333 students (41.4%) younger than 15. Mean for education was 8.9 years (SD=1.4), 510 students (63.4%) were taking high school education (grades ten or eleven); 629 participants (78.2%) were men; 414 (51.5%) were in public school; 456 (56.7%) belonged to middle or high socioeconomic status; 170 (21.1%) perceived their health status as bad or regular during the last month; 202 (25.1%) described their academic performance as bad or regular during the last month; 330 (41.0%) had experimented cigarettes; 742 (92.3%) had consumed alcoholic beverages; and 64 (8.0%) had consumed some illegal drug, such as marihuana. With regard to sexual behavior, 33.7% informed inconsistent condom use, 18.4% reported sexual www.eerp.usp.br/rlae Campo-Arias A, Ceballo GA, Herazo E. intercourse after alcohol consumption, 5.8% after illegal drugs consumption and 40.0% had sexual relations with a little known person. A group of 290 students (36.1%) showed a pattern of risky behavior for sexual and reproductive health. The following odds ratios (OR) were associated, in bivariate analysis, with the PRBRSH: age under 15 years (OR=1.2; CI95% 0.9-1.6), male gender (OR=1,2; CI95% 0.8-1.7), being a high school student (OR=1.3; CI95% 0.9-1.7), going to a public school (OR=0,9; CI95% 0.7-1.2), belonging to a middle or high social class (OR=1.7; CI95% 1.3-2.3), perception of bad or regular health (OR=1.3; CI95% 0.9-1.9), perception of academic performance (OR=1.0; CI95% 0.7-1.4), having experimented cigarettes some time in life (OR=1.7; CI95% 1.3-2.3), having consumed alcoholic beverage some time in life (OR=2.5; CI95% 1. 3-4.8) and experimenting some illegal drug (OR=10.2; CI95% 5.2-19.9). In the multivariate model, it was observed that a significant association continued to exist between the following variables and the PRBRSH: having consumed an illegal drug some time in life (OR=11.4; CI95% 5.7-22.7), having consumed alcohol some time in life (OR=2.5; CI95% 1.3-5.1), being a mid secondary student (OR=1.7; CI95% 1.2-2.4); and belonging to a middle or high socioeconomic status (OR=1.4; CI95% 1.1-2.0). Goodness of fit of this model was adequate (Hosmer-Lemeshow test X 2 =4.87; degrees of freedom=5; p=0.181). --- Discussion The pattern of risky behavior for sexual and reproductive health was observed in 36% of adolescents with a history of sexual relations. The pattern was more frequent among student who informed previous consumption of an illegal drug some time in life, previous consumption of alcohol some time in life, being a high school student (grades ten and eleven), and belonging to a middle or high socioeconomic class. No studies are available that inform on the PCRSSR among adolescents in the global context. Until date, most researchers have only informed on the variables associated with sexual relations some time in life (2)(3)(4) . As several behaviors can jeopardize health, in general, they appear in the same group of people (10) . Some recent studies among adolescents have looked at the following as a whole: sexual behavior, level of physical activity, nutritional habits and consumption of legal and illegal drugs as a pattern of risky behavior for health (11)(12) . Undoubtedly, Research needs to adopt an integrated and holistic perspective towards behavior during adolescence. The PCRSSR may be related to the pattern of risky behavior for health, with a common biological or social and cultural predisposition (5) . The PCRSSR may be a necessary but insufficient manifestation to observe the pattern of risky behavior for general health. The personality characteristics that are being consolidated during adolescence may very well explain these behavioral patterns (7) . Adolescents with antisocial, dependent or paranoid personality characteristics display more risky sexual behaviors for sexually transmitted infections or unplanned pregnancies (6,13) . A collective approach towards adolescents' sexual health is important from a public health perspective, as sexual practices that equally consider the personality characteristics that are being consolidated (5,7) . Careful assessment of how these programs affect the sexual behavior of Colombian adolescents will undoubtedly be necessary. One important contribution of this research is that it gives a composite picture of risky sexual behaviors in adolescents, as a pattern of risky behavior for sexual and reproductive health, which had not been investigated this way until date. The research shows the limits characteristic of a cross-sectional study though, which does not permit clarity on the sense of the association. --- Conclusion In conclusion, approximately one in every three adolescent students presents a pattern of risky sexual and reproductive health behavior, that is, they are at high risk of HIV infection or unwanted pregnancy. Safe sexual practices need to be promoted and further research is needed on adolescent sexual behavior in general. --- www.eerp.usp.br/rlae Rev. Latino-Am. Enfermagem 2010 Mar-Apr; 18(2):170-4.

This research aimed to establish the prevalence and factors associated with the pattern of risky behavior for reproductive and sexual health (PRBRSH) among secondary education students in Santa Marta, Colombia. A cross-sectional study was done. The PRBRSH was defined as having had two or more out of four possible risky sexual practices across the lifetime. Logistic regression was calculated to control for confounding variables. In total, 804 students reported lifetime sexual intercourse. PRBRSH was reported by 36.1% of the sample. Illegal substance use (OR=11.4), alcohol drinking (OR=2.5), being a middle-school student (OR=1.7) and middle or high socioeconomic status (1.4) were associated with PRBRSH. Around one out of three adolescent students is at high risk for HIV infection or

AGE-RELATED MICROAGGRESSIONS: A FOLLOW-UP DESCRIPTIVE STUDY Hannah Lewis 1 , Stephanie Patt 2 , Luke Gietzen 3 , and Jeffrey Buchanan 2 , 1. University of Minnesota,Mankato,Minnesota,United States,2. Minnesota State University,Mankato,Mankato,Minnesota,United States,3. University of North Dakota,Fargo,North Dakota,United States Age-related microaggressions are forms of ageist discrimination that occur during day-to-day interactions. The aim of this study was to identify common types of age-related microaggressions as well as to determine how negative affect influences emotional reactions to microaggressions. Using an online survey, participants (n = 200) were asked if they had experienced any of the 20 most common examples of age-related microaggressions reported in previous research (Gietzen et al, 2022). Follow up questions inquired about the frequency, emotional reactions, and behavioral responses to these microaggressions. Participants also rated their physical health and completed the Positive and Negative Affect Scale (PANAS; Watson et al., 1988). The results indicated that participants were familiar with these microaggressions 53% of the time. Participants also reported having negative reactions to 43% of these microaggressions. The frequency of negative emotional responses to microaggressions was significantly correlated with scores on the negative affect subscale of the PANAS (r = .34, p < .001) and with ratings of perceived physical health (r = -.32, p = .002). Finally, an analysis of the 20 survey items revealed that two items were "highly impactful" microaggressions, defined as microaggressions that older adults reported experiencing often and reported having a negative emotional reaction to at least one-third of the time. The results of the study provide further insight into what age-related microaggressions look like, and how older adults experience these interactions. Abstract citation ID: igad104.2128 --- AGING AND MENTAL HEALTH DURING AND AFTER THE PANDEMIC. AND OLDER ADULT SPECIALTY PSYCHOTHERAPY CLINIC FINDINGS Melba Hernandez-Tejada 1 , Deborah Little 2 , Madeleine Desrochers 3 , Sarly Butte 1 , and Ron Acierno 1 , 1. University of Texas Health Science Center at Houston, Houston, Texas, United States, 2. University of Texas Health Science Center, Houston, Texas, United States, 3. --- University of Houston, Houston, Texas, United States A specialty clinic addressing psychological trauma secondary to elder abuse opened a few months before the pandemic began. The aim was to provide evidence-based psychotherapy for post-trauma psychological sequalae. We leveraged technology in the form of home-based telemedicine, to deliver effective treatment directly into older adults' homes. We here present psychotherapy retention rates and clinical outcomes of this endeavor. Method: single arm, repeated measures, clinical series case study design. Outcomes: treatment initiation and completion rates; standardized measures of PTSD (PCL5), depression (PHQ9), anxiety (GAD7) and sleep (PSQI) collected at pre-and post-treatment. Results: Prior to implementing this specialty clinic, the larger clinic within which it was housed saw approximately 2 older adults per year. Tailoring the program to older adults resulted in an annual census of over 100 per year. Analysis of current data indicates excellent completion rates for evidence-based psychotherapy (above 75% compared to 60% of younger patients) and clinical improvements across symptom areas in excess of one standard deviation. Discussion: The success of this specialty trauma clinic for older adults experiencing violence was enhanced by a pre-pandemic decision to use telemedicine to increase reach and ease of accessing care. Initial results indicate that televideo technology was well received, was used by older adults and implemented before and during the pandemic with no issues, even for cases of severe trauma reactions such as PTSD and depression in older adults. Abstract citation ID: igad104.2129 --- PREVALENCE OF ELDER ABUSE AND NEGLECT OF PERSONS WITH DEMENTIA: A SYSTEMATIC REVIEW AND META-ANALYSIS Fei Sun 1 , Xuehan Zhang 1 , Yan Shen 2 , Yali Feng 3 , and Teri Kennedy 4 , 1. Michigan State University,East Lansing,Michigan,United States,2. Hubei Normal University,Huangshi,Hubei,China (People's Republic),3. University

tes Compared to the growing number of the older population in South Korea, there is a scarcity of literature investigating issues about the abuse of older people, as well as effective prevention programs. To fill this gap, this study aimed to identify annual changes in patterns of the abuse of older people including the number of reported abuse cases; the type of abuse; and the characteristics of the subject. Data were drawn from the Korean Statistical Information Service (KOSIS), the public national statistical database. The present study used 13-year data during the period of 2008-2020. Descriptive analyses were conducted via SPSS. The number of abuse cases has increased every year from 2,369 in 2008 to 6,259 in 2020 and 10% of the reported cases in 2020 were repeated cases. The most common type of abuse reported was psychological abuse followed by physical abuse and neglect over 13 years. Physical abuse increased substantially from 22.4% to 40.0%. The majority of subjects are consistently women, accounting for 68.4% in 2008 and 75.3% in 2020. One in fourth of the subjects are older people living with dementia in 2020. Considering the serious impact of abuse including depression and suicide, abuse of older people is no longer a single individual or family problem. To protect the older population and improve their rights in society, collaborative efforts are critical. Micro-level movements such as increasing social awareness and national-level initiatives such as implementing policies and developing relevant legislation should be necessary.

Faith communities can provide older adults support as they plan for end-of-life care, but how this support unfolds for lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people is uncertain. Although many LGBTQ+ people experience marginalization within faith communities, they also report experiences of acceptance and affirmation. This mixed-methods study investigates how LGBTQ+ older adults' involvement in faith communities shape their endof-life care perceptions and preparation. First, we analyze panel data from the Vanderbilt University Social Networks, Aging,and Policy Study (N=1,256) to assess the relationship between faith community involvement and levels of social support. We find that 63% of older LGBTQ+ respondents identify with a religious affiliation, and 31% attend religious services several times a year or more. Attending religious services several times a year are more is associated with having a spouse in the household (11.4 vs 7.1%, p<.05) and reporting larger personal networks (11.7 vs 9.9 individuals; p<.001). Service attendance is also associated with having support when seeking advice about important decisions and having social support from friends. In the second portion of our study, we analyze data from in-depth interviews with 47 LGBTQ+ older adults to understand how faith communities influence preparation for end-of-life care. Many interviewees described their faith communities as guides that help them select reliable healthcare providers and formulate their endof-life care plans. Overall, these findings reveal important ways that faith communities can foster social support and promote optimal end-of-life care among older LGBTQ+ adults. --- SESSION 4005 (SYMPOSIUM) Abstract citation ID: igad104.1364 --- BUILDING BRIDGES ACROSS AGE-FRIENDLY ELEMENTS GUIDED BY THE 4MS FRAMEWORK Chair: Darina Petrovsky Co-Chair: Anne Mitchell The 4 Ms framework is a set of evidence-based elements of high-quality care delivered to older adults. These include What Matters, Mobility, Medication, and Mentation. By following these principles and practicing age-friendly older adults are more likely to experience good quality care that addresses their needs. This symposium aims to build bridges across age-friendly elements that focus on the 4 Ms framework by highlighting the research of four nurse scientists. Representing the "What Matters" element, advance care planning and palliative care interventions aim at understanding and aligning care with older adults' care preferences. In the first presentation, Dr. Rahemi will present findings of health disparities across sociodemographic groups in advance care planning using data from the Health and Retirement Study. In the second presentation, Dr. Carpenter will report on findings from a pilot pragmatic clinical trial that examined the feasibility, acceptability, and preliminary effectiveness of a primary palliative care intervention among nursing home residents with serious illness. Under the element of "Mobility", Dr. Sefcik will present findings from a qualitative descriptive study aimed at discovering how the COVID-19 pandemic affected the outdoor activities of senior living community-residing older adults. In the fourth presentation,

gender-affirming surgery (GAS) on a case-by-case basis. In this study, we use national Medicare data to compare receipt of GAS by beneficiary characteristics. We classified TGD beneficiaries using an algorithm that combines diagnosis and procedure codes. Our study compared characteristics for all TGD identified beneficiaries and those who received GAS using a population-averaged logistic model using a generalized estimating equation (GEE) adjusting for dual status, age group, race/ethnicity, original reason for entitlement, and CMS region. Our sample accounted for 49,945 observations for 11,162 individuals, with a total of 290 identified records of GAS. In our adjusted analysis, we found that TGD beneficiaries in certain parts of the country had lower odds of GAS compared to their counterparts. Compared to CMS Region 1 (which includes Connecticut,

Introduction Present generation in computer era which influence the human kind in many ways. Use of advanced technology is inseparable in all spheres of our life especially in this covid-19 pandemic scenario. 1 Social medias are one of the best communication channel such as applications, websites that allow people to share their ideas, thoughts, and feelings through mediums such as photos, music and videos. It is an environment in which a group of people come together to share their views, data, relationships by using internet communication channels. The use of social media sometimes becomes addictive as it affects our brain's reward area. Social media addiction can be referred as the compulsive use of social media platforms which lead to negative effects on daily life of a person. This term often used to refer to someone who spends too much time on any forms of social media. Research studies showed that the excessive use of technology such as internet and social media by teenagers has caused disruptions in their physical and mental health, sleeping patterns, their weight and levels of exercise, and notably in their school work. Excessive internet usage is sometimes linked to lower grades. 1,2 A recent study found that time spent on Facebook has a strong negative relationship with the average grades obtained by a student throughout his entire academic experience. The effects of social media addiction include anxiety or depression, increased isolation, decreased physical activity, low self-esteem, and poor work or school performance, among many others. Overall social media addiction was observed in 27.4% of the study subjects, 24.0% in government and 30.8% in private colleges (Z = https://doi.org/10.18231/j.jeths.2023.012 2454-4396/© 2023 Author(s), Published by Innovative Publication. 53 3.26, P = 0.001). However, the prevalence of social media addiction among social media users (1389) was 36.9%. The prevalence of mild addiction was high. A study (2019) suggested that teenagers who use social media for more than 3 hours daily are more likely to experience mental health problems, such as depression, anxiety, aggression and antisocial behaviour. The best way to beat social media distraction is create a distraction free zone, use of social media blocker, turning off notifications and setting a schedule for checking social media. The use of multiple social media platforms is more strongly associated with depression and anxiety among young adults than time spent in online. Overusing social networking sites can result in many health and personal relationship problems also seen in other addictions. [3][4][5] The imbalanced time and attention to entertainment activities on the Internet can potentially lead to academic distraction. The heavy use of Facebook or the Internet for entertainment could alter students' habitual behavior in reading, writing, and attention for completing academic tasks. 6 --- Objective Assess the social media addiction among the students. --- Methodology --- Research approach Quantitative research approach. --- Research design Non experimental, descriptive research design. --- Research setting Government Paramedical College, Silvassa. --- Target population All paramedical students. --- Sampling technique Non-probability, convenient sampling technique. --- Sample & sample size Paramedical students who fulfills inclusion criteria and sample size was 140. --- Research variables Social media addiction. --- Data collection techniques & tool Self-report technique through Google forms 1. Tool -1: Self-administered Questionnaire to assess the Socio -Demographic variables 2. Tool -2: Modified Social Media Addiction Scale --- Data analysis Analysis done by using descriptive & inferential statistics. --- Result --- Discussion Present study findings shows that vast majority (103(74%)) of the students were addicted to the social media. This must be the prime concern for the institution because it may affects their academic. Similar findings were obtained from the study conducted in California State University that shows that persons who visited any social media site at least 58 times per week were three times more risk of feeling socially isolated and depressed compared to those who used social media lesser than 9 times in a week. 1,2 In contrast to the present study the other study that shows that most of the students had moderate level of social media addiction whereas very less were shown severe level of social media addiction. Majority 42% of nursing students had moderate social media addiction, 30% nursing students had mild social media addiction, only 14% nursing students had severe social media addiction, and the remaining 14% had no social media addiction. Based on social media addiction scales scores, nursing students had maximum score of 89 with a mean 52.33%, mean score percentage 52.33%, and standard deviation 19.079. [3][4][5][6] --- Implications Study findings helps to understand the influence of Social media. Appropriate usage of Social media need to be insisted in the curriculum for the mental health. So that Social interactions can not be hindered. --- Recommendations 1. Correlation study can be done on Impact of Social media addiction over the academic performance 2. Similar study can be done over the different groups 3. Should make a strategies to limit Social media dependence 4. Strategies to be inculcated to improve Social interactions --- Conclusion Present study shows that our young generation is transforming into dependency on technology which is limiting the Social interactions and also had ill effect on both physical and mental health. It may leads to antisocial behaviour and rise in crime rate. It is the high time for the policy-makers to restrict on this and make provision to improve the interaction skills. --- Conflict of Interest None.

Utilizing the technology made our life very easier and brought the globe in our hand which has got both pros and cons. Young generation is more of techno oriented than the values that makes them to be depending on the social medias easily that affects the domains of health. A study was conducted to assess the Social media addiction among the paramedical students. Quantitative research approach with non experimental, descriptive research design was used. Non probability convenient sampling technique was used to select 140 para medical students who fulfills the inclusion criteria. Self administered structured questionnaire was used. Modified social media addiction likert scale was used with 20 items. Findings of the study shows that vast majority (103(74%)) of the students were addicted to the social media. To conclude, it is the high time for the policy-makers to restrict on this and make provision to improve the interaction skills.

BACKGROUND The Coronavirus disease (COVID-19) was characterised as pandemic in March 2020 by WHO. There is limited information available, on the impact COVID-19 is having on young people. Buzzi et al 1 report that almost 40% of adolescents felt there would be 'a lot' of consequences to their education. Data on COVID-19 information sources accessed by young people is currently lacking. The aim of the Study Of Covid-19 Information AccessibiLity for young people in North Staffordshire was to investigate whether young people aged 11-16 years had access to reliable information on COVID-19, how they accessed this information and the perception of COVID-19 impact on their education. Research questions were generated by the lead author based on personal experience. The survey was piloted on five young people and feedback incorporated. The survey included questions on: frequency with which pupils update themselves on COVID-19 information and sources they access; source trustworthiness and understanding; effect of COVID-19 on education; and information pupils want from schools on COVID-19. Descriptive analyses were used to summarise results. --- METHOD --- RESULTS A total of 408 (23%) responses were obtained. The proportion of females participating increased incrementally with age (56% aged 11, to 74% aged 16). The mean age of respondents was 13.9 years and 88% identified their ethnicity as either White or Asian. A total of 92% of participants have daily access to the internet on a personal device. When asked how often they updated themselves on COVID-19 at the start of the pandemic, 46% responded on a 'daily' basis. When asked the same question at the point of survey completion (July 2020), 'daily' updates were only reported by 10% of pupils (table 1). Older respondents updated more frequently (66% of 16-year-olds updating 'daily', compared with 22% of 11-year-olds). Responders accessed multiple information sources (table 2). 'Television news' (72%) was the most trusted source (60%), although only 'best understood' by 26%. Social media was an information source accessed by 68% of pupils, although this was not considered as trustworthy. --- Open access Eighty-nine per cent of pupils felt that 'to some degree' COVID-19 had negatively affected their education. Respondents felt that schools should be providing more information, including information on: COVID-19 rules, government regulations and how best to keep safe (30%); the wider impact of COVID-19 and global news (25%); and plans to return to the classroom (21%). --- CONCLUSIONS Pupils were concerned about the impact of COVID-19 on their education; findings which have also been reported in published studies elsewhere. 1 A variety of information sources were accessed, often on a frequent basis, despite acknowledgement that the information may not have been accurate. This research is limited by including a single geographical region and by recruiting at the end of the academic year, when pupils may not have been accessing their school email accounts. Teacher facilitated questionnaire completion may have increased response rates. 2 Email invitations were administered by teachers rather than recognised national bodies that may have encouraged participation. Findings demonstrate gaps in the provision of information on COVID-19 for young people, who would like schools to take a more prominent role in --- Open access the provision of information. With internet use widespread, it is important that young people have clear, accurate information available to them, to increase understanding. 3 Ethics approval Ethical approval was obtained by Keele University Faculty of Medicine and Health Sciences Research Ethics Committee on 13 July 2020, ref MH-200137. Provenance and peer review Not commissioned; externally peer reviewed.

COVID-19 has significantly impacted young people's lives yet little is known about the COVID-19 related sources of information they access. We performed a cross-sectional survey of pupils (11-16 years) in North Staffordshire, UK. 408 (23%) pupils responded to an online survey emailed to them by their school. Descriptive statistics were used to summarise the data. Social media, accessed by 68%, played a significant role in the provision of information, despite it not being considered trustworthy. 89% felt that COVID-19 had negatively affected their education. Gaps in the provision of information on COVID-19 have been identified.

GREATER ADHERENCE TO DAILY HEALTH BEHAVIORS RELATE TO BETTER COGNITIVE FUNCTION Fumiko Hamada 1 , and Soomi Lee 2 , 1. University of South Florida, Tampa, Florida, United States, 2. The Pennsylvania State University, University Park, Pennsylvania, United Sta tes Healthy life habits cannot be formed overnight; therefore, adherence to optimal sleep, physical activity, and healthy eating behaviors is vital. This paper examined the relationship between the adherence rate of the three key health behaviors (i.e., sleep, physical activity, and healthy diet) and cognitive function in adulthood. Data were retrieved from Midlife in the United States third wave (MIDUS 3) Project 2, National Study of Daily Experiences (n=1,061). For eight consecutive days, participants reported nightly sleep duration, daily amount of physical activity, and daily consumption of fast food. Adherence rates of health behaviors were calculated by the sum of having optimal sleep (6 < sleep hours ≤ 9), any intensity of physical activity (60 min.≤), and not eating fast food (yes/no) across the study period. Participants also completed a Brief Test of Adult Cognition by Telephone (BTACT). A series of general linear models examined the associations of the three adherence variables with the overall BTACT cognition score adjusting for sociodemographic and health covariates. Greater adherence rates of optimal sleep (𝛽=0.02; SE=0.01; p=0.01), physical activity (𝛽=0.03; SE=0.01; p<0.01 ), and not eating fast food (𝛽=0.02; SE=0.01; p=0.02) were each and associated with higher BTACT score. Among the three adherence variables, adherence to physical activity was the most important for cognition independent of other health behaviors. Consistent associations were found for executive function, but not episodic memory. These findings suggest that adults with greater adherence to a healthy lifestyle have better cognitive function, and consistency of healthy behaviors is vital for cognitive health. Abstract citation ID: igad104.0926 --- POSITIVE EVENT DIVERSITY AND AGE: TESTING CURVILINEAR ASSOCIATIONS Patrick Klaiber 1 , Patrick Hill 2 , David Almeida 3 , Anita DeLongis 4 , and Nancy Sin 4 , 1. Tilburg University,Tilburg,Netherlands,2. Washington University in St. Louis,St. Louis,Missouri,United States,3. The Pennsylvania State University,State College,Pennsylvania,United States,4. University of British Columbia,Vancouver,British Columbia,Canada Prior research has found that older adults report more frequent positive events compared to younger and middleaged adults. It remains unknown, however, to what extent age is related to experiencing positive events spread across different positive event types (i.e., positive event diversity, PED). We therefore examined age differences in PED and its affective well-being correlates across three large daily diary datasets: wave 2 (N = 1919) and the Refresher sample (N = 744) of the National Studies of Daily Experiences, and the Coping with the COVID-19 Outbreak Study (N = 1392). We used Shannon's Entropy to quantify PED. There was a curvilinear association between PED and age, indicating that PED was higher among middle-aged compared to younger and older adults. On a zero-order basis, PED was correlated with higher positive affect and uncorrelated with negative affect. However, the pattern of results changed when considering positive event frequency as a moderator. Among people with high positive event frequency, PED was linked to higher negative and lower positive affect, but not associated with either positive or negative affect at low levels of positive event frequency. These relationships did not differ by age. This study suggests that middle-aged adults experience the widest range of positive event types, perhaps reflecting the diverse set of social roles that middle-aged adults often fulfill (e.g., worker, parent, partner). In addition, there might be negative consequences to experiencing a lot of positive events across very different contexts which may indicate social role strain. Abstract citation ID: igad104.0927 Recent research suggests that affect dynamics (e.g., variability) combined with mean levels are important predictors of psychological and physical health outcomes. This study explores the joint effect of affect levels and variability on depression across 10 years among middle-aged and older adults. We used the data from the second and third waves of Midlife in the United States (MIDUS) study. During telephone interviews, daily positive (PA) and negative affect (NA) were assessed across eight consecutive evenings. Daily affect mean levels were calculated by averaging daily affect across interview days, and daily affect variability was calculated as the individual's standard deviation (iSD). Depression status was assessed using the Composite International Diagnostic Interview-Short form at baseline and 10-year follow-up. The final analytic sample includes 1,499 adults aged 55 years old on average (age range = 34-83; 55.7% female; 93% white). --- REVISITING POSITIVE AFFECT: THE ROLE OF AFFECT MEAN LEVELS AND VARIABILITY ON DEPRESSION IN MID AND LATER LIFE Logistic regression analysis was performed to test the interaction effect of daily affect mean levels and variability on depression. We found a significant interaction effect between PA mean levels and variability on depression status at follow-up. For individuals with high PA levels, higher PA variability was associated with higher odds of developing depression, after adjusting for depression and anxiety disorder at baseline. For NA, we only found main effects where higher NA variability was associated with higher odds of depression at follow-up. Findings suggest fragile high PA (i.e., variable high PA) may be a significant predictor of depression, highlighting the need for understanding PA as multidimensional construct. --- SESSION 3140 (SYMPOSIUM) Abstract citation ID: igad104.0928 --- SPIRITUALITY AND RELIGIOSITY IN BRAZILIAN AND AMERICAN OLDER ADULTS, CHARACTERISTICS AND NURSING CARE APPROACH Chair: Angelo Jose Bós Discussant: Amelia Gallagher This symposium aims to understand two aspects of spirituality and religiosity: the importance of religiosity for older adults, in a population-based study, and a proposal approach for nursing care in cancer patients: Lift the Spirit approach. In the Brazilian study, we will show that religiosity is significantly associated with sex, race, level of education, perceived health status and non-transmittable chronic diseases, including cancer. The results evidence the important role of religious faith in the Brazilian older adult's health. We concluded that religion and spiritual approaches should always be considered for older adults. In the American study, we will show that preliminary findings suggested Lift the Spirit was feasible, acceptable, and positively impacted knowledge, skills, and self-efficacy. The innovative combination of synchronous and asynchronous online delivery of the intervention and data collection methods has implications for research, education, and clinical practice. Lift the Spirit delivered on an entirely online format is widely accessible and convenient to researchers, educators, and practitioners, as well as participants and students. Equipping nurses to conduct spiritual histories through an intervention like Lift the Spirit is crucial to overcoming a significant barrier to providing spiritual care.

although the spread of stressor types experienced in daily life (stressor diversity) declines with age across both cohorts, the types of stressors experienced in modern life differ from those experienced 18 years prior. Together, findings demonstrate how variability in daily life changes across age and has implications for health and well-being of older adults. Dr. Susan Charles will critically discuss these contributions to our understanding of aging in the context of Strength and Vulnerability Integration Theory and provide considerations for understanding the complexity of daily life across the lifespan.

INTRODUCTION It is common to begin intimate relationships and become sexually active, including premarital sex, during young age. The sexual activity is initiated while young people are still physically, emotionally and cognitively developing (1). In many countries, an average of 29% of boys and 23% of girls are sexually active including premarital sex. Premarital sex was associated with unmet need for contraception and unintended pregnancy (1)(2)(3)(4)(5). It is also associated with different reproductive health problems. Among these, age specific HIV prevalence indicates that young people are more infected than others (6,7). Studies indicated that age (8), using social media (9,10) and being male (11,12) were predictors of premarital sex. Other studies indicated that onset of sexual activity is accocaited with alcohol use (13,14). Comprehensive knowledge of HIV/AIDS was an inconsistent predictor of premarital sex (12,15). HIV is transmitted mainly through heterosexual contacts in Ethiopia. More than 87% of HIV cases are transmitted sexually in Ethiopia like in other developing countries (3,16). Despite the acceptance and knowledge of HIV/AIDS and risk of abortion, young people engage in premarital sex, multiple sexual partnership, casual sex and unprotected sex (15,17). However, premarital sex in the last twelve months along with its predictors, i.e. multiple sexual partners, casual sex and unprotected sex has not been well understood in higher teaching institutions of Ethiopia (12). Thus, the objective of this study was to assess premarital sex in the last twelve months and its predictors among regular undergraduate students of Wollega University, Ethiopia. Results of this study could assist higher education institutions and implementers to design appropriate strategies to address premarital sex among university students in this setting. --- MATERIALS AND METHODS A cross-sectional survey was conducted from February to March 2014 at Wollega University, Ethiopia. The total number of regular undergraduate students of Wollega University was 7813 males and 1823 females (18). The source population was all regular undergraduate students of Wollega University, aged 15-24 years. We included students who were never married at the time of the study. Sample size was calculated using EPI info 3.5.2 based on single population, sexually active youths at Mada Walabu University (42.3%) (19), 95% confidence level (Z α/2 ), 2 design effect and 5% margin of error. The estimated total sample size was 750 students. However, the final sample size included in the analyses was 704; incomplete questionnaires were excluded from analysis. Multistage sampling method was used to recruit study participants. First, departments were selected proportionally from each college. Nineteen departments were selected from six colleges of the university randomly. The final sample from each department was taken proportionally by using systematic random sampling technique. Lists of students from each department were obtained from the registrar of the university and every second student from the selected department was included. The questionnaire had items on sociodemographic characteristics and questions related to premarital sexual behaviour. The structured questionnaire was pilot tested on 5% of the sample at Ambo University. Then, some skip patterns were corrected and the consent form was modified. Health care providers who had Bachelor of Science degree administered the pretested, structured questionnaire after they took a two days' training on the objective and relevance of the study. Supervisors were trained and followed up the data collection process closely. The dependent variable was premarital sex in the last twelve months while the independent variables were age, sex, place of origin, educational background of family, parental employment, khat use, alcohol use and social media use. Social media use was categorized into four levels: always, sometimes, rarely and never used. Khat and alcohol use were measured if the participants had practiced khat or alcohol in one year prior to the study. According to the national indicator of HIV/AIDS, people are considered knowledgeable about HIV/AIDS if they have acceptable response to five questions assessing HIV knowledge (17). After data entry and cleaning using Epi info 3.5.2 software, data were imported to SPSS version 20.0 for analysis. Bivariate analyses between dependent and independent variables were performed using binary logistic regression. To control for possible confounding variables, multivariable logistic regression was done. All variables which had association in bivariate analysis (P-value < 0.05) were included in the multivariate model. The strength of association between premarital sex in the last twelve months and independent variables was expressed in odds ratio (OR) through a 95% confidence interval. Data quality was ensured during data collection, entry and cleaning. The purpose of the study was clearly explained to concerned bodies. Ethical approval was obtained from Ethical Review Committee of Wollega University. Written informed consent was obtained from all participants. Anonymity of data was ensured by excluding name and identification number of students. --- RESULTS --- Characteristics of study participants: Of the 704 respondents, 529 (75.1%) were males. The median age of respondents was 21 years (Table 1). --- DISCUSSION This study assessed premarital sex in the last twelve months and its predictors among regular undergraduate students of Wollega University. Proportion of youths who had premarital sex in the last twelve months was 28.4%. It was higher than a study from Ghana (14) but lower than studies from Uganda (20), Hong Kong (8), Papua New Guinea and Mada Walabu University (19). This could be explained by cultural norms as sexual practice is contextually driven. This implies that premarital sex in the last twelve months was not uncommon. Thus, efforts to address the issue of premarital sex are crucial. Multiple sexual partners in the last twelve months was consistent with a study from Ghana (14) but lower than a study among university students of Nepal, 55% (21). In this study, 62% of the respondents who were engaged in premarital sex in the last twelve months were using condom (63.7% consistently, 44.5% during their last sex). Condom use during last sex was lower compared with study done at Brazil which indicated that the overall level of condom use at last sex was 60% (22). The study from Ghana showed that a little over 50% of youths used condom at their last sexual encounter (23). In Kenya, among sexually active respondents, 42% had ever used condom, and 23% had used condom over the past twelve months (24,25). Considering high level of noncondom use and multiple sexual partnership, addressing issues of premarital sex is crucial for prevention of STI/HIV and unintended pregnancy. The school-based peer education intervention should put further effort to decrease premarital sex and multiple sexual partnership thereby improving condom use. This study revealed that males were nearly three times more likely to engage in premarital sex. It was consistent with studies from developing countries like Rwanda and Vietnam (9,11) including Ethiopia (12,(26)(27)(28). Males had more freedom in sexual activity than their female counterparts. This may be due to cultural norms that encourage and approve sexual experimentation of boys in Ethiopia. Also, our study indicated that fifth year students were about 2.5 more likely to engage in premarital sex compared with first year students. Larger proportion (40.8%) practised their first sex during the third year compared with 34% who had it during the first year at Wollayita Sodo University (12). Higher year students' engagement in premarital sex may be explained by longer period of partnership during campus stay. Another predictor of premarital sex was age of respondents. Students aged 20-24 years were about three times more likely to engage in premarital sex. It was consistent with a study which indicated that being less than 18 years was found to be protective against premarital sex (26). Also, it was consistent with studies from other developing countries (8,14,25) and studies from Ethiopia (27)(28)(29). Youthful periods are times in which the youth exhibit youthful tendencies; hence, it is expected that age will cause a significant difference. This study indicated that training on how to use condom was about two times at increased odds of premarital sex in the last twelve months. Youth may be more interested to know how to use condom if they have sexual partner and maybe if they want to experiment sex. Training on how to use condom should thus be supported by positive behaviour change intervention. This study indicated that being tested for HIV was about two times at increased odds of premarital sex in the last twelve months. It is a common belief that boyfriend and girlfriend, once they know each other's HIV status, they are likely to engage in sexual practice including unprotected sex. Another predictor of premarital sex was use of social media. Students who were using social media frequently were nearly two times more likely to engage in premarital sex in the last twelve months. It is consistent with a study from Vietnam (9). It is supported by research from several Asian cities which indicated that many adolescents learn about sex from the internet (10). More university students are exposed to new ideas including information about sex through internet. Thus, it is important to make internet services selective and to use such services in the university compound for academic purposes. In addition, awareness on consequences of social media has to be created. Youth who had comprehensive know-of HIV were about 1.5 more likely to practice premarital sex. Despite the acceptance and knowledge of HIV/AIDS, people still engage in premarital sex (15). However, it disagrees with a study which showed that students with better knowledge on HIV/AIDS were 6.6 times more likely to abstain from sexual intercourse than their counterparts (12). It is supported by a study from Ethiopia which indicated that the quality of information among young people is a concern (30). The reason may be the students are likely to use condom more than the abstinence options. It implies that further study needs to be conducted on the effect of comprehensive knowledge of HIV on premarital sex. Alcohol use was strongly associated with premarital sex in the last twelve months. It is consistent with studies from Uganda, Ghana, WHO studies (1,14,25) and a study from rural Ethiopia (29). This could be because risk perception decreases with alcohol use, indicating that individuals who use alcohol were at higher risk of HIV. The Limitation of this study was that bias introduced by under-reporting is possible as premarital sex is a sensitive issue and may be considered socially unacceptable especially in countries like Ethiopia. However, an attempt was made to minimize this bias by ensuring privacy and using the anonymous selfadministered questionnaire. It is difficult to generalize the result of the study for the general community. It is cross-sectional study, which precludes assessing the temporality, causality and direction of the associations described. The universities and stakeholders should work on comprensive sexuality education. Higher institutions have to deliver abstinence messages alongside information about selfprotection for the youth who find themselves in sexual situations. Our findings suggest that it is important to reinforce reproductive and sexual health education. The intervention has to focus on the risk factors among university undergraduate regular students and provide them with convenient and optional services that are easily accessible.

Nearly one-third of regular undergraduate students of the university were engaged in premarital sex in the last twelve months. Being male, using social media frequently and alcohol use were associated with increased odds of premarital sex in the stated period. Thus, higher institutions have to deliver abstinence messages alongside information about self-protection.

Background Vaccination against the novel coronavirus (COVID-19) plays a critical role in reducing the morbidity and mortality caused by the ongoing pandemic. Currently, 67% of the US population is fully vaccinated against COVID-19 [1]. Having friends and family members that are vaccinated is associated with one's personal decision to vaccinate against COVID-19 [2]. Racially minoritized groups are more likely to experience COVID-19 vaccine hesitancy [3], likely because of past and present-day abuse from healthcare systems and practitioners resulting in mistrust. Compared to their white counterparts, a larger share of Black and Latino/a/x adults reported a desire to "wait and see," or vaccinate only if required, or expressed "definitely not" planning to get vaccinated against COVID-19 [4]. These beliefs translate into suboptimal vaccination rates and have persisted during the pandemic in the context of high community transmission and the emergence of more deadly and contagious viral variants. The Centers for Disease Control and Prevention's (CDC) framework to support vaccination, "Vaccinate with Confidence," identifies the use of trusted messengers as a vital community-based strategy for overcoming vaccine hesitancy [5]. This strategy involves training community members, who may themselves be vaccine recipients, to address specific concerns in priority populations (e.g., adolescents). Previous work indicated that racially marginalized groups may prefer community/religious leaders or friends/family over health professionals as a source of health information about COVID-19 and other vaccines [6,7]. These community vaccine ambassadors serve as an intermediary between health systems and the larger community and address local barriers to vaccination [8]. Our multidisciplinary team (e.g., hospitals, city health department, Latino/a/x and Black serving community-based health organizations) chose to implement this community vaccine ambassador strategy with the goal of increasing the spread of accurate information about COVID-19 vaccines in the local Black and Latino/a/x communities. Our goal was to ultimately increase COVID-19 vaccination rates. Here, we report on the feasibility, acceptability, and impact of our community COVID-19 vaccine ambassador train-thetrainer pilot. We hypothesized that the program would be feasible and acceptable, and that ambassadors would report confidence in having COVID-19 vaccine-related conversations with others in their community. We set a goal that each ambassador would report having conversations with at least 5 individuals. --- Methods --- Participants and Setting This program was conducted in Cincinnati, Ohio, a city with a population that is 41% Black and 4% Latino/a/x. The median household income for Hamilton County residents is $42,663. The Latino/a/x population in the Cincinnati metro area grew nearly 50% from 2010 to 2020 [9]. At the end of May 2021, when this program occurred, national statistics showed that 56% of Black adults and 57% of Latinx adults in the US had received at least one dose of a COVID-19 vaccine; this is compared to 65% of white adults [4]. The lead partner on the program was Cincinnati Children's Hospital Medical Center (CCHMC), a large, freestanding academic pediatric hospital. --- Ambassador Train-the-Trainer Program Using a 2020 COVID-19 community needs assessment, common vaccine hesitations and myths in both communities were identified. Community stakeholders and the public health education team met to design vaccine education goals and objectives based on hesitancy data, preferred information sources and messengers and identify education modalities to empower community advocates. This work was reviewed and determined to be exempt by the Institutional Review Board at CCHMC (IRB ID# 2020-0465). We aimed to train at least 25 community residents and people from community-based organizations (e.g., faithbased groups, schools, businesses, community healthcare institutions) with an expressed interest in learning more about COVID-19 vaccination. Recruitment occurred via existing partnerships, word of mouth, organizational/collaborative meetings, and fliers. Interested individuals registered for the event and were emailed a Zoom link for the program. The 90-minute train-the-trainer program was held in June 2021 and delivered in English with Spanish interpretation available via video. The program included a review of ambassador expectations (i.e., to complete the training evaluation and follow-up survey; to talk with someone about the vaccine following the training). During the training, one Black community member and 1 Latino/a/x community member along with their adolescent children shared their reasons for getting vaccinated. In addition, an infectious disease physician provided information and answered questions about COVID-19 vaccines. Families and experts also addressed common myths identified by community partners. The training ended with talking points for ambassadors, using scenarios for demonstration. --- Measures and Analysis To assess feasibility, registration and attendance were tracked. Immediately following the program, acceptability (overall usefulness, confidence with conversations) was assessed using a computer-based evaluation survey. Two weeks after the training, ambassadors were emailed a follow-up survey asking for information about any conversations about COVID-19 they had with friends, family, or colleagues since the training. Descriptive statistics summarized quantitative survey data. Open-ended questions were iteratively coded using computerassisted content analysis completed by authors AMSC and SG. Consensus was reached for code application, and then codes were grouped into categories. --- Results Of the 41 participants who registered for training, 33 (80%) attended (Table 1). Participants were asked to self-identify their race/ethnicity; 65.6% were Black, 18.8% were white, 12.5% were Latino/a/x and 3.1% were Asian. Twenty-six attendees (79%) completed the initial evaluation and 17 of 26 (65%) completed the two-week follow-up survey (n = 17) (Table 2). For acceptability, all respondents rated the training "good" or "excellent" and would recommend it to others. There was consensus (96.8%) that the content addressed COVID-19 vaccine concerns in their community. Nearly all participants who attended the training reported increased knowledge about COVID-19 and vaccination (96.8%), as well as confidence to have vaccine-related conversations with family and peers (93.5%). At two-week follow-up, all community vaccine ambassadors had engaged in a conversation with a colleague, friend, or family member about COVID-19 vaccination. An estimated 134 people (7.9 people per ambassador) were reached by these follow-up conversations, many of whom planned to get vaccinated following the interaction with their community vaccine ambassador. Family members appeared to be most accessible to trained ambassadors; 88% of our participants had a follow-up conversation with someone in their family within two weeks of our training. Qualitative comments revealed that community vaccine ambassadors would continue to use knowledge and skills they obtained from the training to have COVID-19 vaccine conversations. --- Discussion This paper describes the evaluation of a train-the-trainer community ambassador program to address COVID-19 vaccine misinformation in Black and Latino/a/x communities. Data indicate that the program was feasible and acceptable. Ambassadors reported increased knowledge and confidence, and felt the information was useful for addressing specific COVID-19 vaccine concerns in their communities. Two weeks after our training, ambassadors reported having successful conversations about vaccine benefits and risks with approximately 134 people in their social networks. Qualitative data indicated that ambassadors felt confident even if the individuals they educated remained hesitant; ambassadors also felt they were building trust and might influence future COVID-19 vaccine intention. It is notable that most participants recruited as vaccine ambassadors in this study were trusted stakeholders of community-based organizations serving minoritized communities, positioning them as reliable resources based on a previous needs assessment [6]. This data is consistent with a recent qualitative study of Black and Latino/a/x populations demonstrating that receiving factual, consistent, and transparent information from trusted messengers all help to increase trust in the COVID-19 vaccine [10]. A recent systematic review correlated unwillingness to vaccinate against COVID-19 with being Black American [11], indicating a need for interventions such as ours that equitably address community needs. Limitations of this study include that this was a one-time pilot program with limited recruitment and participation; it is possible that ambassadors who did not complete the follow-up evaluation did not find the program beneficial or did not have conversations in their community. Data was not collected on the age group or gender identity of the ambassadors, further limiting the generalizability of our findings. Future studies with larger sample sizes and a more comprehensive data collection strategy are recommended to determine the impact of this program on vaccination knowledge, intention, and rates in Black and Latino/a/x communities. Future efforts may also allow for collection of additional variables; our work captured myths and misinformation, but there is also room to learn about community strengths and resilience that may facilitate vaccination. --- New Contributions to the Literature The Community COVID-19 Vaccine Ambassador Program was developed to increase access to trustworthy, accurate information about COVID-19 vaccinations by training trusted messengers to have informed conversations. As evidenced by an increase in knowledge and confidence, the engagement of trusted messengers in this train-the-trainer model holds promise for application of this strategy for addressing COVID-19 vaccination hesitancy in marginalized communities. This community vaccine ambassador model could serve as an archetype for mitigating future challenges during the COVID-19 pandemic and addressing hesitancy with other health behaviors. --- Declarations Conflict of interest The authors have no relevant conflict of interest to report. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Racially minoritized groups are more likely to experience COVID-19 vaccine hesitancy and have lower vaccination rates. As part of a multi-phase community-engaged project, we developed a train-the-trainer program in response to a needs assessment. "Community vaccine ambassadors" were trained to address COVID-19 vaccine hesitancy. We evaluated the program's feasibility, acceptability, and impact on participant confidence for COVID-19 vaccination conversations. Of the 33 ambassadors trained, 78.8% completed the initial evaluation; nearly all reported gaining knowledge (96.8%) and reported a high confidence with discussing COVID-19 vaccines (93.5%). At two-week follow-up, all respondents reported having a COVID-19 vaccination conversation with someone in their social network, reaching an estimated 134 people. A program that trains community vaccine ambassadors to deliver accurate information about COVID-19 vaccines may be an effective strategy for addressing vaccine hesitancy in racially minoritized communities.

INTRODUCTION Leprosy is a public health concern worldwide, is an infectious disease caused by Mycobacterium leprae and has tropism for the skin and peripheral nerves, causing skin lesions with altered sensitivity and, in the long term, physical deformitiessecondary to nerve damage [1]. According to the World Health Organization, disease control services in endemic countries are currently facing challenges related to the prevention and care of disabilities that may occur during infection, including those after treatment [2]. India and Brazil have the highest global prevalence rates of leprosy. According to data from the Notifiable Diseases Information System (SINAN), 17,979 new cases of leprosy were diagnosedin Brazil in 2020.In Brazil, the State of Pará ranks fifth among the federative units with the highest rate of detection of new cases, with 18.91/100,000 inhabitants [3]. The spatial distribution of leprosy in Brazil shows a heterogeneous pattern.Risk clusters reveal inconsistent behaviour between the country's regions, indicating areas that requirepriority intervention actions in the North, Midwest, and Northeast regions [4]. The main difficulties during treatment and postdischarge of leprosy in northeastern Brazil were the delay in diagnosis and the consequent presence of disabilities, which reduces the effectiveness of treatment, thus, leprosy is still a neglected, stigmatized, and difficult to diagnose disease [5]. --- Regarding the epidemiological and sociodemographic characteristics of leprosy in the state of Pará, some regions such as the Mesoregion of Marajó have a high detection rate of the disease, and the difficulty in accessing basic health services is a problem correlated with the progression of leprosy, being a scenario of active transmission of the disease [6]. In this context, some factors of the disease compromise its elimination as a public health concern, such as underreporting, failures in data entry, poor coverage by health teams, lack of trained professionals for diagnosis and treatment, monitoring of patients, deficiency of surveillance sectors, and little investment in sustainable action [7]. Therefore, this study aimed to describe the sociodemographic and epidemiological characteristics of the population with leprosy in Pará from 2016 to 2020. --- MATERIALS AND METHODS Cross-sectional ecological study, based on data from the Disease Information and Notification System (SINAN), obtained from the Pará State Health Department..The study was conducted in 144 municipalities in Pará, and the data were distributed across 12 IRs. The following inclusion criteria were applied: all cases of leprosy reported through the SINAN during the study period. The following exclusion criteria were applied: incomplete information and inconsistencies in the notification. The sociodemographic and epidemiological characteristics of the study population were determined by selecting variables according to sex, age, education, ethnicity, year, integration regions and proportion of multibacillary cases. The age variable was presented according to the age group using the standard leprosy notification form. Data analysis proceeded with the hypothesis of the presence of a positive relationship between the study variables for illness from leprosy. The associations between the variables were analysed using the chi-square test of adherence, with a significance level of 5% (α=0.05). This statistical test aimed to verify possible differences in proportions between the various variables related to the illness in the study [8]. The study complies with the terms of Resolution nº 466 of the National Health Council (CNS) of December 12, 2012. --- RESULTS Data analysis identified that the high number of leprosy cases in the population residing in Pará may be associated with socioeconomic level, demographic density and failure in early diagnosis in health reference centers. In the analysed data, 11,687 cases of leprosy were reported, which were distributed among 2,407 cases in 2016, 2,554 in 2017, 2,537 in 2018, 2,538 in 2019, and 1,651 in 2020. Regarding sociodemographic characteristics, Table 1 shows that the disease had a higher proportion in the male population than that in the female populations, with 7,162 (61.28%) and 4,524 (38.71%) cases in the male and female population, respectively. In terms of ethnicity, brown had the highest prevalence with 8,619 cases (73.75%), followed by black with 1,383 (11.83%), white with 1,352 (11.57%), yellow with 92 (0.79%), and indigenous with 40 (0.34%). Analysis of the age variables showed that the population aged 15-59 years comprised the majority of notifications with 8,367 cases (71.59%), followed by the population aged>60 years with 2,206 cases (18.88%), and the population <15 years old with 1,114 cases (9.53%). Regarding education, there were 6,356 (54.39%) individuals with complete primary education. --- Regarding --- DISCUSSION The higher proportion of leprosy cases in males than that in females is consistent with the findings of available literature. However, despite the proportion of cases being more evident in men than that in women, differences exist in the prevalence of leprosy according to sex, as there is no evidence that women present protective factors; lack of care in relation to health and aesthetics in the male population; and troublein accessing health services due to work activities and the scarcity of public policies, justifying the predominance of female sex in some studies [9]. The high frequency of cases in individuals with brown and/or black skin in the State's IR is consistent with the IBGE census (2010), which indicatedthat 76.5% of people in Pará self-declared as having black and/or brownskin colour. Notably, there is a relationship between existing inequalities in this variable and leprosy, as socioeconomic differences corroborate difficulties in accessing the health system [10]. A similar finding was reportedin a study on leprosy in the mesoregions of Pará, with high frequencies for black and/or brown skin colour in the Northeast (84.64%), Marajó (85.76%), and Baixo Amazonas (84. 84%) [11]. This study demonstrated that leprosy is prevalent in vulnerable populations with low socioeconomic status, highlighting social inequalities, since resources aimed at health do not coincide with the interests and health needs of the population in certain regions of the country [12]. The detection rate in children under 15 transmission of the disease, this factor is due to the presence of large and single-parent families, and this early exposure to Hansen's bacillus demonstrated the difficulties of health services in controlling the disease [13]. In this context, in a study on leprosy associated with pregnancy in Pará, a detection coefficient for epidemiological studies of the subject was created. The IRs with the highest prevalence of the disease were Xingu, Araguaia, Carajás, Lago do Tucuruí, Capim, and Marajó, which are regions with active economic growth and unplanned urbanisation, factors that confirm that the epidemiological surveillance program in the state is still unsatisfactory and highlights the need for intensive actions on the disease [14]. Leprosy is also a public health problem in other states in the northern region, such as Tocantins, where the proportion and severity of the forms detected in the population under 15 years of age stand out and where there is a large dispersion of cases in the peripheral areas of municipalities [15]. In other studies, on leprosy in Pará, the regions with the highest prevalence of the disease were also Xingu, Araguaia, Carajás, Lago do Tucuruí, Capim and Marajó, locations with active economic growth and disorderly urbanization, factors that justified the difficulties in the actions of the epidemiological surveillance program in the state [16]. Access to early diagnosis, treatment and rehabilitation are essential factors to prevent the development of physical disabilities, as well as the lower possibility of transmission, that is, the delay in diagnosing leprosy increases individual and collective risks and causes negative impacts on the health of the person. population [17]. The eradication of this endemic disease involves cultural, political and economic issues, especially in aspects involving stigma, as it implies social deprivation of the patient due to isolation,in this context, the World Health Organization (WHO) created programs aimed at eradicating leprosy in partnership with several countries, among which is the Global Strategy for Leprosy, which is based on actions that seek to reduce new cases and eliminate the disease [18]. --- CONCLUSION Monitoring epidemiological indicators of leprosy is essential for evaluating programs and planning public health policies. However, only limited studies in Brazil haveevaluated the relationship between such indicators and the endemicity of the disease.This information can serve in the daily practice of primary health care teams to determine priorities and evaluate actions and interventions. This study confirms and highlights the occurrence of leprosy associated with areas of low socioeconomic levels; the occurrence of cases in children aged<15 years reflects a hidden prevalence, highlighting the gaps in care and follow-up of cases. Therefore, early diagnosis of leprosy helps interrupt the disease transmission cycle, in addition to reducing physical disabilities in patients. --- ETHICAL APPROVAL The --- COMPETING INTERESTS Authors have declared that no competing interests exist.

Objective: To describe the sociodemographic and epidemiological characteristics of the population with leprosy in the State of Pará from 2016 to 2020. Methodology: Cross-sectional ecological study, based on data from the Disease Information and Notification System (SINAN). The study was conductedin 144 municipalities in Pará, Amazon. The data were organised and distributed by 12 integration Regions. Results and Discussion: In the analysed data, a total of 11,687 cases of leprosy were verified in Pará from 2016 to 2020. Sociodemographic data showed a predominance in the male population, in the brown race, and in those with low education, this study demonstrated that leprosy is prevalent in vulnerable populations with low socioeconomic status, highlighting social inequalities. Conclusion: Monitoring epidemiological and operational indicators of leprosy is essential for evaluating programs and planning public health policies to contribute to epidemiological surveillance.

Introduction China has entered a period of rapid development of population aging and aging. In 2009, the number of elderly people over 60 years old in China reached 167 million, accounting for 12.5% of the total population [1]. It is predicted that the elderly population will reach 374 million by 2040, accounting for 24.48% of the total population [2]. At present, there are some social institutions for the aged, and there are more and more district-run, township-run, or private-run institutions for the aged, which pay more attention to the living care and physical health of the elderly, but pay little attention to their mental health and psychological needs. ere have been some research studies on the mental health status and psychological needs of the elderly, but there are few research studies on the elderly under different pension modes [3]. is study summarizes the research progress of mental health status of the elderly under different pension modes. It is pointed out that the four pension modes of family pension, institutional pension, home pension, and mutual pension have their own advantages and disadvantages. Each mode should learn from each other and develop in a diversified way to jointly improve the mental health level and quality of life of the elderly. e state, society, and families should choose different pension modes according to the different ages, periods, and health states of the elderly and change the mode of one person into the mixed pension track of one person and multiple modes, so as to promote the vigorous development of pension undertakings in China. rough the questionnaire, this study investigates the mental health status of the elderly under different pension modes, analyzes some existing problems, and puts forward some suggestions, hoping to arouse the attention of society, families, and the elderly themselves to the mental health of the elderly and at the same time provide scientific basis for the development and improvement of the pension cause. 2) Gender: there are 84 males and 81 females, with almost half of them. All the respondents had no serious physical and mental diseases, and their intelligence was normal. --- Object and Methods ere was no significant difference between the two groups (p > 0.05). --- Research Technique --- Literature Data Method. e research consulted the national policies and regulations on the elderly and some literature on the psychology of the elderly in recent years. --- Interviewing Method. rough the collected data, interviews were conducted with the elderly and managers of 10 nursing homes and the heads of the elderly and neighborhood committees in 3 residential quarters. --- Questionnaire Survey Method. e survey was carried out by the workers of old-age care institutions and grassroots doctors with college degree or above and special survey training. e self-made questionnaire, Geriatric Depression Scale (GDS), activities of daily living scale (ADL), and social support rating scale (SSRS) were used to investigate the two groups of elderly. --- Statistical Method. SPSS 17.0 software was used to process the data, and the data utilization rate (%) was counted. e X-test was used to compare the mental health status of the elderly under different pension modes, p < 0.05. e difference was statistically significant. --- Result --- Comparison of Mental Health Status of the Elderly under Two Ways of Providing for the Aged. e total scores of mental health and self, emotion, and adaptation subscales in the social group were higher than those in the home group, with a significant difference (p < 0.05). e scores of cognitive and interpersonal subscales in the home group were higher than those in the social group, but the differences were not significant (p > 0.05), as given in Table 1. --- Comparison of Health Status of the Elderly under Different Pension Models. Under the mode of family pension and social institution pension, the health status of the elderly has certain differences. rough investigation and data analysis and comparison, we find that the elderly have good memory, extensive interests, regular physical exercise, self-recognition, and good physical condition. It is obviously better than the old people in the social institution pension mode, and the data difference between them is statistically significant (p < 0.05). e elderly in different old-age care modes have good performance in diet and sleep, and there is no statistical difference between them (p < 0.05), as given in Table 2. It can be seen from Table 1 and Table 2 that the scores of cognitive and interpersonal subscales in the family group are higher than those in the social group, but the difference is not significant (p < 0.05). e social institution pension mode is significantly better than the elderly, and the data difference is statistically significant (p < 0.05). e elderly with different pension modes perform well in diet and sleep, and the difference is not statistically significant (p < 0.05). --- Discussion With the transformation of the modern medical model, the definition of health not only refers to physical health but also includes mental health and good social function. Only the perfect combination of the three is the real health, especially the mental health of the elderly is more widely concerned by the society [4]. In the past, most of the research on mental health of the elderly focused on some specific elderly groups, such as retired military cadres [5], retired college elderly [6], winter swimming elderly, and so on [7]. Among the subjects, there are many younger and older people, but few older people. With the change of family structure in China, the pace of life is accelerating, and both husband and wife lack energy and time to take care of the elderly, so some elderly people are forced or willing to enter nursing homes or nursing homes for the elderly [8]. Some of the elderly are unwilling to adapt to the new living environment, unwilling to actively communicate with others, lacking in interpersonal communication, unable to effectively solve the psychological problems encountered, and forming an unhealthy psychological state over time. e main reason is that with aging, the functions of various organs of the body decline and diseases increase, which will more or less affect behavioral 2 Journal of Healthcare Engineering ability, depression, and cognitive function, and then affect the whole mental health [9]. It can be seen from this study that the mental health status of the elderly in social institutions is basically similar to the above situation except that the gender difference is not significant. is shows that under different ways of providing for the aged, the mental health status of the elderly is similar and has its commonness. At the same time, in the process of communication, entertainment, and self-improvement, the elderly deepened their understanding of themselves and realized their personal values. erefore, the emotional and selfscores of the elderly in the social group are significantly higher than those in the home group. Compared with the home group, the elderly in the social group are less likely to have negative emotions such as loneliness, loneliness, and anxiety, and their mental health level is generally better than that in the home group. is is contrary to the survey results of Sommus Wei and others in Beijing urban area [10]. In this study, the material conditions and life care of the old-age care institutions are good, and the living needs of the residents are met, but the deep psychological needs and self-realization needs may not be met, thus affecting the mood of the elderly and lowering the mental health level. e elderly in the family pension mode are not stimulated by major unfortunate events or major changes, so their personality is relatively sound. In the survey, it was found that the elderly in old-age care institutions lacked hobbies and physical exercise, cognitive, intellectual and memory impairment, poor interpersonal communication, poor emotional state, and low happiness index of life, and some elderly people thought that society did not attach importance to the elderly group [11]. is study found that the mental health status of family based elderly is better than that of institutional elderly, which is inconsistent with the research results of Tian Ying [12] and consistent with the research of scholars such as Zhang Jing [13]. Generally speaking, the elderly with low economic income, strong dependence on family and society, and low social status are prone to feel inferior and suspicious. e higher the education level of the elderly, the higher the economic income, family status, and social status and the better the health status. is study shows that the elderly in the family pension mode have good interpersonal relationship, good cognition and intelligence, good adaptability, sound personality, and high happiness index, which are obviously better than those in the social institution pension mode, and the data difference between them is statistically significant. e most important thing is that there is a lack of intimate people to talk, interpersonal communication is reduced, and negative emotions are easy to occur. In addition, due to their lack of physical strength and less mental activity, their brain function declines, and they gradually come up with the idea of "old and useless" and passive old-age care, which shows the necessity and importance of paying attention to spiritual comfort in old-age care institutions. Although most of the elderly also have home visits, this short-term relationship is far from meeting the needs of emotional communication between the elderly and their children, and it is difficult to maintain family relations. erefore, it is suggested that the elderly themselves should expand interpersonal communication, adhere to regular physical exercise, cultivate hobbies, improve cultural quality, and maintain good mood. Retirement brings the loss of work role and the reduction of interpersonal communication to the elderly. e increase of leisure time increases the monotony and boredom of life, which is easy to induce the physiological and psychological problems of the elderly. rough the psychological needs questionnaire survey, it is found that the physical needs scores of the two groups are higher than the other three dimensions, indicating that the elderly are more inclined to meet the material needs between material needs and spiritual needs. --- Conclusion In the long run, it is a desirable way to provide for the aged in social institutions, and the transition from family pension to socialized pension will become the inevitable trend of the development of the future pension model in China. However, this kind of socialized pension needs not only the change of ideas of the elderly and their children but also the strong support of the government and the attention of the society. Only by combining material and spiritual support for the aged and improving the quality of spiritual and cultural life, can the elderly adapt to the transformation of pension mode as soon as possible and live happily in pension institutions. --- Data Availability e data used to support the findings of this study are included within the article. --- Conflicts of Interest e authors declare that they have no conflicts of interest.

Objective. To compare the mental health status of the elderly under different pension modes and to provide evidence for improving institutional services and the quality of life of the elderly. Methods. A total of 118 elderly people in social welfare homes, nursing homes, and elderly welfare centers in D city and 165 elderly people from families in D city were assessed by self-made questionnaire, Geriatric Depression Scale (GDS), activities of daily living scale (ADL), and social support rating scale (SSRS). Results. e total scores of mental health and self, emotion, and adaptation subscales in the social group were higher than those in the home group, with a significant difference (p > 0.05). e scores of cognitive and interpersonal subscales in the home group were higher than those in the social group, but the differences were not significant (p > 0.05). Under the mode of family pension and social institution pension, the health status of the elderly has certain differences. e elderly in different old-age care modes have good performance in diet and sleep, and there is no statistical difference between them (p > 0.05). Conclusion. e investigation shows that the mental health status of the elderly under the family pension model is obviously better than that under the social institution pension model.

INTRODUCTION (1520 WORDS) Stigma can inhibit uptake of HIV testing (Kelly, Weiser, & Tsai, 2016) and antiretroviral treatment (ART) (B. T. Chan et al., 2015;Katz et al., 2013;Talam, Gatongi, Rotich, & Kimaiyo, 2008). HIV's infectiousness and association with behaviours considered immoral underpin this stigma (Parker & Aggleton, 2003;Roura et al., 2009;Tsai et al., 2016). Internalised stigma affects individuals' self-esteem (Nam et al., 2008;Tsai et al., 2013), while experienced stigma relates to discrimination by others (Liu et al., 2011;Peitzmeier, Grosso, Bowes, Ceesay, & Baral, 2015). Growing availability of ART appears to have reduced HIV stigma (Campbell et al., 2011;Chan, Tsai, & Siedner, 2015;Roura et al., 2009) alongside interventions to change public attitudes (Stangl, Lloyd, Brady, Holland, & Baral, 2013;Tsai et al., 2016). Female sex-workers (FSW) living with HIV (LWH), however, may experience overlapping stigma due to their involvement in sex-work (Logie, James, Tharao, & Loutfy, 2011;Rogers et al., 2014). There is little research on this phenomenon. We examined the intersection of stigma using data from a survey of FSW recruited in 14 sites across Zimbabwe as part of baseline assessments for a cluster-randomised trial (Hargreaves et al., 2016). In Zimbabwe sexwork remains both criminalised and stigmatised. We hypothesised that FSW LWH would experience overlapping stigma, with sex-work stigma being more prevalent than HIV stigma. --- METHODS In 2013, we conducted respondent driven sampling (RDS) surveys in 14 locations in Zimbabwe for the SAPPH-IRe trial (PACTR201312000722390). In each site 6-8 "seed" women representing different types of locally available sex-work (e.g. bar, guesthouse, truck stop or street-based) were enrolled and provided with two coupons to recruit peers. Every subsequent participant was given two coupons for further recruitment. A small financial incentive was provided when women joined the study (US$5 for the survey and US$2 each for up to 2 recruited peers). The target sample size was 200 women per site and we recruited 2722 FSW in total. Following written informed consent, participants underwent a fieldworker-administered interview. Data were collected on socio-demographic variables, HIV testing, antiretroviral therapy, and experiences of HIV and sex-work stigma. Dried blood spot samples were collected and tested for HIV. We asked women to respond to 5 statements in relation first to being a sex worker and then to being HIV positive. Two were on a 4-point Likert scale,: 1) "I have felt ashamed"; and 2)"I have lost respect or standing in the community"; and then three asked the frequency that women had experienced: 3) "people have talked badly about me"; 4) "I have been denied health services" and 5) "I have been verbally assaulted, harassed and/or threatened". Agree/strongly agree responses were coded as 'yes' and disagree/strongly disagree as 'no' and experiences were counted if they happened at least once. Women were also asked whether they had ever disclosed their HIV status to anyone. We applied RDS-II methodology, which weights individual participant responses by the inverse of their reported number of social contacts whom they would potentially have referred to the survey (Volz & Heckathorn, 2008). We report RDS diagnostic statistics elsewhere (Cowan et al., 2016), but found little evidence of seed dependency by HIV status. We included those women who self-reported and tested as being HIV positive and who had no missing sociodemographic, sex-work or stigma data (n= 1039). We calculated the RDS-II weighted prevalence of each characteristic. We examined intercorrelation among the sex-work and then among the HIV stigma variables and calculated Cronbach's alpha. As intercorrelation was low (alpha=0.47 for sex-work stigma and 0.56 for HIV stigma) we report prevalence for each item separately. We calculated two dependent variables reflecting experience of any type of HIV stigma and any type of sex-work stigma, and explored risk factors for these in individual-level logistic regression. Our models dropped seed participants, applied normalised inverse-weights for participant network size and fixed effects for site, and explored the effect of the socio-demographic and sex-work related variables on experience of stigma. We also conducted these analyses for each of the five sex-work stigma items and each of the five HIV stigma outcomes in turn and found that patterns of association between sociodemographic and sex-work characteristics and each of the stigma outcomes were similar to the combined variables. These additional analyses are available in a webappendix. --- RESULTS Among 1039 FSW LWH, 54.4% had secondary education and 54.6% were divorced (Table 1). Their mean age was 35.2, most reported staring sex-work in their 20s and had between 1 and 10 clients weekly, while 83.4% had everdisclosed their HIV status. Sex-work stigma was more commonly reported than HIV stigma for both internalised and experienced forms (Figure 1). For instance, 44.1% of FSW reported "feeling ashamed" due to sex-work compared to 19.1% reporting shame due to HIV; 62.0% of FSW felt they had "lost respect or standing" as a result of sex-work and 21.6% due to HIV. Reporting having been "talked about badly" for being FSW or LWH, the figures were 76.9% and 38.2%. Similarly, 44.8% reported being verbally assaulted as FSW but just 15.8% for living with HIV. Denial of services by health care workers was also perceived to be higher as a result of sex-work (8.5 %) compared to HIV (1.7%). Whether women had ever disclosed their HIV status did not affect either stigma. Almost all (91.2%) FSW reported experiencing at least one type of sex work related stigma compared to half (51.6%) reporting any HIV stigma experiences (Table 2). There was little evidence of an association between sociodemographic or sex-work characteristics and either stigma. However, there was evidence of overlapping stigma, as women reporting any sex-work related stigma were much more likely to also report HIV related stigma, (adjusted OR 6.95, 95% CI 3.16-15.17). --- DISCUSSION Among a large sample of FSW LWH from 14 sites in Zimbabwe we found high levels of reported internalised and experienced stigma. Stigma perceived to result from sex work exceeded that of HIV-related stigma, and appeared to augment experience of any stigma. Limitations of our research include potentially inaccurate reporting due to social desirability bias (Mirzazadeh et al., 2013). We asked few questions about stigma, although these were informed by previous research (Stangl, Brady, & Fritz, 2012). Applying the same wording for questions on HIV stigma to sex-work stigma is new, reflecting the literature (Visser, Kershaw, Makin, & Forsyth, 2008) on parallel stigma, and thus should be treated with some caution particularly as sex-workers may find it difficult to identify causes of specific stigma experiences. It is also likely that visibility of participating in sex-work is greater than for LWH, possibly explaining lower levels of reported HIV stigma. However, we found differences for internalised as well as experienced stigma, with no evidence that disclosure of HIV status influenced either type of stigma. Our data support the hypothesis that Zimbabwe is undergoing a shift in relative levels of stigma associated with HIV-infection and sex-work (Bodkin, Delahunty-Pike, & O'Shea, 2015;Mtetwa, Busza, Chidiya, Mungofa, & Cowan, 2013;Scorgie et al., 2013). Our finding of high levels of reported stigma is consistent with other studies, for example the Zimbabwe stigma index found 65.5 % of people LWH reported stigma while the proportion was higher proportion among sex-workers (90.5%). Legal restrictions exacerbate discrimination against sex-workers (Stahlman et al., 2015;WHO, 2015). Punitive laws both reflect and drive stigmatisation (WHO, 2015), creating an environment that condones human rights violations against sex-workers (Karandikar & Prospero, 2010;Scorgie et al., 2013). This constrains sex-workers' ability to control their lives, reduce levels of risk, and organise collectively to improve conditions, all of which negatively affect uptake of HIV prevention and treatment services (Pando et al., 2013). There are increasing calls for governments to address legal impediments to accessible services for sex-workers, with stigma reduction a critical component (Grubb et al., 2014;Jeffreys, Matthews, & Thomas, 2010). Even in the absence of criminalisation, however, social stigma against sex-workers persists (Begum, Hocking, Groves, Fairley, & Keogh, 2013) and can discourage them from admitting their occupation to providers and obtaining comprehensive examinations (Abel, 2014;Folch, Lazar, Ferrer, Sanclemente, & Casabona, 2013). Health providers sometimes express greater bias against sex-workers than other people LWH (Roche & Keith, 2014;Rogers et al., 2014). A study in Canada, for example, found sex-work stigma to be an independent determinant of restricted access to health care (Lazarus et al., 2012). The persistence of stigma against FSW even in contexts where legal barriers have been removed suggests that targeted services will continue to play an important role in meeting sex-workers' health needs. Sex-work and HIV remain stigmatised in Zimbabwe. While HIV stigma may be declining, sex-work stigma persists. Programmes for sex-workers should confront stigma, strengthen community and support collective action to build self-esteem and work toward mutual goals (Chakrapani, Newman, Shunmugam, Kurian, & Dubrow, 2009;Deering et al., 2011;Robillard, 2010). However, creation of dedicated spaces for sex-workers can dissuade some from participating if they are reluctant to self-identify as sex-workers and risk resulting stigmatisation (Biradavolu, Blankenship, Jena, & Dhungana, 2012). Navigating the complex social environment inhabited by sex-workers, and ensuring services are perceived as welcoming to women selling sex whether they identify as sex-workers or not, remains an evolving priority in HIV programming. Table 1: *Participants pooled across the 14 sites and inverse degree weights normalised across sites. --- Figures and Tables 1039 / 1118 women included in the analysis as they tested HIV positive, had complete data on stigma, self-reported HIV status, and socio-demographic variables Both unadjusted and adjusted models reflect the study design by including a fixed term for site, dropping seed participants and weighting by inverse degree normalised by site. P values are from Wald tests. --- APPENDIX: ASSOCIATIONS BETWEEN INDIVIDUAL STIGMA TYPES AND SEX WORKERS' SOCIODEMOGRAPHIC AND SEX WORK CHARACTERISTICS Tables 3a-e: Association between socio-demographic and sex-work related factors and experience of (i) sex-work related stigma and, (ii) HIV-related stigma among 1039 self-reported HIV-positive FSW For all analyses, both the unadjusted and adjusted models reflect the study design by including a fixed term for site, dropping seed participants and weighting by inverse degree normalised by site. All p values are from Wald tests. In 4 of the 14 sites there were no women reporting that they had ben denied health services as the result of being a sex-worker or of being HIV positive. These clusters have therefore ben excluded from analysis and n=773.

HIV stigma can inhibit uptake of HIV testing and antiretroviral therapy as well as negatively affect mental health. Efforts to reduce discrimination against people living with HIV have contributed to greater acceptance of the infection. Female sex-workers (FSW) living with HIV may experience overlapping stigma due to both their work and HIV status, although this is poorly understood. We examined HIV and sex-work stigma experienced by FSW living with HIV in Zimbabwe. Using the SAPPH-IRe cluster-randomised trial baseline survey we analysed data from 1039 FSW self-reporting HIV. The women were recruited in 14 sites using respondent-driven sampling. We asked five questions to assess internalised and experienced stigma related to working as a sex-worker, and the same questions were asked in reference to HIV. Among all FSW, 91% reported some form of sex-work stigma. This was not associated with socio-demographic or sex-work characteristics. Rates of sex-work stigma were higher than those of HIV-related stigma. For example, 38% reported being "talked badly about" for living with HIV compared with 77% for their involvement in sex-work. Those who reported any sex-work stigma also reported experiencing more HIV stigma compared to those who did not report sex-work stigma, suggesting a layering effect. FSW in Zimbabwe experience stigma for their role as "immoral" women and this appears more prevalent than HIV stigma. As HIV stigma attenuates, other forms of social stigma associated with the disease may persist and continue to pose barriers to effective care.

Introduction Stigma is defined as any situation, feature, characteristic, or behavior that decreases "a whole and usual person to a tainted and discounted one" (Goffman, 1963, p. 3). Three types of stigma frequently investigated in HIV/AIDS research are, perceived stigma, enacted stigma and internalized stigma (Steward et al., 2008). Studies showed that the particular type of stigma assessed have different effect on HIV disclosure to sex partners (Przybyla et al., 2013;Simbayi et al., 2007;Overstreet, Earnshaw, Kalichman, & Quinn, 2013). Regarding perceived stigma specifically, its effect on HIV disclosure to sex partners were not found consistently (Wong et al., 2009;Derlega, Winstead, Greene, Serovich, & Elwood, 2002). It's therefore necessary to further investigate mechanisms by which perceived stigma may affect HIV disclosure to sex partners (Anglewicz & Chintsanya, 2011;Patel et al., 2012;Przybyla et al., 2013;Vu et al., 2012). HIV disclosure is multi-dimensional, including attitudes toward and intention to disclosure and overt disclosing behavior (Dima, Stutterheim, Lyimo, & De Bruin, 2014;Rimal, Bose, Brown, Mkandawire, & Folda, 2009). Guided by the social cognitive theory (Bandura, 1999) and the theory of reasoned action (Fishbein & Ajzen, 1975;Ajzen, 2001), researchers have found that a number of social cognitive factors, particularly disclosure appraisal, may mediate the process from perceived stigma to HIV disclosure. This include reward and cost (Chenard, 2007), self-efficacy for HIV disclosure (Kalichman & Nachimson, 1999), and disclosure outcome expectation (Semple, Patterson, & Grant, 2004;Sullivan, 2005). Serovich (2001) reported a negative relationship between disclosure costs and disclosure attitudes, attention and behavior, and a positive relationship between disclosure rewards and the three disclosure measures. We believe that the disclosure appraisal process may also be affected by perceived stigma, suggesting a mediation model linking stigma to disclosure through disclosure appraisal. The purpose of this study is to investigate the relationship among perceived stigma, disclosure appraisal, and HIV disclosure. We hypothesized that (1) perceived stigma is negatively associated with HIV disclosure and (2) the association is mediated through the disclosure appraisal, including disclosure outcome expectations, disclosure costs and rewards, and disclosure self-efficacy. --- Methods --- Participants and sampling The survey was conducted between December 2009 and April 2014 in two large cities, one in the Midwest and another in the Southeast. Eligible participants were HIV-positive MSM, ≥ 18 years, had sex with partners in the past 90 days involving a disclosure decision, had sex with ≥2 partners in the past year, was interested in or had intention to disclose their serostatus to sexual partners. The average age of participants (n = 297) was 41.8 years (SD = 11.1) with an average of 10.3 years of HIV+ (SD = 8.3). Among the total sample 145 (48.82%) were self-identified as white/Caucasian, 105 (35.35%) as Black/African American, and 26 (8.75%) as Hispanic; 235 (79.12%) as gay and 224 (75.42%) had sex only with men. Most participants reported being single (n = 210, 70.70%), 196 (65.99%) completed at least some college, 201 (67.68%) unemployed with income ≤ $1,000 per month. --- Data collection Participants completed the survey questionnaire using the audio computer-assisted selfinterviewing (ACASI) for more reliable data (Des Jarlais et al., 1999;Perlis, Des Jarlais, Friedman, Arasteh, & Turner, 2004). The survey protocols were approved by the appropriate Institutional Review Boards at Ohio State University and University of South Florida. The survey took approximately 1 to 1.5 hours to complete. Participants were reimbursed $35 upon completion of the survey. --- Measurements Perceived stigma was measured using the HIV Sigma Scale (Berger, Ferrans, & Lashley, 2001) and used as a predictor variable. The 21 items were rated on a 4-point likert scale with 1(strongly disagree) and 4(strongly agree). A typical item of the scale reads as "I feel guilty because I have HIV." The Chronbach's alpha coefficient = .96 for the scale and mean scores were computed for analysis with higher scores indicating severer stigma. Four measures of disclosure appraisal were used as mediators and they are disclosure outcome expectations, disclosure costs, disclosure rewards and disclosure self-efficacy. Two short 3-item scales (Semple, Patterson, & Grant, 2004) were used to measure the expectations with alpha=.47 (e.g., I believe that disclosing my HIV status to my sexual partner(s) will increase my sexual pleasure") and self-efficacy with alpha=.80 (e.g., "I can bring up the topic of my HIV+ serostatus with any sex partners"). The disclosure costs (8 items) with alpha = .80 and rewards (10 items) with alpha = .76 were assessed using published scales (Serovich, 2001). A typical cost item is "Relationship would get bad if I disclose my HIV+ status" and a typical reward item is "Disclosure my HIV+ status to my partners will bring us closer." Items for all the four disclosure appraisal subscales were assessed using a 4-point likert scale with 1(strongly disagree) and 4(strongly agree). Mean scores were calculated for analysis with higher scores indicating stronger beliefs. Three HIV disclosure measures were disclosure attitudes, intention, and behavior, each being measured with an author-derived subscale (14 items) and used as outcome variables. The alpha for the attitudes subscale was .94 and a typical item is "People with HIV should disclose their status to causal sexual partners"(1=strongly disagree and 5=strongly agree); the alpha for the intention subscale was .95 and a typical item is "I plan to tell my future sex partners about my HIV status if they specifically ask" (1=strongly disagree and 4=strongly agree); and the alpha for behavior subscale was .97 and a typical item is "I have disclosed my HIV status to my sexual partners with whom I had insertive anal sex"(y/n). Mean scores were computed for analysis. --- Statistical Analysis Cronbach alpha coefficient was used to measure scale reliability. Pearson correlation was used to assess the relationships among the predictor, mediator and outcome variables. Path modeling analysis was used to test the proposed structural relationships among these variables with GFI>0.90, CFI>0.90, RMSEA<0.05 and Chi-square/df (<2) as the indexes of data-model fit. The bootstrapping method (MacKinnon et al, 2002) was used to test the indirect effect. The software AMOS was used for path modeling analysis. 1 indicate that perceived stigma was significantly correlated with all three outcome measures (disclosure attitudes, intention and behavior) and three (outcome expectation, cost and self-efficacy) of the four mediator variables assessing social cognitive process of disclosure appraisal. Furthermore, the four mediator variables all were significantly correlated with the three outcome variables, supporting the proposed mediation model. --- Results --- Correlation analysis --- Results in Table --- Structured path modeling analysis Results in Figure 1 indicate a good data-model (GFI=0.99, CFI=0.99, CHISQ/DF=4.31, RMSEA=0.11). Perceived stigma was significantly associated with three of the four mediators, disclosure outcome expectation (b=-0.23, p<.01), cost (b=0.51, p<.01), and selfefficacy (b=-0.36, p<.01). Among the four mediators, two (disclosure expectation and disclosure self-efficacy) were significantly associated with all three outcomes; disclosure costs were negatively associated with disclosure behavior (β=-0.15, p <.01); and disclosure rewards were positively associated with disclosure attitudes (b=0.11, p<.05) and intention (b=0.11, p<.05). --- Discussion and conclusions In this study we tested the mechanism by which perceived stigma may affect HIV disclosure through social cognitive process. The hypothesized structural relationship model was tested with data from a sample of 297 MSM from two large US cities. The mediation mechanism was supported by correlation analysis and confirmed by structural path modeling analysis, supporting further longitudinal studies to determine if the relationships are casual. The results show a central role of disclosure self-efficacy in mediating the influence of stigma on sexual risk behavior. This finding is in line with the notion that efficacy beliefs are a necessary step bridging causal attributions with achievement strivings (Bandura, 1999;Schunk & Gunn, 1986). In the current study, disclosure self-efficacy has higher coefficients with the three dimensions of HIV disclosure than disclosure outcome expectation. This finding suggests the importance for behavioral interventions in enhancing efficacy beliefs in order to achieve expected behavioral changes against stigma for HIV prevention. With the improvement in disclosure self-efficacy, HIV+ MSM may change their negative outcome expectations to positive, and then they are more likely and better prepared to disclose their HIV status in a sexual setting. Drawing on the behavioral and social cognitive theories (Ajzem, 2001;Bandura, 1999), it's practical to increase HIV+ MSM's mastery experiences of HIV disclosure to casual sex partner. According to our study findings, training programs can be developed to facilitate HIV+ MSM practicing role-playing of different strategies in how to disclose HIV+ status to casual sex partners in specific scenarios and how to minimize potential negative outcomes thereafter. It is also worth noting in the current study that disclosure rewards was associated with disclosure attitudes and intention; while disclosure costs was associated with disclosure behavior. Additional studies are needed to verify these study findings. There are limitations to this study. Data used for this study were cross-sectional in nature, causal relationship cannot be warranted. The low alpha coefficient of the 3-item subscale disclosure outcome expectation indicates a potential of underestimate of the associations between the disclosure outcome expectation and other variables. Additional studies are needed to improve the reliability of this variable by adding more items. In addition, this study was conducted in only two cities, caution is needed when generalizing the findings to other populations and settings.

HIV stigma is widely believed to be related to HIV disclosure. However, there is a dearth of studies examining the mechanisms that link stigma to disclosure. This is a specific study to assess the relationship between perceived stigma and HIV disclosure to casual sex partners based on a social cognitive theory. HIV+ men who have sex with men (MSM) from two U. S. cities (N = 297) completed questionnaires administered using audio computer-assisted self-interviewing. Path modeling analysis was used to assess the theory-based structural relationships. Perceived stigma was negatively associated with attitudes, intention and behavior of HIV disclosure to casual sex partners. The association was fully mediated by disclosure appraisal, including disclosure outcome expectations, costs and self-efficacy. Findings of this study add new knowledge regarding HIV stigma and disclosure, and provide timely data supporting more effective behavioral interventions to encourage HIV disclosure among MSM.

Social networks have multiple uses from facilitating scientists to communicate and make their research more accessible, to healthcare professionals generating interest and helping the general public be more aware about their health & wellbeing, all this while countering the the uncontrolled dissemination of misinformation. Study design, size, duration: From ESHRE annual meeting 2022, the 5YEA shared scientific messages and personal considerations on research and topics presented at the meeting. Through the various SNs(mainly Twitter-Instagram-Facebook-LinkedIn) they have directed many participants to follow the topics from the comfort of their homes and, generating curiosity for people even outside the scientific community. Even today, the topics shared on SNs are followed by users both from the scientific world and from the whole social world. Participants/materials, setting, methods: The 5YEA actively participated during the 5 days of the annual meeting. The sharing of their messages on the SN involved thousands of registered users across various platforms. The conspicuous increase in the number of users who have begun to follow them has allowed us to express the considerations of this abstract. Main results and the role of chance: Scientific integrity, defined in particular by the methodological rigor and honesty of the researcher, is essential for the validation of his work by the scientific community. SNs, accessible to research professionals, on the one hand, and to the general public, on the other, have given specialists a voice to raise awareness of scientific integrity in these two populations. SNs are also a forum for discussing methodological weaknesses or distorted results of some studies. But they are also an educational tool to educate their readers about scientific fraud. SNs has increased the massive diffusion of fake news. Raising scientists' awareness of the use of these powerful communication tools seems to be a necessity, as these tools can interfere with the visibility of their research work but also, sometimes even, with their private life. Today on SNs there is therefore a struggle going on, difficult to ignore, which questions the credibility of scientific discourse and its integrity and for which very few researchers are prepared. It is a fight for which it is necessary to attract the attention of all generations of scientists. This fight must not be lost to restore and preserve the still fragile trust between science and society. Limitations, reasons for caution: New SN platforms are born every day. Some are reserved to scientific professionals (high scientific rigor), others not (general public creates confusion by indulging in inappropriate comments). Given limitations to text length, information is always condensed, while users are pushed to share information frequently to get a greater reach. Wider implications of the findings: With all the emerging and sometimes misinformed discussions taking place on social media, experts should spend more time clarifying them. However, the quantification and corresponding appreciation of this work is currently lacking. Trial registration number: not applicable --- QUALITY, INNOVATION, AND SERVICE-IT'S ALL AT THE CENTER OF EVERYTHING WE DO. From developing assisted reproductive technologies that maximize performance, like the first ART media and cultures, to expertise that streamlines productivity, FUJIFILM Irvine Scientific brings together decades of industry expertise with a powerhouse of innovation, turning opportunities into realities. Together, we're working to support healthy futures-from retrieval to realization. --- ALL IN FOR LIFE. irvinesci.com/ALLIN FUJIFILM Irvine Scientific and its logo are registered trademarks of FUJIFILM Irvine Scientific, Inc. in various jurisdictions. ©2023 FUJIFILM Irvine Scientific. P/N 018187 Rev.00

Study question: The 5YEA, experienced how SN can promote dissemination of evidence based scientific education and counter misinformation for both scientific community and general public. Summary answer: An incorrect use of SNs can lead to the massive dissemination of incorrect information but if used correctly they can help scientists, patients and general-public. What is known already: SNs have proved to be a very powerful weapon. SNs are applications available on the Internet, a global computer network that uses the Web as a service to navigate through documents. Their rise, in conjunction with the development of mobile phones, has affected all professional sectors, including the scientific community.

Introduction Shopping is an inherent activity in people's lives, and with the rise of e-commerce, the way consumers shop has significantly evolved. Women, in particular, have shown a keen interest in fashion and apparel, and their shopping patterns differ from those of men. Online shopping has gained popularity due to its convenience, variety of choices, and attractive offers. This study aims to understand the pleasure and preferences of working women in Thiruvallur Town when shopping online for apparel and accessories, considering the impact of recent changes in shopping habits, especially after the COVID-19 pandemic. --- Literature Review The study conducted by Sunday C. Eze and Bello Adenike O. Bello in 2016 explored the factors influencing consumer behavior in marketing consumer goods in Nigeria. The research focused on the impact of demographic factors such as age, income, and gender on consumers' decisions when purchasing clothes.Understanding these influences can help businesses and marketers tailor their strategies to better meet the needs and preferences of different consumer segments. The study conducted by Nethravathi T.S. and Dr. G.S. Vijaya in 2017 highlights the advantages of online purchases over traditional offline retailing. The research emphasizes the various comforts and benefits that consumers experience when shopping online, leading to the rapid growth of online retailing, especially with the integration of information technology (IT) tools. The findings suggest that online retailing, powered by IT tools, is experiencing significant growth, transforming the way consumers shop and presenting new opportunities for businesses in the digital marketplace. The study conducted by G. Hari Shankar Prasad in 2014 explored the priorities and purchase behavior of online shopping customers. The research highlights the factors that influence online shopping behavior, including the importance of the latest designs and product options, convenience, catering to the middleclass segment, family shopping convenience, social compliance, discounts, cost consciousness, customer trust, availability of choice, and product durability. Understanding these factors is crucial for ecommerce businesses to meet the preferences and expectations of online shoppers and enhance their overall shopping experience. The study conducted by Deepali Saluja in 2016 focused on identifying the influencing factors for online purchases, particularly concerning fashion apparels. The research explored the sources of influence that impact consumers' buying behavior when shopping for fashion clothing online. These findings suggest that consumers' online fashion apparel purchase decisions are influenced by their social networks, including friends and family, as well as by aspirational figures like celebrities. Additionally, the quality, comfort, and brand of the clothing items are primary considerations that guide consumers' buying behavior. The study conducted by Dr. Santhosh M in 2021 explored the significance of fashion accessories in completing a fashion look or outfit. The research particularly focused on men's fashion accessories and identified the major factors that influence their purchase behavior. The findings suggest that men's fashion accessory purchases are influenced by a combination of product-related factors, external stimuli, and social influence. These factors collectively impact their choices and preferences, leading them to select accessories that align with their fashion tastes and the current trends. The research conducted by Mandarić, Doroteja, Anica Hunjet, and Dijana Vuković in 2022 aimed to determine the percentage of consumers who actively seek information about fashion brand sustainability before making a purchase of their products. The study sought to understand the extent to which consumers consider sustainability as a factor when buying fashion items However, the study also points out that there is still a gap between consumers' positive attitudes towards sustainability and their purchasing behavior. To bridge this gap and promote sustainable fashion consumption, the industry may need to implement systemic changes, such as adopting more sustainable production processes, transparent supply chains, and offering clear sustainability information to consumers. The research conducted by Metrigy focuses on customer experience (CX) and reveals the growing significance of technology investments in enhancing customer engagement and satisfaction. According to the findings, 65% of companies are increasing their technology spending, with some organizations raising their outlays by as much as 24%, to improve their CX efforts. Businesses that prioritize CX and invest in the right technology tools are likely to build stronger customer relationships and gain a competitive edge in the market. Previous studies have explored various aspects of online shopping behavior, including demographic factors, influencing factors, and sustainable fashion choices. The literature review highlights the significance of online shopping in the fashion industry, the factors that influence purchase decisions, and the impact of sustainability concerns on consumer behavior. Based on the data obtained from the study, the following observations were made: Age Distribution: The highest percentage of working women who participated in the study were aged above 35 years, accounting for 46.5% of the respondents. On the other hand, 23.9% of the women were below 25 years old. --- Results & Discussions DEMOGRAPHIC PROFILE Marital Status: The study included opinions from both married and unmarried women. The majority of respondents (68%) were married, while 31.9% were unmarried. Income Level: Among the women shoppers surveyed, 42.3% belonged to the income range of 20,000 to 40,000 rupees. This income group showed a higher interest in online shopping for apparel and accessories. Online Shopping Duration: Of the total 176 respondents, 39% of the women shoppers had been using online platforms for apparel purchases for the past three years. The findings indicate that the online shopping behavior of working women in Thiruvallur Town is influenced by age, marital status, income level, and the duration of their engagement with online shopping platforms. These factors play a significant role in shaping their preferences and choices when purchasing apparel and accessories online. --- REASONS FOR ONLINE SHOPPING TABLE -2: OPINION OF WOMEN SHOPPERS THE REASONS FOR ONLINE SHOPPING Rotated Component Matrix a Reasons for online shopping Component Information 1 2 3 Browsing for information at leisure time .761 Gathered information from friends and relatives through chatting .742 Popups, banner and online advertisement from sellers .740 Choices I shop for the goods available at national and international market .784 I can select both traditional as well as fashionable .626 I am free to select the seller as well as number of products at different sellers .663 --- Benefits I feel comfortable to shopping from home shipping at door step .807 I am getting more offers, discounts and bonus points etc., for future purchase also .763 I am getting product at low price because cost reduction to sellers. .739 Based on the above table, the study identified three main reasons why most working women prefer online shopping to purchase apparel and accessories for themselves and their family members: Information Accessibility: One of the primary reasons for the preference towards online shopping is the easy accessibility of product information. The majority of shoppers acknowledged that they receive sufficient details about the product, including descriptions and usage information provided by the sellers. Additionally, they rely on reviews posted by other customers, as well as recommendations from friends and relatives to make informed decisions about their purchases. Wide Range of Choices: Online shopping platforms offer a diverse and extensive range of choices, which is a significant attraction for women shoppers. They are enticed by the variety of products showcased with appealing images and dimensions. Online shopping provides the flexibility to select from both traditional items available in the national market and trendy fashion items from international markets. The convenience of browsing through multiple sellers and having access to numerous products at one click on their mobile devices enhances the overall shopping experience. Convenience and Cost-Effectiveness: Working women find online shopping more comfortable and costeffective. They appreciate the convenience of shopping from the comfort of their homes, saving time and effort. The added advantage of doorstep delivery further adds to the appeal. Moreover, online platforms often offer products at lower prices compared to brick-and-mortar stores and frequently provide attractive offers and discounts, making online shopping a more economical option. In conclusion, working women's preference for online shopping for apparel and accessories is driven by the easy access to product information, the wide range of choices available, and the convenience and cost-effectiveness offered by online platforms. These factors contribute to the increasing popularity of online shopping among this demographic. --- REGRESSIONANALYSIS Multiple regression analysis has been applied to explore the influence of online shopping among the working women in Thiruvallur Town the results are presented intable -3. The results of the multiple regression analysis at a 5 percent level of significance indicate that the independent factor "information" has a positive influence on the dependent factor "choices and benefits" among women shoppers for their online purchases of apparel and accessories. This suggests that providing sufficient information about products positively impacts the choices made by working women when shopping online, leading to greater benefits for them. --- Conclusion In conclusion, the study highlights the increasing independence of Indian women, allowing them to balance their domestic, professional, and social roles. This independence has led to a rise in women shoppers who are passionate about spending on themselves and their family members. With financial autonomy, women are becoming more selective about their purchases, paying attention to factors like price, quality, and brand when shopping for apparel and accessories online. The study also emphasizes that woman shoppers in Thiruvallur Town are experiencing a similar fashion fascination as those in metropolitan cities, thanks to the convenience of online shopping. The COVID-19 pandemic, which prompted many women to stay home for extended periods, further accelerated the shift towards online shopping to refresh their fashion choices and accessories. Overall, the study indicates a positive trend in the online shopping behavior of working women, driven by their financial independence, desire for choice and quality, and the convenience offered by online platforms. As technology and e-commerce continue to evolve, online shopping is likely to remain a preferred mode of shopping for women shoppers in Thiruvallur Town and beyond.

Online shopping has become an integral part of modern life, offering convenience and a wide range of choices to consumers. This study focuses on the online shopping behavior of working women in Thiruvallur Town, analyzing 176 responses collected through a survey. The research aims to identify the determinants of online shopping behavior, particularly for apparel and accessories. The study employs statistical tools to analyze the data and draws conclusions regarding the factors influencing the shopping preferences of working women in the region. Key factors such as convenience, product variety, and social influence are explored to gain insights into the changing dynamics of shopping patterns in this segment.

The increasing focus on multimorbidity in clinical studies points to the need for more holistic, upstream, and integrated approaches to health and care. However, defining multimorbidity in purely biomedical terms is limited and inadvertently sidelines other concepts that have labelled, analyzed, and precipitated action on this challenge over the past half century. Following the Whitehall Studies, which were among the first efforts to rigorously demonstrate the association between socio-economic status and disease, several theories referred to and, in some cases, explicitly named multimorbidity as emergent within larger social and ecological constructs. These theories include, for example, eco-social theory, fundamental cause theory, local biologies, recursive cascades, and syndemics. 6 These frameworks emphasize how multiple conditions emerge and interact, often with social, ecological, and political domains, albeit to different degrees. Among these theories, syndemics provides a useful bridge between the social and medical sciences because of its biological focus. 7 Syndemics involve a set of intertwined and mutually enhancing epidemics involving disease interactions at the biological level that develop and are sustained in a community or population because of harmful social conditions and injurious social connections. 1,2 By emphasizing where disease concentrations emerge geographically and how diseases interact biologically, syndemic thinking also highlights the need to design interventions that might mitigate these effects. For example, the Soweto Syndemics study, conducted in Soweto, an urban township in Johannesburg, South Africa, demonstrated that patients with comorbid disease who experienced high stress levels reported considerably lower quality of life than patients with fewer stressors and the same comorbidities 2 . This study indicates how social and structural interventions might improve the health of people living with multimorbidity more than medical interventions alone. Syndemic thinking can be understood using three orientating rules that define what is a syndemic and what is not (Figure 1). The first rule involves identifying multimorbidity, where two or more diseases concentrate within a population, for example, through epidemiological analysis of co-occurring diseases within the same individual and/or the same population. In the Soweto Syndemics study, type 2 diabetes mellitus (T2DM) clustered primarily with one or more conditions (primarily hypertension, depression, and HIV infection) within six neighborhoods of Soweto. This was measured using standard survey and biological measures to evaluate glucose, blood pressure, HIV status, and depressive symptoms in a large sample. The second rule requires identification of disease interactions that are measurable through biological pathways and interact with social, psychological, or concurrent biological disturbances, which may include anything from well documented biological interactions (such as inflammation) to cultural dynamics (such as stigma). In Soweto, earlier clinical research illustrated how closely these conditions interact (for example, diabetes with depression and/or hypertension) and ethnographic work highlighted how HIV infection and T2DM are linked through stigma. 8 Finally, the third rule considers how upstream or macro-scale forces precipitate disease concentration, such as policies around food, housing, rights, education, and healthcare, which may impede an individual from living a healthy and secure life. 9 The Soweto Syndemics study evaluated how these factors affected health and well-being, such as stress related to finances, safety, housing, family, knowing someone who can lend you money, or having someone to rely on in a crisis. Hence, investigations of the third rule clarify what factors may perpetuate not only disease concentrations but also disease interactions that make people sick. By identifying specific pathways through which upstream factors cause syndemics, the third rule emphasizes how interventions for multimorbidity require a combined effort of both clinical (downstream) and policy (upstream) interventions because clinical interventions cannot address the root cause of disease clusters. Syndemic care provides a practical conceptual interface between policy and clinical interventions. 1 It involves a shift in emphasis from curative care to active screening for conditions known to interact syndemically in a particular setting. This approach may include, for example, integrated mental health and HIV screening (as is increasingly practiced in HIV care) as well as screening for social vectors of mental health conditions, such as discrimination, stigma, domestic violence, and chronic poverty. 1 The example in Soweto emphasizes how social dynamics may be an important space for intervention: ethnographic data revealed how health interventions through church groups and meetings might be effective in improving health. 2 In this way, screening and care in non-medical settings may be an effective intervention on a patient's own terms. Patients may subsequently be more open to[ attending coordinated medical visits for multiple conditions at once in medical or non-medical settings, including home visits. Thus, syndemic care conceptualizes patients receiving treatment that addresses their conditions as one unit in contrast to an approach of managing discrete diseases. Health workers devising treatment plans are trained in holistic health models that integrate management of physical, mental, and social ills. This requires an expanded view of 'generalism' -well-recognized as crucial for multimorbidity care -to emphasize the importance of structural competency within training curricula and continuous professional development. 10 Today, people live within a complex, changing world where diseases cluster, interact, and become embedded in their everyday lives. Multimorbidity emphasizes how multiple conditions cluster within individuals and populations, but the dominant biological concept of multimorbidity tends to stop short of meaningfully incorporating non-medical factors in health and wellbeing. Syndemic care meets people where they are: spaces where they feel safe, treatment plans that include their various symptoms and diagnoses, and recognition of the social and emotional dynamics that drive their ill or good health. Syndemic care can, therefore, help reinvigorate long-standing calls for more upstream, integrated, and person-centered approaches by putting the coexistence of multiple social and health conditions at the center of care.

The concept of syndemics specifies which, where, and how disease concentrations and interactions emerge and persist. Recognizing multimorbidity within a population or region is fundamental to syndemics because multimorbid conditions often share upstream drivers, including social inequalities. Applying syndemics to healthcare can inform clinical and policy interventions. The concept of syndemics (synergies of epidemics) focuses on both concentrations (clusters) of diseases and interactions of diseases, which together worsen health. Although individual-level analysis of disease interactions are crucial to understand syndemic conditions, generally a syndemic is evaluated at the population-level. These disease concentrations are driven by mutually exacerbating upstream factors, such as inequality, inadequate housing, climaterelated stress and/or racism, as well as the iatrogenic effects of maladaptive medical systems. 1,2 The concept places multimorbidity -the co-occurrence of two or more long-term conditions in one individual 3 -at its theoretical center. Multimorbidity is among the most pressing threats to health systems globally and has been welcomed as a more realistic understanding of disease. Research and care in this framework pushes boundaries beyond the siloed diagnosis and treatment domains of singular conditions, acknowledging disease clusters and their shared upstream determinants. [3][4][5] Syndemics also takes into account where these multiple conditions come from, how and why they occur together, and where to intervene.

Introduction Twitter and Instagram are popular microblogging services with many users having active accounts on both these sites (or platforms) (Lim et al. 2015;Chen et al. 2014). While research has recognized immense practical value in understanding the user behavioral characteristics on these platforms separately, there is no existing research that has examined how the content posted by the same set of individuals differs across these two platforms. Instagram is a photosharing application whereas Twitter emerged as a text-based application which currently lets users post both text and multimedia data. Of particular interest is the question of why and how a particular individual uses these two sites when both of them are similar in their current functionalities. We aim to answer this question by analyzing content from the same set of individuals across these two popular platforms and quantifying their posting patterns. We focus on ordinary users who are neither celebrities nor popular organizations. By leveraging Natural Language Processing and Computer Vision techniques, we present some of the first qualitative insights about the types of trending topics, and social engagement of the user posts across these two platforms. Analysis on the visual and linguistic cues indicates the dominance of personal and social aspects on Instagram and news, opinions and work-related aspects on Twitter. As a part of the linguistic analysis, we observed that Instagram is largely a sphere of positive personal and social information where as Twitter is primarily a news sharing media with higher negative emotions shared by users. We see the same set of users posting remarkably different categories of visual content -predominantly eight categories on Instagram and four categories of images on Twitter. An extended analysis on textual and visual content is presented in the archive version (Manikonda, Meduri, and Kambhampati 2016) of this paper. Background: Twitter has been explored extensively with respect to the content (Honey and Herring 2009), and language (Hong, Convertino, and Chi 2011). It is established that Twitter is primarily a news medium (Kwak et al. 2010). Research on Instagram has focused mostly on understanding the user behavior through analyzing color palettes (Hochman and Schwartz 2012), categories (Hu, Manikonda, and Kambhampati 2014), filters (Bakhshi et al. 2015), etc. On the other hand, it has been of significant interest to the researchers to investigate the behavior of a user (Benevenuto et al. 2009), mapping same user accounts (Zafarani and Liu 2013), study how users reveal their personal information (Chen et al. 2012), etc all across multiple OSNs. We extend the current state of the art by examining the nature of a given user's behavior manifested across Twitter and Instagram. Close to our research is the work of Raphael et al. (Ottoni et al. 2014) that compared Pinterest and Twitter, Bang et al. (Lim et al. 2015) where six OSNs were studied to analyze the temporal and topical signature (only w.r.t user's profession) of user's sharing behavior but they did not focus on studying the comparative linguistic aspects and visual cues across the platforms. Here we employ both textual and visual techniques to conduct a deeper comparative analysis of content on both Twitter and Instagram. --- Dataset To get a set of users maintaining accounts on both OSNs, we use a personal web hosting service called About.me (http://about.me/). This service enables individuals to create an online identity by letting them provide a brief biography, connections to other individuals and their personal websites. Using its API, we initially crawled a set of 10,000 users and pruned users who do not maintain accounts on both the platforms. The final crawl includes 963 users with a total of 1,035,840 posts from Twitter (using the Twitter API https://dev.twitter.com/overview/api) and 327,507 ). Each post in this dataset is public and the data include user profiles along with their followers and friends list, tweets (insta posts), meta data for tweets that include favorites (likes), retweets (Instagram has no explicit reshares; so we use comments as a measure of the attention the post receives), geo-location tagged, date posted, media content attached and hashtags. 3 Text Analysis --- Latent Topic Analysis To analyze the types of content posted by a user across Twitter and Instagram, we first mine the latent topics from the corpus of Twitter (aggregated posts on Twitter of all users) and corpus of Instagram (aggregated posts on Instagram of all users where we use captions associated with posts for this analysis). Topic analysis is meaningful as it is pertinent to understand the reasons behind users joining the two platforms and making posts actively. We use TwitterLDA (https://github.com/minghui/Twitter-LDA) developed for topic modeling of short text corpora to mine the latent topics. The topic vocabulary listed for both the platforms in Table 1 indicates the unique topics for each site as well as the overlapping topics. For instance topics 0 and 4 on Instagram are similar to the topics 1 and 2 on Twitter. However, a significant difference is that Instagram is predominantly used to post about art, food, fitness, fashion, travel, friends and family but Twitter hosts a significantly higher percentage of posts on sports, news and business. Another notable difference is that the vocabulary from non-English language posts like French and Spanish is higher on Twitter as compared to the captions on Instagram mostly using English as the language medium. The topic distributions obtained from the two corpora listed in Figure 1 show that friends and food are the most frequently posted topics on Instagram as against sports and news followed by work and social life being popular on Twitter. To further validate the observations made about the distinctive topical content across the two platforms, we compared the topic distributions for each individual on the two 2 shows a significant fraction of the users posting distinct content on the two platforms. This distinction is statistically significant with an estimated p-value < 10 -15 for each user. --- Social Engagement Since our findings revealed that the topics across the two platforms are significantly different, we wanted to investigate how the posts made by the same user engage other individuals on the two sites. We define the social engagement as the attention received by a user's post on the social media platform. It can be quantified in various ways varying from the sum of likes and comments on Instagram to the sum of favorites and reshares on Twitter. For each topic in the unified topic model for both Twitter and Instagram, the logarithmic frequency of posts is plotted against the magnitude of social engagement that is binned to discrete ranges. The results are shown in Figure 3. An interesting observation is that the socially engaging topics in the combined model are same as the overlapping topics from the topic models built in isolation on the Twitter and Instagram posts (Figure 1). The dominating topic on Twitter is about sports, news and business and on Instagram it is about love, fashion and food. Surprisingly, we found that the overlapping topics (Topics 2 and 3) focusing on social and personal life fetched predominant social engagement on both the platforms. Though the dominating topic (commonly A notable difference between the platforms with respect to social engagement is that the magnitude of attention received for Instagram posts is significantly higher than the level of attention received on Twitter. We can see this from the ranges plotted on the x-axes in Figure 3. This observation is consistent regardless of the activity level of a user. Even when a user is more active (Figure 4) on Twitter than Instagram, the observation of higher social engagement on Instagram on an absolute scale holds. A possible explanation to this is that the users on Twitter use it as a news source to read informative tweets but not necessarily all of the content that is read will be "liked". On average, there are 30% more hashtags for a Twitter post compared to an Instagram post (Pearson correlation coefficient = 0.34 between distributions with p-value < 10 -15 ). This may also indicate that on Instagram since the main content is image, textual caption may not receive as much attention from the user. --- Linguistic Nature To characterize and compare the type of language used on both platforms, we use the psycholinguistic lexicon LIWC ((http://liwc.wpengine.com/)) on the text associated with Twitter posts and Instagram posts. We obtain measures of attributes related to user behavioremotionality (how people are reacting to different events), social relationships (friends, family, other humans) and individual differences (attributes like bio, gender, age, etc). 2 that posts on Twitter have more negative emotions and contain more work-related and swear words. In contrast, positive social patterns are more evident on Instagram. By relating these results to the topic analysis results in the previous section, we note that on Instagram users share more light-hearted happy personal updates. --- Visual Analysis This section develops a better understanding of the types of photos individuals post on Twitter in comparison with their Instagram posts. To achieve this we employ computer vision techniques mainly in terms of visual categories (kinds of photos). --- Visual Categories We further investigated if the visual categories of the posts made on Twitter and Instagram are different. We first sampled two sets of 5000 images from both platforms separately. Using the OpenCV library (http://opencv.org/) on these two datasets, we extracted Speeded Up Robust Features (SURF) for each image. We used the vector quantization approach Visual categories on Instagram agree with our previous work (Hu, Manikonda, and Kambhampati 2014) which detected eight different categories of images. We tried to categorize the Twitter images into the same format as Instagram images. This shows that there are four prominent cluster categories on Twitter. Figure 7 shows that the percentage of photos in the activity category outnumbered any other category followed by captioned photos. To better understand the kinds of activities and captions shown in these two sections, we sampled around 200 images and asked the two researchers to label them manually into different sub-categories. Figure 5 indicates the most popular subcategories in the activity category -news, events (football games, concerts, conferences) and races. Figure 6 indicates that majority of the captioned photos are snapshots, memes, and quotes or opinions. These categories show that the topics of photos on Twitter are mainly related to news, opinions or other general user interests. In contrast, on Instagram users seem to mainly share their joyful and happy moments of their personal lives. --- Conclusions In this paper, we presented a detailed comparison of the textual and visual analysis of the content posted by the same set of users on both Twitter and Instagram. Some of the insights obtained from linguistic analysis reveal the fundamental differences in the thinking style and emotionality of the users on these two platforms and how the posts receive varying degrees of attention as per the underlying topics. The visual analyses with respect to categories and color palettes indicate that the pictures posted on Instagram contains more selfies and photos with friends where as Twitter contains more about user opinions in the form of captioned photos -memes, quotes, etc. We observed that the differences are deeply rooted in the very intention with which users post on these platforms with Twitter being a venue for serious posts about news, opinions and business life while Instagram serves as the host for light-hearted personal moments and posts on leisure activities. Interestingly, user posts on Instagram seem to receive significantly more attention than Twitter.

Understanding the usage of multiple Online Social Networks (OSNs) is of significant research interest as it helps in identifying the distinguishing traits of each social media platform that contribute to its continued existence. A comparison between two OSNs is particularly useful when it is done on the representative set of users holding active accounts on both the platforms. In this research, we collected a set of users holding accounts on both Twitter and Instagram. An extensive textual and visual analysis on the media content posted by these users reveals that these platforms are indeed perceived differently at a fundamental level with Instagram engaging more of the users' heart and Twitter capturing more of their mind. These differences get reflected in the linguistic, topical and visual aspects of the user posts.

INTRODUCTION Traditionally, the recognition of tangible properties of data, such as objects and scenes [7], have overwhelmingly covered the spectra of applications in multimedia, computer vision and signal processing. In the recent past and partly fostered by social media, the understanding of subjective attributes (SA) of data has attracted the attention of many research teams at the crossroads of computer vision, multimedia, and social sciences. These subjective attributes include the ones assessed by individuals (e.g. safety [5], interestingness [2], Permission to make digital or hard copies of part or all of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for profit or commercial advantage and that copies bear this notice and the full citation on the first page. Copyrights for third-party components of this work must be honored. For all other uses, contact the owner/author(s). MM'17, , October 23-27, 2017, Mountain View, CA, USA. © 2017 Copyright held by the owner/author(s). ACM ISBN 978-1-4503-4906-2/17/10. https://doi.org/10.1145/3123266.3132057 evoked emotions [3], memorability [6]) as well as aggregated emergent properties (such as popularity [4] or virality [1]). Given the inherent abstract nature of such concepts, many new challenges arise when attempting to automatically detect such properties in multimedia data, or to perform SA-based large-scale retrieval, including: • Collecting huge amounts of annotations reflecting subjective judgments, as opposed to binary, objective annotations. • Designing features or learning representations specifically tailored for subjective attribute recognition. • Reliably evaluating the accuracy of detectors of subjective properties. • Translating (social) psychology theories into computational approaches to systematically understand human subjective attribute perception. This MUSA2 workshop aimed to gather high-quality contributions on the latest methodologies for understanding and recognizing intangible properties of multimodal data. In a nutshell, the focus of the workshop was on computational and experimental methods to learn, infer, or retrieve subjective attributes from multimodal data and their applications (e.g. subjective attribute-based advertising, retrieval and search), as well as to understand how and why humans perceive subjective attributes. The scientific scope of the MUSA workshop stands on three areas of the ACMMM'17 program: Multimedia and Vision (Understanding), Multimedia Art, Entertainment and Culture (Experience), and Social Multimedia (Engagement). The first, because many recent and highly relevant studies to the proposed to topic appeared in the computer vision community (memorability, virality, etc); These studies would be helpful to inspire truly multimodal research in understanding subjective attributes. The second, because subjective attributes such as aesthetics or evoked emotions are a priori strongly tied to the culture, and hence it is worth boosting research in this direction. The third, not only because some of these subjective properties are required to be socially -as opposed to individually -perceived, but also because it is worth investigating the perception of intangible properties from a psychological and sociological perspectives. Papers accepted at the MUSA workshop will be encouraged to submit and extended version to the associated ACM TOMM special issue1 . --- TOPICS This workshop is an opportunity for researchers and practitioners in the area of multimedia, computer vision, computational social science, and social-media analytics to present creative works in the area of subjective attribute understanding from multimedia data. More importantly, the multidisciplinary nature of this workshop allows submissions from research groups focusing on multimedia, computer vision, hci, experimental social and personality psychology, digital humanities, and cultural analytics. We called for papers on multidisciplinary topics regarding subjective multimedia analytics. These topics included: • Data collection/annotation and evaluation methods for subjective attribute studies, including active learning and crowdsourcing. --- PROGRAM The workshop program includes oral presentations, invited keynote presentations, and a poster session. We received 13 submissions, out of which we accepted 4 for oral (15 minutes) presentation (30% acceptance rate) and another 4 for spotlight (1 minute) presentation. All speakers will have the chance to further discuss with the audience during a 45-minute poster session. Each paper received 3 high-quality reviews. Submissions span a variety of different topics related to the workshop, including, among others: the impact of personality on media consumption, how head pose affects photo aesthetics, how people caption images they wish to share, interpretable models for sentiment-biased concept detection. This exciting scientific program will be completed with an invited talk. Ayman Shamma,Senior Research Scientist at FX Palo Alto Laboratory, and Saeideh Bakhshi Quantitative UX Research at Facebook, joined our workshop as keynote speakers, sharing their knowledge at the intersection of --- FUTURE EDITIONS In future editions, we would like to foster even more the multidisciplinary of our workshop. Welcoming such a wide spectrum of research fields could create an unprecedented opportunity to gather experts from domains that are traditionally disjoint, thus fostering interdisciplinary discussions and enabling the formation of solid collaborations between computer science and social science researchers. We will organize an interdisciplinary round-table where students and researchers will openly discuss the future of the rising field of intangible multimedia understanding, as: (1) How to actively engage social science experts in subjective attribute multimedia research, thus enriching the theoretical foundations of computational frameworks for subjective attribute detection. (2) How to design multimedia analysis tools and solutions that can support social psychology and computational social science studies. --- ORGANIZERS Our organization committee is very diverse in terms of expertise, topics, geographic location and seniority. •

Multimedia scientists have largely focused their research on the recognition of tangible properties of data, such as objects and scenes.Recently, the field has started evolving towards the modeling of more complex properties. For example, the understanding of social, affective and subjective attributes of data has attracted the attention of many research teams at the crossroads of computer vision, multimedia, and social sciences. These intangible attributes include, for example, visual beauty, video popularity, or user behavior. Multiple, diverse challenges arise when modeling such properties from multimedia data. Issues concern technical aspects such as reliable groundtruth collection, the effective learning of subjective properties, or the impact of context in subjective perception. The first edition of the ACM MM'17 MUSA2 workshop has gathered together high-quality research works focusing on the computational understanding of intangible properties from multimodal data, including visual emotions, user intent, human relationships, and personality.

Introduction Historians and sociologists aim at characterizing the social relationships between people of a period and region of interest. For this, they rely on a corpus of documents-which can be birth certificates, marriage acts, work contracts, or migration forms-which mention people and their social ties. From this corpus, they construct social networks on which they can follow a Social Network Analysis (SNA) [Fre04]. This type of dataset is best modeled using Bipartite Multivariate Dynamic Social Networks, where both documents and persons are modeled as nodes, containing additional information extracted from the original sources, such as the document time and location [Bor09]. A link represent a mention of a person in a document and encode the role of the person in the document (husband, wife, or witness in a marriage act for example). However, most visual analytics tools for social network either enforce a simple person-to-person model [BHJ09] or no model at all [SGL08], and lack complex interactions needed by social sci-entists. We thus present a new visual analytics system to explore Bipartite Multivariate Dynamic Social Networks, based on a visual query system that allows social scientists to easily filter and characterize specific groups of persons and patterns of interests. --- Visual Analytic System Our proposed tool allows exploring the data with two coordinated views shown in Figure 1: the node-link view and the map view. The node-link view allows users to explore the topology of the graph, while the map allows seeing the geolocation of the documents. Two documents are linked if they share at least one person in common. This way, the map allows to rapidly see in which areas people are interacting. The two views are coordinated and selecting a person or a document in the bipartite view highlights her/him in the map view and vice versa. Moreover, every attribute in the data can be selected to show a plot of its distribution. When selected, the nodes are colored in the two views according their attribute value. --- Visual Query Our visual query system is similar to VERTIGo [CSIP21] and [SW13] for topological queries, but enforces the bipartite network model and allows more complex attribute constraints. It is based on the Neo4j database [neo] and the Cypher language. In contrast to other visual query systems that hide the raw script request, we show both representations (visual and textual) and enforce a one-to-one synchronisation between the two. This way, users can start to build a query visually, and modify it later textually for very complex constraints. Users can build two types of constraints: Topological: An interactive node-link diagram let users construct patterns visually. They can build documents or person nodes by clicking on the canvas, and links by clicking and dragging between nodes. They can choose any of the roles of the dataset when creating a link, along an ANY link type, representing a link which can be any of the existing role. Attributes: Widgets let create attribute constraints on the created nodes, using the dynamic queries principle [Shn94]. The widgets designs differ according to the attribute type: text input for nominal attributes, checkboxes for categorical and double sliders for numerical ones. These simple designs allow social scientists to easily make attribute constraints. When modifying the query visually or textually, the results are directly highlighted in the two views, and summary results are shown along an occurrence table and attribute distribution plots. --- Use Cases We elaborated our system in collaboration with historians and sociologists who have a variety of datasets: marriage acts, birth certificates, construction contracts, work contracts and migration forms. The questions they had on their data often consisted in extracting groups of people or finding document and persons with specific patterns, and studying their characteristics in respect of the rest of the network, or to compare two groups of nodes between them (see supplementary material). We describe here a use case in collaboration with one historian Here are some of the questions he had that we collected from him, which can be answer with queries: 1. Find the pairs or persons who are mutually guarantor to each other in two separate construction documents. 2. Find the persons who are collaborating with the Zo family. --- What are the characteristics of the construction documents in Torino, and who are the people working there. 4. Who are the persons with 3 different roles: Guarantor, Associate and Approbator. Figure 2 shows the visual representations of the constructed queries to find the patterns one of our collaborator is interested in. After he constructed the queries, he was able to explore the results in the two views, as shown in Figure 1. Figure 3 shows the results of the four queries with an occurrences table (left) or attribute distributions (right). It shows that the constructions in Torino are mostly military (mil) and civil (civ). The Zo family collaborates with other persons mostly in Torino (but not only). Finally, the persons who have the 3 different roles only come from Biela (BI). --- Conclusion We present a new visual analytics for Bipartite Multivariate Dynamic Social Networks constructed from historical sources. It allows to explore the topology of the network and the localization of the documents, along node attribute distributions, including time. Moreover, the interface includes a new visual query system. Using it, social scientists can isolate specific patterns or groups of entities and look at their positions in the network, along with the values of their attributes compared to the global distributions. We demonstrate the power of the query system with one real-world use case, showing that it can be used to answer sociological questions.

Figure 1: Proposed interface, used to search for people who are mutually guarantors to each other in construction contracts [CR18], retrieved from dynamic visual queries. (A) shows the visual query the user created. (B) shows the bipartite node-link view and (C) the document map view. (D) shows the query results panel where one attribute is selected, showing its distribution.

Introduction: Increased life expectancy has resulted in population aging and subsequently entails addressing the needs of older adults. Shifting family structures from multigenerational to nuclear have had a significant effect on the older adults' livelihood and their ways of interaction with community members. This research aims to comprehend the relationship between neighborhood context and older adults' quality of life (QoL) in Nepal. Methods: A total of 847 non-institutionalized older adults (≥60 years) from eastern Nepal were interviewed in 2021. The QoL was measured by13-item version of the Older People's Quality of Life questionnaire (OPQOL-brief), and each item was measured on a 5-point Likert scale. The OPQoL mean score < 3 was recoded as low, and ≥3 was high QoL. Ethnic diversity, monthly income, connection with family, friends, and neighbors, cultural connection, residential instability, and accessibility were measured to see the effect of neighborhood context. --- SUCCESSFUL AGING AMONG OLDER PERSONS IN VIET NAM Yasuhiko Saito 1 , Nguyen Vu 2 , and Linh Dang 2 , 1. Nihon University, Chiyoda-ku, Tokyo, Japan, 2. Institute of Population, Health and Development, Hanoi, Ha Noi, Viet nam The present study aims to explore the prevalence and correlates of successful ageing among Vietnamese older persons. Data used for this study is from the baseline survey of the Longitudinal Study of Ageing and Health in Viet Nam (LSAHV). LSAHV is a nationally representative survey of older persons aged 60 and above in 2018-19 with 6,050 respondents. Face-to-face interviews were conducted using structured questionnaires and tablets. Rowe and Kahn's definition was used to study successful ageing among older persons in Viet Nam. Study sample size was 4,370 older persons. Logistic regression was employed to examine the association of sociodemographic and lifestyle factors with successful aging among older persons. The prevalence of Vietnamese older persons meeting criteria of successful ageing was 16.2% at the time of baseline survey. The percentage of older persons reporting no major diseases, no disability, high cognitive function, high physical function, and engagement with life was 35.0%, 88.5%, 55.1%, 77.9%, and 79.7%, respectively. Logistic regression analysis showed that older persons who were younger, male, having higher education level, and often doing physical exercise were likely to be successful

a facility, or legal punishment of someone they care about. Given these findings, the RISE team engaged in a lengthy outreach and planning phase with state and local prosecutors, elder victim service providers, restorative justice experts, and researchers, to design a novel intervention, using RISE in conjunction with drug court, to divert cases involving substance using defendants alleged to have mistreated an older person. This session will describe the extensive planning and design process and provide a case study analysis, which suggests that a combination of drug court's in-patient treatment for the defendant, services for the victim, and RISE's focus on restorative justice approaches that repair breached relationships reduced harm and benefited the older person, the defendant, and their families. Implementation of RISE in partnership with the criminal justice system carries important implications for the integration of restorative justice practices in some EA cases.

I. INTRODUCTION When is the last time you changed your profile information such as name, description and location on social media? If you change jobs, you will add a new job title to the description on your profile. If you move, you will update your location. If you are separated from your partner, you will change and indicate that you are now looking for a new partner. As we can see, social media users change their profile information for various reasons. Changes in their lives will affect their profile information. We are interested in discovering the regularity of profile information changes. Twitter 1 is one of the most popular social media which has been frequently used by many global users in recent years. The profile is used to better understand the user's background on Twitter, and the user can freely change it at any time. Twitter is used all over the world, and the timing of changing profile information may vary depending on the language sphere. Also, when changing the profile, there is a possibility that keywords related to changes in specific events and living environments are inserted. Many researchers have been attempting to analyze and utilize the profile information on Twitter. Semertzidis et al. [1] analyzed the profile information in order to understand what Twitter users choose to expose about themselves in their profile information. Mislove et al. [2] used the profile information in order to compare the Twitter population to the U.S. population along three axes (geography, gender, and race/ethnicity). 1 https://twitter.com/ Alowibdi et al. [3] and Vicente et al. [4] used the profile information to conduct a gender classification on Twitter. Uddin et al. [5] used the profile information to understand types of users such as humans, bots, spammers, businesses and professionals. Vainio and Holmberg [6] used the profile information to identify the user's research field. Previous study has assumed that the user's profile information remains unchanged. However in reality, users often change their profile information. We focus on user's profile information changes and analyze the timing and reasons for change on Twitter. In this paper, we address the following two research questions: RQ1 When do users change their profile information on Twitter? RQ2 What keyword should be inserted when the profile information is changed? The results indicate that the peak of profile information change occurs in April among Japanese users, but there was no such trend observed for English users throughout the year. Our analysis also shows that English users most frequently change their names on their birthdays, while Japanese users change their names as their Twitter engagement and activities decrease over time. --- II. DATA In this study, we use Japanese (ja) and English (en) retweets on Twitter collected from 2015 to 2016. The details of these data are shown in TABLE I. These data were collected using the Twitter Search API2 . Normally, tweets collected using the Twitter Sample Tweets API 3 are used in such study. Tweets we can collect with this Sample Tweets API are less than 1% on Twitter. Thus, we used retweets collected using the Search API 4 because we need more tweets. Since many users are using retweets [7], we assume that sampled "retweeting" Twitter users are same as usual Twitter users. For example, users registered in June 2016 cannot change their profile information in March 2016. We select users in 2015 data and monitor their profile information in 2016 data. For analysis, we use only the retweet date ("created at") and the user object 5 among tweet objects 6 . In addition, we focus on "name", "description" and "location" as user's profile information, unlike previous studies [7], [8] focused on "screen name". A real name or a nickname may be written in the name field. It may include a current status (e.g., holiday and busy). A brief self-introduction may be written in the description field, and an actual residential area may be written in the location field. In our analysis, the retweet date is converted into Japan Standard Time (JST) in Japanese and English retweets. For example, in the analysis on the United States, the date will shift due to the time difference. --- III. RESULTS AND ANALYSIS --- A. RQ1: When to Change User's Profile In this section, we investigate the trend of the date users change their profile information. In Japan, new lives (e.g., university admission and employment) often start from April. If life changes affect profile information, we will observe many profile information changes occurring in April. In Fig. III.1, we show the trends of profile information change dates in Japanese and English. The vertical axis indicates the ratio of users who changed their profile information on that day. The denominator of the ratio is the number of users retweeting on that day. The description was the most changeable in both Japanese and English. As far as observing the results, Japanese users more frequently change their profile information over English users. We found that a peak occurs on April 1 in Japanese. This may be the effect of the new life or April Fools' Day. There was no change trend in English as much as Japanese, but a small peak of name change was found in November. This is consistent with the presidential election in the United States. For transient events like April Fools' Day, users may quickly restore their profile information. We investigated when the users restored the profile information like A → B → A. The result is shown in Fig. III.2. The vertical axis indicates the retweets whose profile information was restored on that day. The name was the most restorable in both Japanese and English. We found that a sharp peak occurs on April 1 in the name of Japanese. This shows that a special name is used only on April 1. In other words, it seems that the April Fools' Day influence was greater than a new life starting. We also found that a peak occurs on November 17 in the names in English. This may be the effect of Halloween. The second peak was November 98 in English. This day is consistent with the date of the presidential election in the United States. --- B. RQ2: Keywords Inserted When Changing Profiles In the previous section, we only investigated the date when profile information was changed. In this section, we investigate what kind of keywords are inserted when changing profile information. In order to extract the inserted keywords when changing profile information, we make character strings before and after the profile change, and extract the difference of the strings as a keyword. In this analysis, we only report changes in the name. A universal noun and a place name appeared in the description and the location but this was not a characteristic result. 1) Japanese Retweets and Users: Keyword extraction was executed as follows. First, we use Python class "difflib.SequenceMatcher" to extract common strings of character strings before and after the profile change. Next, we divide the string after the profile change by the common strings. Each divided character string is an inserted keyword candidate. We regard candidates with lengths greater than four characters as inserted keywords. For example, the inserted keyword is "固 定ツイ" when the string before the profile change is "しまし ま@低浮上" and the string after the profile change is "しま しま@固定ツイ". In TABLE III, we show the top 20 keywords inserted when changing the name in Japanese. Characteristic keywords are underlined. The keywords in the table were sorted by the number of occurrences (retweets), and the number of unique users was also shown. English translation by the authors is added to the table. Many users are inserting "低浮上" (Teifujo; Activity goes down) and "固定ツイ" (Kotei-tsui; Pinned tweet). These words are often used by young people, especially students. Students cannot make time to tweet when they are busy, such as when they are preparing for an examination. The users use "低浮上" to indicate to friends that their Twitter engagement and activities decrease over time. The users also describe recent status to the pinned tweet9 , and appeal contents to friends that cannot be described by the name alone. In such a case "固定ツイ" is often inserted. We also observed the results for each month. The top five keywords were largely fixed, but time specific keywords such as "ポケモンGO" (Pokémon Go), "の名は。 " (Substring of movie title "Your Name."), "ハロウィン" (Halloween) and "クリスマス" (Christmas) appear in the top 20 keywords. Users add both seasonal event names and their own status to their names. 2) English Retweets and Users: Keyword extraction was executed as follows. First, strings of character strings before and after the profile change are divided into words with space characters. Let an inserted keyword candidate be the word that appeared in the string after the profile change but did not appear in the string before the profile change. We regard candidates as those including alphabet characters and lengths greater than four characters as inserted keywords. For example, the inserted keyword is "sunny" when the string before the profile change is "It's raining today." and the string after the profile change is "It is sunny today.". In TABLE IV, we show the top 20 keywords inserted when changing the name in English. Characteristic keywords are underlined. The keywords in the table were sorted by the number of occurrences (retweets), and the number of unique users was also shown. Many users insert keywords related to birthdays (e.g., BIRTHDAY, birthday and BDAY). This is a trend not observed at all in Japanese. We also observed the results for each month. The top five keywords were largely fixed, but time specific keywords such as "spooky", "Christmas" and "Merry" appear in the top 20 keywords. September to November 2016 was the presidential election season in the United States. During this season, keywords related to elections such as "Deplorable", "VOTE" and "Trump" appeared in the top results. --- IV. CONCLUSION We focused on user's profile information changes and analyzed the timing and reasons for change on Twitter. The results indicated that the peak of profile information change occurs in April among Japanese users, but there was no such trend observed for English users throughout the year. Our analysis also showed that English users most frequently change their names on their birthdays, while Japanese users change their names as their Twitter engagement and activities decrease over time.

We can see profile information such as name, description and location in order to know the user on social media. However, this profile information is not always fixed. If there is a change in the user's life, the profile information will be changed. In this study, we focus on user's profile information changes and analyze the timing and reasons for these changes on Twitter. The results indicate that the peak of profile information change occurs in April among Japanese users, but there was no such trend observed for English users throughout the year. Our analysis also shows that English users most frequently change their names on their birthdays, while Japanese users change their names as their Twitter engagement and activities decrease over time.

The site director instructed KY to do a preoperative history and physical for a 77-year-old woman, Ms B, who was diagnosed with a left-sided colon mass after coming to the emergency department with a painful obstruction. During the examination, Ms B informed KY that she needs to see a traditional medicine person for a ceremony before her operation. KY's review of Ms B's lab values and imaging suggests that Ms B's operation needs to happen soon to minimize her risk for perforation. Unsure what to do, KY found NZ and asked why Ms B needs a healer. NZ explained the value of the ceremony to KY and worked with staff to locate a traditional healer. --- Commentary The majority of university-tribal work has centered on research, and, unfortunately, there is a long-standing history of exploitation with sweeping negative consequences. 1,2,3,4,5 Community-based participatory research (CBPR) is changing the paradigm of "helicopter research" by drawing upon community members' skills and by more equitably distributing risks and benefits of research. Uptake of CBPR principles demonstrates a much-needed institutional makeover of tribal research engagement. Just as university researchers are reformulating how to conduct responsible research, so university clinical educators have an obligation to reframe the health sciences curriculum and ensure that the tribal health facilities are equal partners in its implementation. Since 1997, the College of Medicine at the University of Arizona has run the Rural Health Professions Program (RHPP, directed by the second author) to prepare a culturally competent workforce for practice in Arizona's underserved communities. The RHPP has graduated many students, Native and non-Native alike, who have become practicing clinicians at partner tribal facilities. Outstanding feedback from students, preceptors, and tribal members has helped the program thrive for more than 20 years. Although numerous publications share recommendations on how to conduct tribaluniversity relationships for research, 1,5,6,7 we could find none that outline how to build a responsible tribal-university educational partnership. Here we consider the 3 key principles that have fostered the program's success: (1) the development of relationships rooted in trust and equality, (2) the commitment to a rigorous educational experience, and (3) the investment of resources by the academic institution. --- Trust and Equality Relationship building with tribes involves historical and political challenges that take an immense amount of trust and time to overcome. 3 The RHPP has relied upon general guiding mechanisms to confront these challenges. In particular, by personalizing communication and travel and endorsing a collaborative approach to management, the program has built relationships infused with trust and equality. Travel and communication. Working with AI/AN partners often requires rural, remote travel. 1,2,4 Academic institutions should plan for extended timelines and dedicated, frequent personal communication. 1,2,5 The RHPP director visits partner sites, which sometimes entails a full day of travel, at least once a year to maintain the personal relationship with each partner. Email and teleconferencing maintain interim communication, but tribes greatly value the person-to-person relationship. Collaborative management. Too often, tribal entities have not been viewed as full partners in tribal-university partnerships. 1 This antiquated thinking hinders any enterprise, as university-tribal interactions only succeed when each partner functions as an equal. Tribes are sovereign nations with the autonomy to make their own decisions. The RHPP respects tribal sovereignty by allowing the partner tribal health services facility to set up the process for student entry. Each site has its own established protocol and its own requirements for background checks, fingerprinting, and vaccination records that the RHPP helps the students complete because it supports the tribe's autonomy to vet who works with tribal members. We recognize that tribes want clinical education that protects and benefits their patients just as much as the university wants to provide rich educational opportunities for its students. This sense of reciprocity is similar to a tenet that a growing number of universities hold for research. 3,4 With equal participation in the relationship comes mutual benefit. --- Rigorous Education and Training The RHPP is under obligation to make the rotation at the tribal facility equal to the home campus rotation. These rotations are neither "vacations" for students nor a chance for them to cross "red tape" and practice above their level. We believe that several key components have made the program academically rigorous and thereby fruitful for both partners: • The RHPP is competitive. The rotations with AI/AN communities are not mandatory, and there are a limited number of available assignments. Currently, there are only 28 positions for a class of 120 students. RHPP students go through an application process to rotate at tribal facilities. This process leads to a self-selected group of students who are highly motivated to conduct their training with the AI/AN community. • Students are sent for clerkship rotations. These rotations are not electives. Students must obtain the same educational experience, hours, and case volume as if they were at the main campus institution. They are evaluated under the exact same rubric as the university hospital sites. The tribal facility preceptors have just as much import for their grades as any campus faculty. This arrangement leaves no room to slack and helps the students arrive on site with the same learning goals and respect that they bring to the rest of their academic curriculum. • The students undergo extended preparation. They participate in a 16-week seminar series on issues in rural health with dedicated AI/AN topics. Upon arrival, each tribal facility runs a self-designed orientation to provide tribalspecific history, sensitivity training, structure, and advice on how to work with their patients. This kind of preparation helps students like KY in the scenario manage cross-cultural conflicts between Western and traditional medicine and integrates philosophical teaching into hands-on practice. As representatives of the academic institution, students like KY then show tribal members a favorable impression of visiting clinicians, which is important for the restoration of medical trust. • Rotations are controlled by the tribal facility. We recognize that clinical teaching demands a major investment by the clinical instructors at the tribal facility, many of whom are overworked and dealing with stressors unique to their patient population. We structure the student rotations such that no one site is overburdened, and at each site there are gaps between student rotations as a way for preceptors to recuperate. By controlling when and how often students rotate, the preceptors can maintain a higher level of enthusiasm and investment in the students. • The RHPP is a blend of AI/AN and ethnic-majority students. This mix allows the students to be peer teachers and collaborative colleagues. As seen in the scenario, NZ's knowledge benefits her classmate and their patients and additionally demonstrates the value of enrolling AI/AN students in medical school. --- Institutional Commitment Academic institutions with health professions educational programs have a duty to invest in tribal health care infrastructure and sustainability. Each level of medical training and every health discipline should participate. We have described the RHPP, which functions at the medical student level. Two residency programs (Family Medicine and Surgery) at the University of Arizona College of Medicine have rotations with tribal facilities as well. Several other institutions have also recently developed programs that place fellows in clinical positions at tribal facilities. 8 Since there is a physician vacancy rate of over 25% in AI/AN communities, these continuity models are intended to reduce local physician staffing gaps. 8 There are nursing student equivalents of these immersion programs as well. 6 These programs represent several institutions' commitment to building the workforce of clinicians who know how to navigate the range of culturally sensitive issues and to narrow AI/AN health disparities. 8 These institutions have allowed their faculty the time it takes to engage tribal entities in the provision of education and clinical care. 6,8 They have also prioritized recruitment of AI/AN students and provided additional support for retention so that they can complete their education and enter practice. 8 Tribal-university research infrastructure requires substantial time and resources, and the same is true of clinical educational infrastructure. 3 There are financial resources that the university pledges in these partnerships. The university has to support a faculty member with adequate full-time employees to devote to a tribal-university educational program. 1 Salary support must be allocated to a program coordinator, as the coordinator is instrumental in managing the nuanced logistics at each tribal site. The university must also account for student expenses and be prepared to reimburse the tribe for housing and transportation. The university investment is not simply financial. Expertise and technical assistance are fundamental to program success. It is the responsibility of the university, usually by way of the program director and staff, to verify that the doctors on site want to teach and can maintain high standards, to be selective of the students that are sent, to properly prepare and evaluate students, and to conduct program evaluation by soliciting feedback from all stakeholders. --- Conclusion A health professions educational relationship can flourish between tribes and academic institutions when it starts with true relationship building so that the partnership is collaborative and equal. The educational curriculum should be held to a high standard so that academic rigor is preserved and AI/AN patients receive culturally sensitive, quality care. The academic institution must invest financial resources and technical assistance to build sustainable infrastructure. These 3 principles-of relationship building, rigorous education and training, and institutional commitment-can generate a partnership that enhances health professions education, fills gaps in clinical care, fosters the AI/AN clinical pipeline from student to clinician, and builds a diverse workforce dedicated to improving the health of AI/AN communities. --- Conflict of Interest Disclosure The author(s) had no conflicts of interest to disclose. --- The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA. Copyright 2020 American Medical Association. All rights reserved. ISSN 2376-6980

Many health professions education institutions exist on land once inhabited by American Indians and Alaska Natives (AI/AN). Land acknowledgment by these academic organizations is helpful, but collaborative support of AI/AN health is also needed. Because tribaluniversity partnerships in education are fewer than in research but just as important, this article considers health professions schools' responsibilities to offer students clinical rotations on tribal lands and to recruit AI/AN students. Such investment expands student educational opportunity, diversifies clinical workforces, and helps tribes improve health infrastructure and sustainability. This article also offers an adaptable roadmap for building such partnerships.After months of processing paperwork and permissions between the medical school and tribal health facility, NZ and KY, 2 medical students, finally start a surgery clerkship on tribal land. In prior weeks, they attended seminars to learn some of the history and culture of this area of the Southwestern United States. NZ grew up on the Navajo reservation and KY grew up in Ohio and has never been on a reservation. Both students are interested in rural health and hope this clerkship will help them make career decisions.

previously noted that 4% of patients dying behind bars had a diagnosis of dementia but that this was likely to be a conservative estimate (Prisons and Probation Ombudsman, 2017). Robust mechanisms for epidemiological purposes in prison are often lacking, relying instead on retrospective analysis of healthcare data. The quality of such data is contingent on the effectiveness of the healthcare consultation as a tool to detect dementia but also the frequency of consultations. In the UK, for example, prison recommendations are that a prisoner has health screening at incarceration yet this may not routinely occur resulting in an incomplete data set from which to produce national demographics (Health and Social Care Committee, 2018). In 1990, the United Nations Human Rights Office of the High Commissioner established basic principles for the treatment of prisoners including that "Prisoners shall have access to the health services available in the country without discrimination on the grounds of their legal situation". Although increasing attention has been given to the scale of the problem and methods to address it in the general, non-incarcerated population, little research exists within imprisoned populations. Previous publications in International Psychogeriatrics have highlighted the mental health needs of older prisoners (Baidawi, 2016) and older remand prisoners (Davoren et al., 2015) but what are the best ways to support and care for prisoners at risk of developing dementia or who have developed dementia? These questions were explored in a scoping review undertaken in this volume by du Toit and colleagues (2019). Their review identified a lack of support and services for older prisoners and those with dementia (du Toit et al., 2019). A number of recommendations were made based on the findings from the review. Given that prisoners may lack insight into their cognitive impairment or may be reluctant to report them, screening for cognitive impairment for older prisoners was recommended on a regular basis and on admission. Given the recognised demographic differences between incarcerated and non-incarcerated populations, Du Toit and colleagues suggest screening for age related conditions such as dementia at the comparatively young age of 50 or 60 years of age (Cloyes et al., 2015, Rothman et al., 2018). Screening for dementia would not be without its challenges. There are difficulties in accessing specialists to undertake dementia assessments in the prison setting. Clinicians working in prisons and prison officers need training to undertake basic cognitive screening to identify those who may require specialist assessment. To our knowledge, there are no dementia screening tools which have been validated in a prison setting. To further complicate the challenge screening would need to take into account the high rates of learning disability and low literacy amongst prisoners (Loucks, 2007, Prison Reform Trust, 2017). Screening would need careful consideration to ensure a diagnosis of dementia did not have unintentional adverse effects. Significant levels of distrust have been found to exist amongst prisoners towards healthcare providers and so an ostensibly well-intentioned screening programme may adversely affect the therapeutic relationship between prisoner and staff (Howerton et al., 2007). The potential of being diagnosed with a mental illness carries significant fear amongst prisoners and may reduce future health-seeking behavior (Howerton et al., 2007). In our clinical experience, a new diagnosis or treatment may have unintended consequences, including loss of social contacts or perks. For example, a prisoner started on a new treatment may be involuntarily moved from the support of their cell-mates to a wing where medical or social care can be better delivered (Burtonwood andForbes, 2019c, Burtonwood andForbes, 2019a). The ethical issues surrounding screening for dementia are also complex. Ensuring that consent is given freely by an incarcerated individual (who may also have dementia) is challenging. Low literacy levels and high rates of learning disabilities would mean that provision of information and checking of understanding would have to be scrupulous to ensure informed consent had been obtained (Loucks, 2007, Prison Reform Trust, 2017). In order to be ethically viable, the benefits to the prisoner would have to be significant and unequivocal. At the moment, care for patients with dementia in prison appears to be lacking. Although screening would bring much-needed attention to the issue and clarity to the scale of the problem, there are significant ethical challenges to overcome. Possibly the priority is to improve care pathways for those with known dementia so that the benefits of screening become clearer. Indeed, Du Toit and colleagues (2019) go on to explore some of the alternative approaches. Training of prison staff, clinicians and prisoners was also recommended in the review to improve the care of prisoners with dementia. Studies in community settings such as residential aged care, indicate that residents with advanced dementia have long term symptoms of pain and agitation indicating that even in environments developed for people with dementia, access to specialist support can be lacking (Sampson et al., 2018). Providing an individualised approach to care in a prison context appears a much greater challenge than in residential care. A number of strategies have been proposed in the literature to tackle this. Penrod et al have described a novel programme aimed at prison security staff who have daily contact with prisoners and are well-placed but often untrained to spot the telltale signs of declining health (Penrod et al., 2016). Through action research, an aide-memoire was developed to assess for changes in memory, grooming and increasing social isolation; symptoms often seen in dementia. Although developed to identify prisoners approaching end of life, such an approach may also prove valuable in identifying prisoners with dementia. Training younger prisoners was an innovative approach identified in the review that can benefit both the younger prisoner and the person with dementia. These interventions need to be implemented with support and training for the younger prisoner and careful selection and supervision of prisoners. The lack of suitability of the physical prison environment was another theme in the review (du Toit et al., 2019). Again, these challenges occur in the residential aged care context (Moore et al., 2011). As the Prison and Probation Ombudsman of England and Wales notes: "the prison estate was designed for young, fit men and not for its current ageing population" (Prisons and Probation Ombudsman, 2017). The review identified potential benefits of having separate, specialised units for prisoners with dementia. Again, this is not often available and has cost implications, but the comparative cost of retrofitting and modifying existing prison environments need to be examined. This needs to be balanced with the potential risk of moving prisoners away from family and disturbing routines which can be particularly unsettling for people with dementia. There are simple environmental modifications that can be low cost but aid in orientation and reduce anxiety. The prison environment may also be key to reducing the future burden of dementia. For example, smoking cessation programmes may be an important public health measure to reducing the rates of dementia in younger generations of prisoners. Where appropriate, helping prisoners maintain family contacts may be an inexpensive yet beneficial intervention. It is rarely possible for a prisoner to receive calls and so maintaining contact with the outside world is contingent on a prisoner's ability to organise permission to make outgoing calls; which may be difficult for a prisoner with dementia. Assistance from family liaison officers or chaplaincy staff may help to reduce social isolation which can be especially detrimental to those with dementia. Parole or early release of prisoners with dementia was also recommended in the review, but again there were obstacles including finding suitable alternative accommodation and establishing risk assessment protocols. Many countries have mechanisms whereby prisoners approaching the end of life can be considered for early release on compassionate grounds. Dementia is a life-limiting illness yet the practicalities of early release of prisoners with dementia are complex. This may be partly due to the fact dementia may go unrecognised as a life-limiting condition and partly because the prognosis and trajectory may be too difficult to predict (Iacobucci, 2019). Of 48 prisoners released on compassionate grounds near the end of life over the last 5 years in England and Wales, none included dementia as the primary reason for release (Burtonwood and Forbes, 2019b). Recommendations from the review, however, need to be considered with caution. Du Toit and colleagues (2019)acknowledged the dearth of robust research in these settings and so undertook a scoping review, a preferred approach in emerging research areas, incorporating grey literature, commentaries and opinion pieces. Only five of the 35 papers included were based on empirical research including four qualitative studies. Of these five studies, findings included that prisoners did not seek help for cognitive difficulties and that peer support or buddy systems for older prisoners could provide a positive role for both the older prisoner and the peer supporter. With the exception of one conference paper from Malaysia, the remaining 34 papers were from Europe, North America and Australia showing a lack of literature in low and middle income countries. As the review was limited to English language papers, however, there may work in this area that was excluded. Research into dementia is considerably underfunded compared with other life limiting conditions. The ratio of publications on neurodegenerative disorders compared with articles on cancer is only 1:12 (Alzheimer's Disease International, 2018). In the UK for every £10 spent on health and social care for patients with cancer, £1.08 is invested in research compared with only £0.08 in research on dementia (Luengo-Fernandez et al., 2015). A similar picture occurs in the prison context with low levels of research funding from national health research bodies with approximately 0.1% of health research finding in North America focusing on health in the criminal justice system (Ahalt et al., 2015). Consistent with low levels of research funding, there are many obstacles to conducting research in these vulnerable populations. Qualitative research methods amongst prisoner cohorts can take years longer than similar studies in the non-incarcerated population (Wakai et al., 2009), partly as a result of the additional ethical checks and balances needed for this vulnerable population. The Declaration of Helsinki indicates that medical research should only involve vulnerable groups if the research relates to their health needs and cannot be conducted in a non-vulnerable group. Ethical guidelines and Acts such as the UK's Mental Capacity Act (2005) provide a framework for enabling vulnerable groups to participate and benefit from research. To provide appropriate dementia care to prisoners it is vital that research is conducted in these populations to develop an understanding of effective interventions in this unique context. Without improved research and funding to improve the care of prisoners with dementia, we are breaching the human rights set out by the United Nations to offer access to health services without discrimination.

As the population ages, the prevalence of dementia is rapidly increasing. Within the prison system, these demographic changes are also occurring. Socio-economic inequalities, poorer health and lower life expectancy mean age related diseases occur earlier in prisoners compared to the agematched, non-incarcerated population (Cloyes et al., 2015, Rothman et al., 2018). These factors are likely to result in high rates of dementia in prison, however, dementia prevalence is not well documented and may be poorly identified in correctional facilities (Brooke et al., 2018). Currently, in England only 147 prisoners are recorded as having a diagnosis of dementia (NHS England, 2019). Recognition of prisoners with cognitive impairment can be challenging. Lack of variation in day to day activities and rigid routines might allow better compensation for cognitive impairment and reduce the outward signs of dementia (Ginn, 2012). A mistrust of prison healthcare staff or limited access to healthcare services could delay diagnosis. Where dementia manifests as lack of conformity, resistance or challenging behaviour, deficiencies in staff training or awareness may mean this is viewed as misdemeanour rather than recognised as cognitive impairment (Health and Social Care Committee, 2018). Thus, most estimates of dementia prevalence behind bars are likely to under-represent the true figure. For example, the Prison and Probation Ombudsman (PPO) of England and Wales has

Results The results reveal that older people have no alternative but to provide care and support to their ill children, and following the death of their children to become parents again in taking care of the orphaned grandchildren. This is a particularly big challenge in a country like Malawi, dependent on hand-hoeing for subsistence agriculture, where food production requires people who are physically strong. 79% of older people taking care of HIV/AIDS patients or orphans were found to have limited or no information about HIV/AIDS. 31% were dependent on relatives for support, while 69% sustained themselves through piece work, small business or farming. --- Conclusion Elderly people need more resources and assistance to enable them to fulfil their vital role in caring for HIV-AIDS orphans. They are also in critical need of more information about HIV-AIDS, as many are sexually active with multiple partners, and preventive information is currently not reaching this important section of the community. --- Introduction. According to the World Health Organisation and the United Nations AIDS Programme. 34.4 million people were living with HIV/AIDS as of the end of 2008 and AIDS had resulted in more than 25 million deaths since the first clinical evidence was reported in 1981 1 . The high incidence of HIV/AIDS in the sub-Saharan African region is leading to a devastation of individual and family life. Studies in Eastern and Southern Africa indicate that women and children are AIDS' greatest victims 2 . In Malawi according to a Ministry of Health 2007 report, about 970,000 people are living with HIV, with new infections estimated at 90,000 per annum. These figures pose an enormous challenge in terms of care for people who will soon develop AIDS, some of whom will die leaving orphans --- Impact of HIV and AIDS on the eldery: A case study of Chiladzulu district --- Anthony P. Sefasi Catholic University of Malawi in need of support 3 . Throughout sub-Saharan Africa, older people -particularly older women -are a key resource for combating AIDS and alleviating its impact 3 . At household level, they are the persons who provide daily care for both AIDS patients and children left orphaned by the pandemic. These older people have taken on new roles by providing care and financial support to orphaned children, playing child-rearing roles within their extended families and continuing their more traditional roles as advisors to their adult children and grandchildren. They largely absorb the enormous additional burdens placed on families and society by the AIDS pandemic. According to a study in Zambia(1996) 57% of primary care givers were grandparents. Of these, 37% were between 60 and 85 years of age. This 'skip-generation parenting' accounted for 45% of the cases in another study of 1996 in Zimbabwe. According to Kadzandira (2007) in countries that have a high prevalence of HIV and AIDS such as Malawi, older people are increasingly playing the principal role of caring for younger adults sick with HIV and AIDS and for orphaned grandchildren 4 . The World Health Organisation (2002) reported that 30% of all households in sub-Saharan Africa were headed by an older person. In Namibia, South Africa and Zimbabwe, 60% of orphans live with their grandparents. Up to 56% of carers for orphans and vulnerable children in Namibia are more than 60 years old 5 . In terms of older people themselves being infected with HIV, UNAIDS (2005) reported that 2.8 million adults aged 50 years and older were living with HIV worldwide, representing 7% of all cases. Since there have been few studies of this kind in Malawi, we investigated whether older people in Malawi -who account for 6% of the general population -are undergoing similar challenges in this era of HIV and AIDS. --- Objectives The main objective of the study was to establish the impact of HIV/AIDS on older people in Malawi using Chiradzulu district in southern Malawi as a case study. --- Methods. Design We used both qualitative and quantitative approaches. Using in-depth interviews and focus group discussions, we collected data from 116 older people who were found to be taking care of HIV and AIDS orphans. We conducted the study between January and April 2010. Questions and discussions during data collection centred on personal information, numbers of children, possible causes of death of the orphaned children's parents, the burden of care being undertaken, and mechanisms used to cope with this. --- Study population and Site This study was conducted in Chiradzulu district in the Southern part of Malawi, a district with a high HIV/AIDS prevalence. The age criterion for inclusion in the study was 60 years. (For individuals who did not know their age, we estimated it using major historic events -eg 'At what stage in your life did Dr. Kamuzu Banda first return to Malawi?') The Group Village Headman and a child protection worker identified households where an older person was taking care of a terminally Ill HIV/AIDS patient or taking care of HIV/AIDS orphaned grandchildren. Once we knew the number of older people for possible inclusion per village we employed a simple random sampling technique to come up with our sample. Once an individual had consented to participate, s/he was interviewed using a questionnaire. Another sample was identified for focus group discussion, with 12 participants being drawn from different villages in the district. --- Results Roles played by older people in caring for a sick relative from within the household 40% of the respondents had been guardians of a sick child or grandchild; while 38% reported having been providing financial and other support to the sick relative. 22% were recorded to have been providing palliative care and spiritual counselling to the patient prior to their death. --- Challenges faced by older people taking care of orphans. 59% of the sample reported that they had difficulty sourcing money for orphan grandchildren's school uniform, for food and for meeting hospital bills in case of illness. 22% of the sample indicated that taking care of orphaned grandchildren halted their own development because they were forced to be at home looking after the sick grandchild or taking the child to hospital. They particularly stressed that they had to spend their reserved resources to make the lives of their grandchildren better, while impoverishing themselves in the process. 19% of the respondents indicated that while they were able to support their orphaned grandchildren now, they were worried about what will happen to these children following their death; as to who will support the children, who will look after them when they are sick, and who will remind them to take their anti-retroviral treatment without fail every day. --- Challenges faced during illness and death of a family member. 43% of the respondents reported spending all the money they had on medication (which included both western and traditional) and on buying food. 44% of the respondents indicated having sold property to get money for meeting expenses both for medication and for the funeral ceremony. 12.5% indicated losing direct support from the deceased (who had been working and supporting them, financially and otherwise, before their illness made this impossible). --- Economic impact of HIV and AIDS on the Aged 55% of the enrolled elderly people were affected through death and sickness of their children who gave them support and care. One grandmother commented; "All the money had been used to care for my children. They all died and now I have the responsibility to look after the grandchildren." There was regret that an economically productive person had been lost by the household. Generally, the longer the illness dragged on, the more resources were depleted. For example one old lady recounted her ordeal as follows; "I cared for my daughter who suffered for three years at home. All the resources which she had were exhausted, and I started using my own resources thinking that she will get better." An old Lady of 77 years from Masikini Village lamented, "The illness and eventual death of my son exhausted all our financial resources and now I do not have anybody to ask for help and support." --- Factors that put older people at risk of getting infected with HIV. 56% of the respondents felt that lack of knowledge on HIV/ AIDS speeds up the infection rate among their age group, as most of the times preventive messages target the youth and not older people. One old lady explained that following the death of a young person, "we are asked to wash the dead body; most of the times we do not know the cause of death, hence we wash the body without gloves. This puts our lives at risk." 12.5% believed that taking care of a sick relative with HIV/AIDS without protection at home put them at risk of the infection. Respondents reported that having multiple sexual partners is common among older people. --- Discussion Old people face a lot of challenges because of the HIV/ AIDS pandemic. HIV/AIDS is wiping out productive children, and grandparents must assume responsibility for the orphaned grandchildren, without sufficient resources, and often without sufficient strength, to do so. These findings are consistent with studies worldwide from areas hardest hit by HIV/AIDS pandemic. HIV/AIDS messages have not been reaching older people 5 . There is a great misconception that when people grow old they become sexually inactive. Our study established that in fact older people do commonly have multiple sexual partners, which is why we need to include them in our preventive messages on HIV/AIDS. In a country like Malawi where there are no social pensions for older people, the HIV/AIDS impact is particularly intense. Some older people, as established by this study, have no alternative but to be beggars in an effort to make ends meet. --- Conclusion The impact of HIV/AIDS on older people in Malawi is diverse and deep. Social support networks are disrupted, and older people are left impoverished. Meanwhile they are also at risk of becoming infected themselves because preventive information on HIV/AIDS is not reaching them. --- Recommendation Diverse stakeholders should take an active role in alleviating the burdens being carried by older people in Malawi as a consequence of HIV/AIDS. Access to subsidized fertilizer and other amenities should not be age-based, as this leaves out older people who are taking care of orphans. Messages about the disease and its prevention strategies should not be limited to people in the reproductive age groups only, as is the case currently10. There is need for more research in this area for us to begin influencing policy change with Government. --- WHO HEALTH STATISTICS ON Malawi

HIV may affect the elderly in a number of ways. They may become infected themselves; their children may suffer prolonged illness and incapacity, and need the elderly to look after them; the same children may then die from the illness, leaving the elderly without the support of the next generation; this bereavement also leaves the older people to meet funeral costs and then to take care of orphans left behind. HIV has impacts on old people in ways that are social , economic, psychological and physical in nature.We wanted to understand the socio-economic impacts of HIV/ AIDS on lives of older people following the death of their productive children, and to examine how the elderly struggle to take care of HIV/AIDS orphans. While it is generally appreciated that older people undergo such hardships, little research has been done in Malawi to unravel the magnitude of these problems. We hope that our findings will increase awareness and lead to more being done to alleviate the problems faced by older people as a result of HIV/AIDS.