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insights and best practices on transformation in integrated primary care. Although the differences in health care coverage make financial barriers to first contact access to medical services lower for citizens of Canada than of the United States, both countries show differential health status and health care quality by social characteristics 1 , making zip or postal code a greater predictor of health than genetics. Persisting inequity can be overwhelming. Many problems are structural and evade simple solutions. The macro-economic system creates an increasing wealth gap between rich and poor, as do the incentives and barriers in the health care system. 2 Payment systems are not explicitly designed to improve health equity, nor are health organizations and plans held accountable for health disparities in their clinical performance measures. 3,4 Payers are increasingly rewarding providers for achieving measures of clinical quality, consumer satisfaction, and efficient resource use. But achieving target levels of technical quality can be very challenging for providers serving socially vulnerable populations, whose persistent social conditions and limited economic resources place them at high risk of both poor health and poor health care 5,6 -populations for whom affordable housing and food security take priority over preventive health screenings and adherence to medications. 7,8 Many risk factors such as race/ethnicity, socioeconomic status, remoteness, and indigenous status overlap in the same individuals or communities, exacerbating their vulnerability. The limited socioeconomic, racial, and ethnic diversity of health providers limits their ability to understand the issues and intervene effectively. In this session, 4 presentations on strategies to reduce racial and ethnic disparities in health care delivery (Chin, Katz, Young, Foley) were commented on by 4 discussants, followed by a lively exchange with the audience. Marshall Chin emphasized the need to make equity integral to quality of care, with consequent implications for payment reform and health professional education in the United States. Alan Katz described how partnering with indigenous, First Nations communities in Manitoba, Canada led to a holistic conception of primary health care, with potential to address historic inequities and health system inefficiencies. Kue Young used the case of medical evacuations in the far north of Canada to illustrate a whole-system and network approach to primary care organization, reaching to telecommunication and transport systems. Jon Foley presented New Zealand's primary health care transformation policy with equity considerations at its core. Four discussants commented: Groulx as a policy maker for primary care delivery; Pe ´rez-Stable emphasizing health professional education; Turnbull combining his experience in delivering clinical care to marginalized populations with a role in defining quality of care; DeVoe on harnessing big data to address disparities in family practice. Mentioned solutions included risk adjustment measures that integrate social factors; increasing socioeconomic, racial, and ethnic diversity of health providers; teaching cultural humility; supporting community-oriented primary care; and integrating equity considerations into health system funding. Here, we expand briefly on some of the solutions. --- From Retrospective Analysis to Proactive Measures Too often, equity is addressed retrospectively. Disparities are observed and bemoaned in the secondary analysis of access, quality, or health outcomes by the social factors mentioned above. But as suggested by Turnbull, DeVoe and others, by making equity integral to our definition of quality of care and by including equity in root cause analyses in quality improvement initiatives, we can move toward provulnerable care delivery. 9,10,11 Combining these approaches with real-time analyses to track anticipated impact on vulnerable populations may help to better align performance-based remuneration and incentives for those who care for vulnerable populations. 12 Crucial to integrating equity into quality measurement and producing proactive measures of equity will be systematically identifying social determinants in patient care, integrating them into quality improvement indicators and risk adjustments for funding, and incentivizing the reduction of disparities. 8,[13][14][15] We need to agree on a minimal set of metrics that can be captured uniformly so that social determinants can become visible and inform care delivery. We do not advocate setting lower achievement targets for providers serving vulnerable populations, implying that these populations may never achieve equal health status, thus cementing historic inequities. Rather, clinicians and organizations should be funded and rewarded for cross-sectoral coordination that addresses social determinants and the reduction of disparities. --- Beyond Equality to Equity Approaches that deliver equal quantity and/or quality of care to all can leave behind those with more need. An equity orientation requires a provulnerability bias in policies. New Zealand's Primary Health Care Strategy was presented as an example of a provulnerability policy and funding formula. A 10-year life-expectancy gap existed between Maori and European or Asian men in 1999. 16 Therefore, the Ministry of Health in 2001 established a population-based funding formula that directed additional funding to Primary Health Organizations (PHOs) that served higher numbers of enrollees who identified as Maori, Pacific Island, and/or were residents of the most deprived areas in the country. All PHOs receive funding to reduce the enrollees' cost of receiving general practitioner and practice nurse services. PHOs receive additional funding proportional to the number of vulnerable enrollees for health promotion efforts and to improve access for vulnerable populations including transportation services, nurse clinics on traditional Maori meeting spaces or remote locations, and community health workers. PHOs that serve disproportionately high need populations (more than 50% Maori, Pacific Island, and/or highest deprivation quintile) receive funding deemed sufficient to offer free or low-cost services for all enrollees. The New Zealand case demonstrates that it is possible to incorporate social determinants into population health funding. Although it remains a challenge to get the right funding formula, e.g. directing funds to evidence-based interventions and rigorously monitoring outcomes, the mechanisms exist and can work where there is political will. Provulnerability policies also exist in the United States and Canada. In the United States, federally funded community health centers, first established in the 1960s as part of President Lyndon Johnson's Great Society, address social risk factors from a community-oriented primary care perspective. 17 More than 1200 Health Centers serve disproportionately high numbers of uninsured and lowincome patients. They are governed by boards that include a majority of area residents, and they use provulnerable practices such as community health workers and targeted outreach campaigns. 18 They provide preventive care and clinically appropriate chronic illness care on par with or better than private providers, even before controlling for the socioeconomic conditions. 19,20 More recently in 2017, the Center for Medicare and Medicaid Innovation is testing an Accountable Health Communities model of care in 32 communities, where new "bridge" organizations coordinate coalitions of health and social service providers to address health-related social needs such as deficiencies in patient housing, social isolation, lack of adequate transportation, food insecurity, interpersonal violence, utility concerns, and poor coordination with social services for Medicaid, Medicare and dual enrollees. The evaluation of the impact on cost, quality of care, and health outcomes will provide valuable policy lessons in the United States and Canada. In 2001, the Canadian province of Manitoba introduced the Healthy Baby Prenatal Benefit, where low-income women are eligible for an unconditional income support (up to $81.41 Can monthly) during their second and third trimesters. Compared with low-income women who did not apply for or receive the benefit, low-income women who received the income supplement were significantly less likely to have infants with low birth weight, preterm births, or small for gestational age. 21 The province of Ontario is poised to experiment with a guaranteed minimum income policy, with benefits expected to extend beyond health status. In the United States, interventions such as earned-income tax credit may provide income support. --- From Needs-Based to Strength-Based Approaches A purely needs-based approach risks confounding social vulnerability with incapacity. Vulnerable populations often demonstrate resourcefulness, resilience, and social cohesion that can be leveraged to address their needs and improve wellbeing. Combining needs assessment with a strength-based analysis requires health care organizations and providers to have respectful relationships with communities, and to use methodologies that are sensitive to culture and values. Recognition of community strengths and available resources is the first step to collaboratively establishing common goals and un- derstanding community needs. 22 For example, despite the long history of abuse at church-run residential schools, some Canadian First Nation communities identify themselves strongly with the Church and Christian values. Others find their strength from traditional practices and customs. Failure to recognize these sources of strength and wholeness may lead to importing culturally inappropriate interventions that may even cause harm. Identifying strengths and leveraging resources may be more challenging in areas that are culturally, racially and religiously heterogeneous, as in core areas of large cities. Whatever the challenges, working effectively with communities means relinquishing some control. Often the needs and metrics the community chooses are different from what clinicians or planners want them to have. Being part of the solution means recognizing that our unexamined internal biases have been part of the problem; we need the humility to sit, listen, and be partners, and to have the courage to fail at times. --- From Individual to Population Focus Integrating social determinants into clinical assessments and identifying and harnessing community resources and strengths will require a population focus. We need to better integrate primary care and public health care. 23 A primary care policy-maker discussant (Groulx) mused that integrating public health workers into the interdisciplinary primary care team could help providers feel more empowered and effective in addressing social and health needs. Actionable public health data could help primary care practices address the needs of catchment populations, even as detailed as "in that highrise apartment building." Combining community vital signs-aggregated community-level information about social deprivation and associated chronic disease risks-with social determinants will enable providers to take action at both the individual and population level. 24,25 Someone asked, "Who owns the problem of health and health care inequity?" We all own a piece of the problem. Yet, this solution-focused exchange created optimism for the way forward, affirming that we all also own part of the solution. We can make progress on enhancing equity by developing risk-adjustment measures that integrate social factors, making equity intrinsic to quality, increasing the social diversity of health providers, practicing cultural humility, supporting community-oriented primary care, and integrating equity into formulas for health system funding. Working toward equity will also recapture providers' and policy-makers' intrinsic motivation to make a difference in the health and wellbeing of the individuals and communities they serve. To see this article online, please go to: http://jabfm.org/content/ 31/3/479.full.

Introduction: Health inequities persist in Canada and the United States. Both countries show differential health status and health care quality by social characteristics, making zip or postal code a greater predictor of health than genetics. Many social determinants of health overlap in the same individuals or communities, exacerbating their vulnerability. Many of the contributing factors and problems are structural and evade simple solutions. Methods: In March 2017 a binational Canada-US symposium was held in Washington DC involving 150 primary care thought leaders, including clinicians, researchers, patients, and policy makers to address transformation in integrated primary care. This commentary summarizes the session's principal insights and solutions of the session tackling health inequities at policy and delivery levels. Discussion: The solution lies in intervening proactively to reduce disparities-developing risk-adjustment measures that integrate social factors; increasing the socioeconomic, racial, and ethnic diversity of health providers; teaching cultural humility; supporting community-oriented primary care; and integrating equity considerations into health system funding. We propose moving from retrospective analysis to proactive measures; from equality to equity; from needs-based to strengthbased approaches; and from an individual to a population focus. ( J Am Board Fam Med 2018;31: 479 -483.

INTRODUCTION Health is basic right of all, therefore access to health care is necessary. Access is a complicated and active thought that resists modest meaning and clarification. The right to use HS is a multifarious idea [1]. Pakistan is a developing country, and stressed in various fields in which the health structure has suffered a lot, resulting in a 122 rank out of 190 countries [2].The health services in Pakistan are not fully satisfied with various issues. Government of Pakistan is spending less percentage of its GDP on health for last one decade against the World Health Organization (WHO) benchmark. It is spending 0.5 to 0.8 per cent of its GDP on health for the last 10 years, while WHO benchmark of health expenditure is at least 6 per cent of the GDP [3]. But services are obtainable and there is a sufficient supply of health services, at that time. The amount to which a people gains access furthermore depends on economic, secretarial and social or civilizing barriers that boundary the utilization of health care services [4]. The health and socioeconomic determinants have been shown to be positively related in humanoid residents on every region crossways in the world, in current time's period. In Pakistan, the most important feature of HS is ignored. In its 70-year past, Pakistan's successive governments national and military have not completed basic health facilities [5]. The outcome of this lack of concern is inexcusable health indicators. The socio economic determinants of HS are typically liable for health discriminations [6]. The Health equity and social determinants are recognized as a precarious factor of the post-2015 supportable development global agenda, and of the impulsion towards enlightened achievement of universal health coverage (UHC). The lack of interest of Pakistan's government to health is reflected in the fact that Pakistan spends a mere 1 percent of its gross domestic product on health care services [7]. In year 2018 Pakistan has reduced its health budget further. Pakistan's citizens have lot of private hospitals for basic benefit through out of pocket expenditure [8]. Health care sector in Pakistan consists of both private and public sector. The private sector assists nearly 70% of the population, is primarily a fee for services and covers the range of health care facility from trained allopathic physicians to reliance healers operating in the informal private sector. Non-government sectors do not work within a regulatory framework and very little information is available regarding the extent of human, physical, and financial resources involved. According to [9] less than 30 percent of the population has the access to the facilities of the public health center (PHC) and on average every person visits a private health center facility less than once a year. Main reasons behind it are; lack of health care professionals and specially women, high rates of absenteeism, poor quality of services and inconvenient location of PHC units [10]. Punjab contains 36 districts and it has highest population and second largest province of Pakistan with respect of area. Although health access services in Punjab are provided by both public and private sector, the government is considered the key provider of precautionary care throughout the province and the major provider of beneficial services in most of the rural areas [11]. The population is rising day by day in the Pakistan. Punjab is the most populous province of Pakistan, but it does not fulfill the proper health facilities required by people. Due to poor access to basic health facilities, we choose the area of Punjab for determining the HH health access services and check the effects of socio economic determinants on health access services. Punjab has contributed a lot in the development of Pakistan and its contribution in GDP is around about more than half of total. But unfortunately, total expenditure on health care services are just 1 percent of its annual GDP. The severity of these challenges, motivated to conduct the present study. HH access to health services and effects of socio economic determinants for these access services were analyzed. --- Materials and Method This study used cross sectional data from latest Pakistan Social and Living Standard Measurement (PSLM) released by Federal bureau of Statistics, Government of Pakistan [12] i.e. for 2014-2015 to determine the social and economic determinants of health care services in selected districts of Punjab, Rawalpindi, Faisalabad and Layyah. Household data of respondents was used. Three districts were selected for the sake of analysis. This data provides social and economic indicators in the alternate years at provincial and district levels. It provides a set of representative, population-based estimates of social indicators. Here, Rawalpindi is situated in upper Punjab, Faisalabad is in central Punjab and Layyah is situated at lower Punjab. The data was categorized by different types of variables related to HH health access services. Total sample size was 2000 and atleast 653 HHs were taken from each district. The PSLM data set was taken for the sake of study as it is one of the best sources of districts wise data to determine the households' access to HS [13]. --- Measuring variable The variables (determinants) of HH health access services examined in the paper were HH health access (disease status of HH members), wealth index, and work status, source of drinking water, HH head gender, education level, economic situation, and place of residence. Dependent variable was Health access (number of times respondent used the services in last two weeks) and it was used as a proxy to health access services. Education level, gender, age, income of HH head, family size, marital status, region, kind of health provides were taken as independent variables. In the analysis value equal to 1 was assigned if the HH has health access and this value was 2 if the HH has not health access services. Gender of the HH head was characterized by 0 if head is male and 1 if the HH head gender are female [4]. In case of source of drinking water; value 1 was given to piped water, 2 was for hand pump, 3 for river and 4 for other sources of water. Economic situation of HH were categorized by 1 for much worse, 2 for worse, 3 for better than before and 4 for don't know. These variable were also taken by [4] in his study. As in the log linear model, we assumed that some sets of X variables were useful for predicting the Y value, Socio-Economic Determinants of Household Access to Health Services in Selected Districts of Punjab we are claiming that this set predict probability that Y=1. And this function is called the Logistic Regression Model. Because of binary dependent variable, OLS cannot be applied. If the OLS is applied then that model would be the Linear Probability Model (LPM). It is why Binary Logistic Model was applied in the study as were applied by [15]. This function guarantees the probability ranging from 0 to1 as the regression equation value predicts that values are from the negative infinity to positive infinity. This model is also called log-odd. The similar variables were used by [16] for determining the socio economic determinants of HS through following equation. The general form of the logistic regression equation can be written as, Log (ATHS) = β 0 + β 1 X 1 + β 2 X 2 + β 3 X 3 + β 4 X 4 + β 4 X 4 + β 6 X 6 + μ(1) Where, ATHS = Access of households to HS β 0 = Intercept term X 1 = Gender (Male or Female) X 2 = Marital status X 3 = Education level X 4 = Occupancy level X 5 = Residential status X 6 = Drinking water sources Suppose there are p independent variables and the conditional probability of the outcome occur is denoted by Π(x) = P(Y =1|x) (2) So the logistic model is Π(x) = e g(x) / (1+e g(x) ) (3) --- Results and Discussion Table 1 shows the population characteristics of Punjab. Whole and district-specific information for population, house hold and area are given. The results of the Table 2 shows that there exists a positive and significant relationship between gender (Female) and health access services at 1 % level of significance. With regard to HH residential status, it has negative and significant impact on health access services at 5 % level of significance. HH education level is positively and significantly affecting HS at 1 % level of significance. In case of marital status, it has positive and insignificant impact on household HS. Nature of work would have positive impact on household HS and it was significant. In case of currently working HH, it was contributing negatively insignificantly impact on HS. In case of economic situation of the household is negatively and insignificantly impact on HS. It provides the information about HH how many people were better off and how many worse off in the societies. The same results were shown by the [11]. The results of Table 3 shows that there is positive and statistically significant association between gender (female) and health access services. HH residential status has negative and significant impact on health access services, similar results were estimated by [17]. Age is positively and significantly affecting HS. Education level is positively and significantly affecting HS. In case of marital status, it was positively and insignificantly impacting household HS. The HH work nature is positively and insignificantly impact on household HS. In case of currently working HH, it was negatively and insignificantly impacting HS. In case of water sources of the households, it was negatively and significantly impacting HS. Economic situation of the HH was negatively and insignificantly impacting HS [18]. It is evident from Table 4 that there exists a negative and statistically significant relationship between gender (female) and health access services at 1 % level of significance. HH residential status has positive and insignificant impact on health access services with in the study area. In case of age, it has positive and statistically significant impact on HS. Education level would have positively and significantly affecting HS at 5 % level of significance. Similar results were measured by the [19] in their study. The work nature could positively impact household HS this result was significant at 5 % level. In case of currently working HH, it was positively and significantly impacting HS. Source of water showed negative and insignificant impact on HS. Economic situation of the HHs was positively and insignificantly impacting HS. Similar findings were observed by [9]. --- CONCLUSIONS Results of the study showed that health access services in Faisalabad are better as compared to the other two --- Ethical considerations Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors. --- Conflict of interest The authors declare that there is no conflict of interests.

Background: Sound health is basic right of every individual and access to health care is necessary. The right to use health services (HS) is a multifarious idea. In Pakistan provision of basic health facilities of health are inadequate. Current study was aimed at highlighting the primary reasons behind it. Methods: This study used cross sectional data from Pakistan Social and Living Standard Measurement (PSLM) to determine the social and economic determinants of health care services in selected districts of province Punjab. Logistic regression technique is used to measure the impact of selected variables on health access. Results: Results of the study showed that the health access services in the district of Faisalabad are greater as compared to the Rawalpindi and Layyah districts. Moreover, people were using private health facilities as compared to government health facilities.The study indicated that the education level, household (HH) head gender, work status, region and place of residence, and economic situation, affect the health access services in selected regions. Measures should be taken to reduce the monopoly of private health sector by providing better government health facilities.

INTRODUCTION In 2001, Prensky 1,2 argued that a new generation of technologically literate young people were entering university who he termed Digital Natives. He went onto say that this generation was fundamentally different from previous generations. They have 'spent their entire lives surrounded by and using computers and videogames, digital music players, videocams, cell phones and all other toys and tools of the digital age' (p1) and this has changed the way they think. He claims these students have a natural technological affinity and digital literacy; they prefer receiving information quickly, are adept at processing information rapidly, prefer multi tasking and non-linear access to information, have a low tolerance for lectures, prefer active rather than passive learning and rely heavily on communications technology to access information and to carry out social and professional interactions 1,2 . There have been a number of studies which have investigated these claims [3][4][5][6][7][8][9] . Studies have shown that the access and use of technology is very high amongst young people 3 and they have more positive attitudes towards technology than older people 4,5 , but other studies have reported that the use of more advanced technologies was not as high as expected 9 and there was considerable variation amongst young people 7 . Very few studies have compared the use of digital technology across two different generations of young people. The Educase Center for Applied Research has conducted large scale surveys of undergraduate students' use of technology every year since 2004 9- 15 . The 2010 report 14 is a survey of 36,950 students and they reported that communication technologies dominate students use of IT and the use of SNS has increased significantly over recent years to almost universal levels. Web 2.0 services are still a minority activity even in 2010 with 42% contributing to video sharing websites, 40% contributing to wikis and 36% to blogs. Prensky defined a Digital Native as anybody who was born after 1980 1 . However, the Internet has changed considerably since then, especially with the introduction of Web 2.0 technologies and a number of commentators have argued that it is more appropriate to talk of first and second generation Digital Natives, with the second generation of Digital Natives defined as anybody who is born after 1993. They have been termed the Google Generation 17 and the i-Generation 18 . They are often seen as the real Digital Natives 19 because they have grown up with Web 2.0 technologies. Therefore, we aim to test if there were differences in attitudes and use of the Internet between first and second generation Digital Natives. We would predict that second generation Digital Natives will have more positive attitudes and use the Internet more than first generation Digital Natives. --- METHOD --- Participants The first generation Digital Natives were 558 psychology undergraduate students (448 females and 110 males) who we surveyed in 2002 and who were born after 1980. They were from six universities across the UK and their mean age was 19 years (SD = 1.5). The second generation of Digital Natives were 458 first year psychology undergraduate students (362 females and 88 males, 8 participants did not specify their gender) who were born after 1993 and were surveyed in Digital Natives, Internet Use and Internet Attitudes 4 2012. They were from six UK universities and their mean age was 19 years (SD = 1.3). The sample in 2012 was chosen to match as closely as possible the sample taken in the 2002 by using where possible the same universities that we used in 2002. --- Procedure and Measures We surveyed the students' use of and attitudes towards the Internet in the first semester of their first year of university. In 2002, the measure of students' use of the Internet consisted of nine items (see Table 1 for the full list). They answered using a five point scale (never, once a week, several times a week, once a day and several times a day -alpha = 0.90). They were also asked to list any activities they used the Internet for but which were not listed above. In 2012, the measure contained 24 items (see table 2 for the full list). They answered using a six point scale (never, less than once a week, once a week, several times a week, once a day and several times a day -alpha = 0.90). To make the 2012 scale directly comparable to the 2002 scale, it was collapsed into a five point scale, with 'never' and 'less than once a week' collapsed into one category relabelled 'never'. Students then completed an Internet anxiety scale (alpha = 0.80), which consisted of six questions answered using a five point Likert Scale (1 = strongly disagree to 5 = strongly agree). The Internet anxiety scale was based on the Clinical Computer Anxiety Scale 20 and scores above 70% are considered technophobic. The final part of the questionnaire was an Internet identification scale (alpha = 0.77), which consisted of ten items answered using a five point Likert Scale (1 = strongly disagree to 5 = strongly agree). For a full description of both scales see Joiner et al. 21,22 . --- RESULTS We found, as expected, that second generation Digital Natives had more positive attitudes towards the Internet than first generation Digital Natives. They had significantly lower Internet anxiety scores (t = 9.8, p < 0.05, d = 0.59The mean for second generation Digital Natives was 11.7 (SD = Digital Natives, Internet Use and Internet Attitudes 5 2.3), compared with a mean of 13.6 (SD = 3.6) for first generation Digital Natives. There were 21 first generation Digital Natives who were classified as technophobic, however there were no second generation Digital Natives who were classified as technophobic. Furthermore, second generation Digital Natives had a significantly higher Internet Identification score than first generation Digital Natives (t = 12.6, p < 0.05, d = 0.80). First generation Digital Natives had a mean of 2.7(SD = 0.5) compared to second generation Digital Natives who had a mean of 3.1 (SD = 0.4). See Joiner at al. 24,25 for a discussion of the relationship between the students attitudes and internet use We also found that second generation Digital Natives were using the Internet more than first generation Digital Natives (see tables 1 and 2). They were engaging in more Internet activities and engaging in them more frequently. Email was the most popular Internet activity for both first and second generations of Digital Natives, however the modal score for second generation Digital Natives was significantly higher than the modal score for first generation Digital Natives (t = 26.4, p < 0.05, d = 1.7). SNS was a very popular activity for second generation Digital Natives. In 2002, we did not directly ask how frequently they used a SNS, but there was an open ended question where students could list any activities they used the Internet for but which we had not included. No first generation Digital Natives listed using any SNS. The Internet was also being used more for entertainment by second generation Digital Natives than by first generation Digital Natives. Second generation Digital Natives were using it more frequently for watching television and listening to music. Table 1 and 2 also reveal a number of interesting similarities between the two generations. The first is that both first and second generation Digital Natives only use the Internet for a small number of activities and these are primarily for social and entertainment purposes. The modal scores in both Digital Natives, Internet Use and Internet Attitudes 6 tables show that students are not regularly using the Internet for a whole range of activities. For first generation Digital Natives only a third of the activities had a modal score of greater than 'once a week'. For second generation Digital Natives only 5/24 of the activities had modal score of greater than 'once a week'. Furthermore, some of the least popular activities have often been associated with Digital Natives. Only 27.4% of students used microblogging websites, 18.8% played games online and only 1.5% visited virtual worlds. --- Insert table 1 Insert table 2 --- DISCUSSION The aim of this study was to compare the attitudes and uses of the Internet of first generation Digital Natives with second generation Digital Natives. We found that second generation Digital Natives The finding that students' attitudes towards the internet were higher for second generation digital natives compared with first generation digital natives was expected and can be explained because of the ubiquitous and pervasive nature of the technology this generation has grown up with. This explanation is supported by our finding that second generation digital natives are using technology significantly more than first generation digital natives and is also consistent with previous research 14 . The other finding which was less expected was the low use of Web 2.0 technology. Prensky 1,2 and others had commented that these two digital generations would be make considerable use of this technology. Our finding does not support this and is consistent with previous research which has also reported a low use of web 2.0 technologies by students 14,16 . One of the main limitations with this research is the large number of female students in our sample, which could partly explain the findings. Our previous research has demonstrated that the type of Internet activities students reported using were influenced by gender 22,23 , with females using the Internet more for communication and males using the Internet more for games and entertainment. Further research is required on a more representative sample to see if these findings are an artefact of this particular sample or a more general phenomenon. However, until such research is conducted it appears, at least for the moment, that there is no great universal adoption of web 2.0 technologies by first or second generation Digital Natives, with the notable exception of SNS.

The aim of the study was to compare first and second generation Digital Natives' attitudes towards and use of the Internet. The sample of first generation Digital Natives consisted of 558 students who we surveyed in 2002 and who were born after 1980. The sample of second generation Digital Natives consisted of a sample of 458 students who we surveyed in 2012 and were born after 1993. They completed a questionnaire in the first semester of their first academic year and consisted of a measure of Internet experience, an Internet anxiety scale and an Internet Identification scale. Second generation Digital Natives' had more positive attitudes towards the Internet than first generation Digital Natives. They had higher scores on the Internet Identification scale and lower scores on the Internet Anxiety scale compared with first generation Digital Natives. Furthermore, we found that second generation Digital Natives used the Internet more than first generation Digital Natives. Email was the most popular activity for both generations, although second generation Digital Natives used it significantly more than first generation Digital Natives. SNS emerged as a very popular activity for second generation Digital Natives. Both generations reported low use of Web 2.0 technologies.

Abstract --- Background Despite the compelling scientific evidence on the superiority of stroke unit (SU) care, far from all acute stroke patients have access to SU care. In congruence with what has been observed when other new methods are introduced in health care, we hypothesized that there has been an inequality in the build-up phase of SUs, but that the gradients between patient groups have decreased as the total capacity of SU care has increased. The purpose of this study was to explore if patients in a national sample, who were socioeconomically disadvantaged (low education or low income) had reduced access to SU care and if differences varied over time. --- Methods All patients 18-74 years of age in 1995-2009 year cohorts in Riks-Stroke, the Swedish stroke register, were included. "The Stroke unit Trialists" definition of a stroke unit has been adopted by Riks-Stroke and hospitals participating in the registry. Basic patient characteristics, stroke risk factors, process and outcome variables are recorded in Riks-Stroke. Socioeconomic data was accessed from Statistics Sweden. Multiple logistic regression analyses were used to calculate odds ratios for stroke unit care between pre-specified patient subgroups. --- Results A total of 319240 stroke patients were included in Riks-Stroke during year 1995-2009 and 124173 were in ages between 18 and 74 years; they were included in final analyses. After adjustment for confounders in a multiple regression model, women were slightly less often treated in stroke units (OR 0,97. 95% CI 0.95-0.99). There were no statistically significant associations between stroke unit care and age or between stroke unit care and being cohabitant or living alone. Highest level of education predicted access to stroke unit care --- Introduction Despite the compelling scientific evidence on the superiority of stroke unit (SU) care vs. stroke care in general wards as to death and disability, far from all acute stroke patients have access to SU care [1]. In Sweden, the first SUs were established in the 1970s. Since then, there has been a gradual increase in the access to SU care so that, by 2011, 85 % of all acute stroke patients were treated in a stroke unit, i.e., they spent at least part of the hospital stay in a SU [2]. The national stroke care guidelines in Sweden state that all acute stroke patients should be treated in a SU. This recommendation has rank 1 on a 10-level priority list [3]. Although the guidelines are explicit, it may be that resource limitations have resulted in disadvantages for certain patient groups. In congruence with what has been observed when other new methods are introduced in health care, we hypothesized that there has been an inequality in the build-up phase of SUs, but that the gradients between patient groups have decreased as the total capacity of SU care has increased. We explored if patients who were socioeconomically disadvantaged (low education or low income) had reduced access to SU care and if possible differences varied with time. --- Methods This study is based on patients included in Riks-Stroke, the Swedish stroke register, between 1995 and 2009 [4,5]. The register, started in 1994, covers all hospitals that admit acute stroke In 2011, Sweden had a population of 9.5 million inhabitants. There were 74 hospitals that admitted acute stroke patients and all of them had a stroke unit. The SU Trialists have defined a SU as "organized specialist in-patients stroke care" and have provided a set of criteria that should be fulfilled (1). This definition has been adopted by Riks-Stroke and the hospitals participating in the registry. In a detailed inventory performed in 2007, >90% of the SUs fulfilled all criteria [7]. Proportions of patients that were treated in a stroke unit are presented for pre-specified groups, including highest obtained level of education (primary, secondary, university), income (categorized by tertiles) and stroke subtype (ICD10 codes: cerebral infarction I61, intracerebral hemorrhage I63, unspecified stroke I64). All statistical analyses were pre-specified. Multiple logistic regressions were used to adjust for possible confounders and simultaneously test the effect of predictors on the probability to be treated in a stroke unit care. Parameters were estimated using generalized estimation equations with an exchangeable correlation structure for patients within the same hospital. The two-way interaction terms (year*sex, year*age, year*income, year*education level) were added to the model to test if differences between subgroups in access to stroke unit care varied over the years. Parameters that did not improve the model were removed. The statistic software IBM SPSS statistics 20 was used to perform the analysis. --- Results A total of 319 240 stroke patients were included in Riks-Stroke during year 1995-2009 and 124173 were in ages between 18 and 74 years; they were included in final analyses. After adjustment for confounders in a multiple regression model, there were no statistically significant associations between stroke unit care and age or between stroke unit care and being cohabitant or living alone (Table 1). Women were slightly less often treated in stroke units. Between 1995 and 2009, there was a statistically significant increase in the proportion treated in stroke units from 57.2% to 87.6% (OR 4.961; 95% CI 3.47-7.09). In the beginning of the study period, patients with lower education had less access to stroke unit care (Figure 1). Over time, these patients had a more rapid implementation rate and the differences in stroke unit care between educational groups diminished over time (p-value 0.001). In multivariable GEE analyses, higher level of education was independently associated with increased access to stroke unit care (Table 1). Ignoring the dependency between patients within the same hospital and instead adding a fixed hospital effect to the multiple logistic regression model did not change these results (OR 1.050; 95% CI 1.014-1,087 for secondary, and OR 1.068; 95% CI 1.017-1.112 for university education, compared to primary school education). Over time the proportion of patients treated in stroke units increased at a similar rate in all income groups (p-value 0.12)(Figure 1). Income was not independently associated with stroke unit care after adjustments for other factors (Table 1). --- Discussion In the present study, we show that inequality by socioeconomic status existed in Sweden when overall access to stroke unit care was limited. The socioeconomic gradients have gradually diminished as stroke services have expanded. In 2009, 86.5% of all stroke patients in Sweden received stroke unit treatment. It is likely that a similar development with diminishing socioeconomic inequalities is to be expected in any country with increased overall access to stroke unit care. As reviewed by Addo et al., socioeconomic status has been associated with inequalities in the delivery of care across the stroke pathway [8]. From Denmark, Canada and the US, lowincome patients have been reported to be less likely to receive evidence-based care and being treated in university-hospitals [9][10][11]. However, in a single center study performed in the UK, no significant differences in stroke management by socioeconomic status were observed [12]. What is new with our study is the analyses of the relationships between socioeconomic status and access to SU care over time. One of the potential problems in analyses of disparity of care may be the influence of the patients' geographical location. Therefore multiple regression analyses were performed using generalized estimation equations with an exchangeable correlation structure for patients within the same hospital. An additional analysis included hospital as a fixed effect in the logistic regression model. This way, the potential effect of relationship between socioeconomic differences and geographical location of the treating hospital was adjusted for. Strengths of this study included (a) register coverage of all hospitals admitting acute stroke patients, (b) prospective data collection, (c) use of linkage to socioeconomic data using the unique personal identification numbers available in Sweden (and in other Scandinavian countries), (d) sufficient statistical power to detect even modest socioeconomic differences, and (e) the study has been performed in a country where all acute stroke care is publicly funded, eliminating selection of study patients by socioeconomic characteristics. A possible limitation of the present is that coverage of the Riks-Stroke register has changed over time. An increased access to stroke unit care in Sweden has been paralleled by an increase in coverage in the register from approximately 50 % in the early years to the proportion increasing to well above 85 % in 2009. Patients treated in general wards are overrepresented among stroke patients not recorded in Riks-Stroke (A3). Had missing patients been included in early years, the socioeconomic gradients would most probably have been greater, strengthen our hypothesis that more stroke unit beds reduce social inequalities in access to stroke units. Another limitation is that our study included patients up to the age of 75 years, i.e. only half of all stroke patients (2), because socioeconomic data were not available for older age groups. Although we did not find that access to stroke unit was age-dependent, it is possible that it is so in patients above 75 years. --- Summary/conclusion Even in a country with modest socioeconomic differences in the general population and public financing of all acute hospital care, socioeconomic inequalities in access to stroke unit care were evident during the early years but they diminished as the total capacity for SU care increased. --- Conflicts of interest/Disclosures None

and university vs. primary school (OR 1.06, 95% CI 1.01-1.10)). Differences by level of education diminished over time (pvalue 0.001). Income was not independently associated with SU care and over time the proportion of patients treated in SUs increased at a similar rate in all income groups (p-value 0.12).Even in a country with modest socioeconomic differences in the general population and public financing of all acute hospital care, socioeconomic inequalities in access to stroke unit care were evident during the early years but they diminished as the total capacity for SU care increased.

Introduction 49 Taking part in physical activity (PA) during childhood and adolescence has a 50 multitude of health benefits 1,2 . Yet, globally, participation levels in this age group 51 remain low 3 . In particular, the existing gender differences among adolescents are of --- 59 The CSPPA 2018 study 8 across the Republic of Ireland reported that only 10% of 60 second level school adolescents met the PA guidelines 9 and only 58% of children 61 and youth participated in community sport at least once a week. It is well-established 62 that boys participate in sport more frequently than girls, specifically during 63 adolescence 6,8 , with data from the Health Behaviour in School-Aged Children 64 (HBSC) survey finding that 75% of 10-to 14-year old boys report playing with a 65 club, when compared to 59% of girls 10 . Given the argument that organised sport is 66 more tailored to suit boys 4 and changing the PA behaviour of adolescent girls is 67 challenging 6 , much work is needed in order to increase the PA and sport 68 participation of Irish female adolescents. [12][13][14] . It is unsurprising given the surge in data 12,14,15 that physically active 76 pursuits during free time appear to be slowly disappearing at the expense of screen 77 time in developed countries for adolescents. --- 78 In the Biddle et al., (2014) 16 --- 231 --- INSERT TABLE 2 APPROXIMATELY HERE --- 232 A one-way between-groups analysis of variance (ANOVA) was conducted to After adjusting for age and screen time, there was a statistically significant difference 265 for social support from friends across the four types of sports participation groups: F 266 (3, 3062) = 96.24, p = .0001 (see Table 3). The medium effect size, calculated using 267 eta squared, was 0.09. Specifically, post-hoc comparisons using the Tukey HSD test 268 indicated that the mean social support score in friends for Group 2 (M = 16.32, 95% 269 CI 16.07, 16.57) was significantly higher and different from Group 3 (M = 14.98, 95% 270 CI 14.74, 15.22). --- 271 There was also a statistically significant difference for familial social support across 272 the four types of sports participation groups, after adjusting for age and screen time finding that it is the most popular sport played by adolescent girls is encouraging. --- 338 The National Governing Body (Ladies Gaelic Football Association) has invested 339 efforts into increasing participation rates for this age group through its Gaelic4Girls 340 programme 19 , and as key partners in the aforementioned 20x20 42 campaign. There is no such research available on the effects of teacher support for sports 391 participation in either primary or secondary school-aged children. The current 392 study's findings for adolescent girls highlights the need for more teacher involvement 393 in sport and PA promotion; considering that students spend a significant proportion 394 of their time in the school setting 55 . Furthermore, teachers can be great advocates 395 for student involvement in sport and PA by being supportive role models and agents 396 of change 56,57 . --- 397 The cross-sectional nature of the study somewhat restricts the interpretation of our 398 findings, particularly as there were only a small percentage of participants that were 399 both active and participating in sport. Nevertheless, the social supports surrounding 400 the participants appear to be key mediators for why they partake in sport. A 401 prospective cohort design is recommended in order to confirm whether the large 402 effect sizes observed for family and friends increase the likelihood of participating in 403 sport and PA; most notably the most popular team sports of Ladies Gaelic Football, 404 Camogie, and Soccer, over the longer term.

The association of family, friends and teacher support with girls' sport and physical activity on the island of Ireland.

City University of Hong Kong, Kowloon, Hong Kong There is little understanding about how a dementiafriendly community can be constructed in East Asian societies, particularly in geographically remote areas characterized with majority older adult residents and limited external support. A pilot project using an asset-based community development (ABCD) approach in constructing a dementia-friendly community in Hong Kong was implemented. Informed by the theoretical tenets of ABCD, the purpose of this paper is to examine the effects of this pilot project in enabling older adult residents and other community stakeholders to better respond to challenges resulting from growing prevalence of dementia. Multiple stakeholder interviews were conducted with older adult residents, church leaders, district councillors, and social workers. Participants were asked to share the strengths and challenges of this ABCD pilot project in building a dementia-friendly community. Data generated from interviews were analyzed using thematic analysis. Four key preliminary themes were identified, including on the individual level: enhanced dementia literacy, and enacted proactive behaviour; and on the community level: strengthened bridging social capital, and improved community caring capacity. Uncertain long-term financial and professional support posed challenges to participants. Nevertheless, findings underscore the importance of departing from traditional service delivery models, to one that infuses ABCD approaches in constructing a dementiafriendly community. Mobilising existing human and social capital in the community, and embedding older adults in co-creating solutions are key to improve dementia-related interventions. We contribute to ongoing theoretical and practice discussions on the intersections between population aging and employing community-based solutions to create a more dementia-friendly society. Older adults and informal caregivers' involvement in policy-making processes can enhance the creation of responsive policies and the provision of better health and well-being services. However, current involvement literature is more focused on involvement in research and healthcare decision-making. This research aims to explore stakeholders' perspectives on approaches for the involvement of older adults and informal caregivers in health policy development. A qualitative study using semi-structured interviews was conducted within the European TRANS-SENIOR consortium and included policymakers, researchers, and advocacy organizations in nine countries. Participants were included if they had experience with older adult/informal caregiver involvement in health policy development. A total of eighteen interviews were conducted with nine representatives from older adult/informal caregiver advocacy organizations, five policymakers, and four researchers. Identified themes were: 1) diversity of involvement approaches, 2) impact of involving older adults and informal caregivers in health policy development, and 3) facilitators and barriers of involvement. Findings indicated that older adult and informal caregiver involvement vary in nature and intensity and that the actual effect of older adult and informal caregiver involvement in health policy development is difficult to assess. There is no one-size-fits-all approach for involving older adults and informal caregivers in health policy development; stakeholders can focus on exploring and implementing context-specific tailored strategies. Our study findings provide evidence that can be useful to decision-makers to involve older adults and informal caregivers in health policy development.

to society, and offers tools and steps to help release hospitalized inmates to the care of their families. To obtain compassionate release, the first step is to identify eligible inmates with a terminal illness and a life expectancy of less than six months, which must be confirmed by a medical evaluation. The second step involves filing a petition for compassionate release with the appropriate authority, including medical records, a statement from the treating physician, and a plan for the inmate's release and care in the community. The third step entails advocating for the inmate's release, which may involve working with advocacy groups, contacting elected officials, and raising public awareness. By granting compassionate release to dying inmates, we can provide them with the opportunity to die with dignity and spend their final moments with their loved ones, which is a fundamental aspect of social justice.

Background Prostate Cancer has become the number one cancer in men with increasing incidence and morbidity in men of black African ancestry [ 1 ]. Its incidence and prevalence in black men is in multiples of those from other races in several studies [ 2 ]. The reason for this is not yet clear cut and an explanation for the disparity may lie in studies involving black men from different populations to see if there is an enhancing factor associated with the racial origins of these men. Nigeria is an ancestral home of many black men living outside Africa and it is hoped that an exploration of research activities emanating from the country may shed some light on the disparity [3]. Odedina et al [4] recommend the need to focus on areas of genetic and environmental risk factors in the group. --- Methods Research studies emanating from Nigeria or involving Nigerian subjects in relation to CaP were sourced using the U.S. National Library of Medicine literature search engine, PubMed [5], using the search terms "prostate cancer" and "Nigeria". Other sources included journal websites and hard copies of journal articles. These gave reports on CaP from all regions of the country, covering topics including epidemiology, clinical presentation, diagnosis, treatment and prevention. --- Findings --- Epidemiology In 1973, Nkposong and Lawani [6], urologists from the University College Hospital, Ibadan, South West Nigeria, at the time the only referral center for cancer treatment, noted a low but increasing incidence of prostate cancer. It moved from 8 th position of male cancers in 1969 to 2 nd place by 1979, with liver cancer leading the pack [7]. In 1981, Udeh [8] also reported the same position from Enugu, but up till 2002, Globocan [9] reported that CaP was not among the top 5 cancers in developing countries. Angwafo [10], while reporting 93.8/10 5 incidence from Cameroon in 1994, asked the question "Is prostate cancer rare in black Africa?" while Osegbe [11] in a report from Lagos where the hospital incidence was put at 127/10 5 , surmised that incidence of CaP may be underestimated in Nigerians. Similar reports of increasing hospital based incidence came from other parts of Nigeria with rates of 61.3/10 5 from Calabar [12] and 182.5/10 5 from Ife [13]. The stance of Globocan has since changed with the 2008 [14] report that CaP had become the top male cancer and fourth commonest cancer in Nigeria. Ogunbiyi and Shittu [15] from the Ibadan Cancer Registry in 1999 announced a definite increase of CaP among Nigerians. It had risen from 8 th position in 1969 to 1 st position in 1996, being 11% of all male cancers. Studies from Kano [16], Zaria [17], Benin [18] and Maiduguri [19] showed CaP as16.5%, 9.2%, 7.13% and 6.15% of male cancers. --- Clinical presentation Reports from all regions of the country emphasize late presentation as the pattern in Nigerian CaP patients. From both South [12] and North [19] about two thirds of patients presented with metastatic disease, and 94.2% [13] and 91% [20] presented with complications respectively. Mortality was generally high with 64% dead within 2 years in a review by Osegbe [11]. Metastases were typically to the spine, with attendant paraparesis or paraplegia, and rare orbital metastases were reported from Ibadan [21]. --- Diagnosis There is growing concern that medical students are not gaining enough skills in DRE [22], such that clinical diagnosis of CaP may become a dilemma for the younger generation of doctors. Though final year students at the University of Jos have adequate teaching, right attitude, perspective, and knowledge about examining for prostate cancer, they have not translated the same into practice and 86% had never felt a malignant prostate while 45% had never examined the gland [23]. Iko [24] in 1987 suggested that prostatic ultrasonography may have great diagnostic promise in developing economies where more sophisticated equipments may be uncommon. However, Ajape [25] in a more recent report(2010) noted 50% sensitivity and false negative correlation between ultrasound and CaP diagnosis. --- Histopathology Studies from all regions of the country found that adenocarcinoma is the predominant histologic type, similar to global findings. CaP constitutes a moderate portion of biopsies of the prostate. Studies from Benin [18], Ilorin [26] , and Kano [16] also reported malignancy rates of 17%, 16.9% and 22.4% respectively. Freeman et al [27] compared the Gleason system interpretation between genitourinary pathologists in Nigeria, Jamaica and US and concluded that the revealed concordance makes international studies using this grading system feasible. --- PSA Although (PSA) is a controversial instrument for screening, it remains a useful parameter for monitoring treatment. The distribution of PSA in a rural Nigerian population was found to be similar to that of unscreened US populations with greater than 4ug/l readings in 14% of men [28], and Igwe [29] found that 85.1% prostate cancer patients had total PSA above the normal cut off level. The median total PSA in CaP was found to be 92.6ug/l and 106ug/l respectively in Ibadan [30] and Ife [12]. --- Prevention There is not yet any national cancer screening program and annual PSA checks are not practiced routinely in Nigeria. Lifestyle and behavioral patterns are known to be important in cancer prevention but education about CaP is sparse in Nigeria and opportunistic. Ajape et al [31] concluded that "there is remarkable lack of awareness of prostate cancer among the Nigerian urban populace. Prostate cancer screening and serum PSA test for screening is globally unknown among them". Though knowledge and risk perception of prostate cancer were low, Oladimeji et al [32] found that 81.5% were willing to be screened for the disease. Odedina et al [33] suggested that emigration of Nigerian men from Nigeria to the US has a significant impact on prostate cancer knowledge and beliefs. Comparing indigenous and immigrant Nigerian men's diet, alcohol consumption, tobacco use and physical activities, Kumar et al [34] found that there were enough differences to provoke deeper search. Meanwhile, reporting from Nsukka , Ejike and Ezeanyiwa [35] suggested that lifestyle changes in Nigerian men leading to westernized diet and use of energy sparing devices (status symbols) may lead to increase in incidence of chronic diseases like cancer. A trend towards high total plasma omega-6 was observed and found to have a moderate positive correlation with prostate cancer in Nigerians [36]. --- Treatment Since most patients present with poor prognostic features including high histological grades and clinical stages, treatment is mostly palliative with bilateral orchidectomy with or without anti androgen therapy [37]. A discomforting finding in Ilorin showed that only 38.9% of patients had histopathological diagnosis before treatment [25]. No clinical trials were reported. --- Conclusion Prostate cancer research in Nigeria is growing and multifaceted. There is a need to collate figures into the National Cancer Registry. Education and knowledge about prostate cancer is sparse, and even medical students need better training in digital rectal examination. Patients often present late with complications, pathological diagnosis is mostly of adenocarcinona, resulting commonly in palliative orchiectomy. Routine screening is not practiced and most PSA testing and digital rectal examination emanate from surgical clinics. The disparity in prostate cancer prevalence and mortality in the black man calls for concerted efforts from all and sundry to include all areas of research. Nigerian researchers stand at a vantage position to carry out local work as well as collaborate with other stakeholders all over the world. --- Competing interests The authors declare that they have no competing interests. Published: 23 September 2011

Prostate cancer (CaP) disparities in the black man calls for concerted research efforts. This review explores the trend and focus of CaP research activities in Nigeria, one of the ancestral nations for black men. It seeks to locate the place of the Nigerian research environment in the global progress on CaP disparities. Literature was reviewed mainly through a Pubmed search with the terms "prostate cancer"and "Nigeria", as well as from internet and hard copies of journal pages. Findings: One of the earliest publications about CaP in Nigeria was in 1973 from the nation's 1st tertiary hospital in Ibadan, reporting low incidence, followed by a lull of nearly one decade. In 1980, the incidence rate of CaP was reported as almost similar for black men in Ibadan and Washington and from then on, research work from surgeons and pathologists, from the south to the north, east to west, continued to report increasing prevalence of CaP. Apart from epidemiology, other areas of research include KAP (knowledge attitude and practice) studies (poor education of caregivers and population), histopathology (mostly adenocarcinoma), diagnosis (digital rectal examination [DRE], prostate specific antigen [PSA], ultrasound), clinical features (late presentation and high mortality), and prevention (lifestyle, education and screening). As of today there is a gaping dearth of molecular and genetic studies. Conclusion: The global focus on CaP disparities in black men calls for more efforts from Africa, in all areas of research, along with international collaborations for capacity building.

ICADECS --- Introduction Tourism is not a new phenomenon, but tourism began to be seen since the end of World War II, and in the last decade, it has exploded on a large scale as one of the economic forces and even has become a business. Millions of people spend their money, leave their homes and jobs to satisfy or make themselves happy to spend their free time. Therefore, tourism is essential to life and lifestyle in developed countries [1]. Tourism is one of the sectors that are the mainstay of the State of Indonesia. Tourism is related to nature and the richness of history, food, traditions and culture [2]; with such a vast country landscape, Indonesia has tremendous tourism potential. Indonesia is an archipelagic country with a wide area. The territory of Indonesia is also crossed by the equator, which has a tropical climate because it has a tropical climate that supports the growth of a wide variety of flora and fauna, so Indonesia has an enormous tourism sector potential. Geographical conditions in the form of mountains, beaches, tropical rain forests, and oceans are Indonesia's principal capital in developing its tourism sector by providing facilities and services and empowering communities around these tourist areas. As stated in Law No. 10 of 2009, Tourism is a variety of tourism activities supported by facilities and services provided by the community, business people, the Government, and Local Governments. In addition to the tourist attraction itself, photography is one of the things that support tourism development, the exposure of which tourism is easier to do with photos. The expression that pictures can speak more is a form of expression of how people will have the impression and receive mixed messages with pictures. The development of photography is in line with the development of technology and information that is overgrowing [3]. One is the development of smartphones equipped with cameras up to 64 megapixels. On the other hand, the widespread use of social media as a means of self-actualization and existence is also related to the development of intelligent trees, especially on the side of the camera used. [4]. With high-resolution cameras, social media and internet networks are getting cheaper and easier to make it easier for people to share photos of the activities they do, as well as when visiting tourist attractions. One social media with many users is Instagram [5]. The world of tourism is very dependent on the number of tourists, both domestic tourists and foreign tourists who come. Unfortunately, the Covid-19 pandemic has been running for almost two years and has harmed tourism development [6]. The DOI 10.18502/kss.v8i15.13919 ICADECS government's policy of restricting and closing tourist destinations has an impact on the decline of local opinion and on tourism actors, which include transportation businesses, hotels and inns, handicrafts, arts and culture, and hawkers in every tourist attraction. At this time, the government has begun opening tourist attractions, expected to restore the economy that had stalled immediately. As mentioned in the previous paragraph, the world of tourism is closely related to photography; efforts to restore the tourism industry, which was torn apart during the pandemic, will be supported more quickly by the presence of tourists who share their experiences both when travelling to tourist objects, while in tourist objects and on the social side. Moreover, humanity encountered this when travelling. In this regard, tourists, attractions, and photography are closely related, so this study takes the title "Visual Analysis Of Indonesian Instagram Travel Influencer Content To Represent Good Travel Destinations." --- Methods This research is descriptive quantitative research, with the research sample being an Instagram influencer who shares his travels with a total of 29 respondents. The primary data from the questionnaires were distributed in August -September 2021. Data analysis was carried out using SPSS software version 26. --- Result and Discussion Respondents in this study are described as follows: Table 1 shows that respondents prefer to upload photos; the ease and speed of taking photos are one of the reasons respondents prefer to share their photos on social media. This is in line with Evans' opinion that a photo taken with a good shooting position can tell a lot more than telling a written and written experience. (Evans 2018). This follows Rainiere's opinion that people prefer to see pictures/photos rather than read DOI 10.18502/kss.v8i15.13919 ICADECS travel stories [7]. Based on Table 1, respondents shared their travel trips via video/IGTV with 529 videos and 164 on reels. From table 2, it can be seen that most of the influencers display the location and account owner in the same frame, namely 1,799 (41.36%). This shows that respondents want to show the tourist destination that is being visited and how the tourist attraction is at this time. This impacts their followers that the location is unique and a good spot for taking pictures. Regarding attractions, taking photos and videos showing locations and people is part of a marketing strategy that objects are worth visiting after being closed during the pandemic [8]. The taking pictures taken by the respondents are shown in Table 3. From this table, more than 46% (2,021) of the respondents took pictures from a distance. This shooting from a distance is intended so all objects can fit in one frame. It is intended that respondents get an attractive landscape image, and all objects can be achieved. Uploading photos or videos using long shots teaches followers to visit tourist objects and see them directly. In addition, taking photos/videos in a long shot also shows the location in more detail. This makes the respondents or their followers able to predict how the conditions of the location and the environment will be when they visit later. Regarding using angle, most of the respondents, 2,356 (54.16%), chose to use eyelevel shots. This angle selection is used to produce a thorough and even impression of the background of an object, highlighting the expressive side of an object (HI), and usually, this shooting angle is also intended to position the camera at eye level with lower objects [9]. DOI 10.18502/kss.v8i15.13919 --- ICADECS The expressive impression is intended to show that the tour is a pleasant trip, gives a positive impression, and provides information that the chosen destination is the right choice, both in terms of security and attraction. Sumber: Data Primer Diolah, 2021 Computerized media such as telephone and short message services make transmitting spoken forms and nonverbal symbols easier than previous generation devices [11]. Side by side with that, explain that promotion can be said to be a promotional activity only if it has fulfilled the following aspects [12]; DOI 10.18502/kss.v8i15.13919 1. a. Frequency: the number of promotions carried out at a time through promotional media; 2. b. Promotion Quality: is a measure of how well the promotion is doing; 3. c. Timeliness, or target suitability, is necessary to achieve the desired target. The development of information and communication technology has an impact on changes in socialization in the community. The era of social media makes it easier for communication activities to be carried out personally or in groups. Even activities such as commercial promotions can be carried out more efficiently. The results showed that the use of social media, especially Instagram, had a significant positive effect on changes in user attitudes in determining vacation travel destinations. This is in accordance with the research that found that social media influences tourist attitudes and travel planning [13]. Meanwhile, Fotis also found that social media, in this case, Instagram has an essential role in determining users' attitudes toward their tourist destinations. Instagram is a visual-based media through videos and images, so it is more attractive to users because of the application's ability to give an accurate picture of the place. The questionnaire results show that the use and access to Instagram are straightforward but cannot be used as a complete reference due to incomplete information obtained through uploaded posts. Only a few accounts based on tourist attractions are still an obstacle to getting information. This could be because many influencers still rely on posts from friends who only highlight the visual picture of the tourist spot without further information. This study also strengthens the uses and gratification theory, where social media users do not accept all information on social media, especially tourist attractions. Users will be more selective and need more detailed and accurate information in determining their attitude towards tourist destinations. So it is not surprising that respondents still seem hesitant to use the Instagram application because it needs to be more reliable in terms of the level of trust (trustworthiness) and usability (ease of use). --- Conclusions Based on the discussion, it can be concluded that 1) most influencers choose to upload photos or videos of locations along with their influencers (41,365), 2) influencers choose to use long shots (46.46%) to be able to show the location of tourist destinations better, DOI 10.18502/kss.v8i15.13919 ICADECS 3) in using an angle of 2,356 respondents (54.16%) using eye-level shots to get a better picture, and 5) a total of 2,255 (51.84%) using cold mode when taking pictures. The discussion results also explain that followers only followed some information shared by influencers because of the limited information.

This study aims to measure the influence of Instagram influencers and their relationship in giving the image of a destination to the interest of tourists visiting tourist destinations in Indonesia. Furthermore, it identifies photo-taking techniques in framing phenomena, events, or the ambience of tourist objects. This is related to the role of influencers and social media that dominates the tourism aspect in the era of the Internet of Things. This study uses a quantitative approach accompanied by a descriptive description. The primary data were 29 Instagram influencers who shared their travels, which were obtained by distributing questionnaires from August to September 2021. The data obtained were then processed and analyzed using SPSS26 modelling software. The results showed that 1) most of the influencers chose to upload photos or videos of the location along with the influencer himself (41,365), 2) influencers chose to use long shot camera shot size (46.46%) to be able to show the location of tourist destinations better, 3) in terms of using angle, 2,356 respondents (54.16%) used eye level shots, and 4) 2,255 (51.84%) used to post photos with cold colour schemes when taking pictures. Based on the statistical data, social media influencers affect purchase intention. Therefore, these image indicators of tourist attractions in quality and track record need to be considered by managers to prepare places that cater to influencers as tourism promotion agents.

INTRODUCTION: Organizations must ensure that their employees work in an environment that is supportive and welcoming, as the working environment plays a crucial role in the achieving job satisfaction (Raziq & Maulabakhsh, 2015). The job satisfaction of individuals is significantly influenced by the working conditions, which are contingent upon the institutional context (Díaz-Carrión et al., 2020). Employed parents may have an impact on their children's opportunities in life, as they might have less ability to focus on their children compared to unemployed parents (Aldrich et al., 1998). Therefore, child care supports working parents by providing care and guidance to their children on the behalf of the guardians, ensuring the children's safety throughout the entire day (Yamoaha et al., 2023). According to some researchers, there isn't sufficient evidence to conclude that formal early adolescent training of even the highest caliber is typically either the long-term beneficial or dangerous to the kids (Buckingham, 2007). However, after an in-depth study Lai & Gill, (2019) conclude that, child care centers offer potential advantages for both children with and without disabilities, but they can also the present difficulties or obstacles for these children. According to an increasing body of research, child care centers foster the development and long-term well-being of children (Sokal, 2020). There could be multiple arguments regarding the quality of child care centers (Pourcq et al., 2019;Li et al., 2023). Though, service quality may vary for different reasons (Dey et al., 2021;Dey et al., 2019). In recent times, daycare has become increasingly regarded as a means to create equal opportunities for children from diverse family backgrounds (Jessen et al., 2020). In economically developed nations, there has been discussion about individuals facing a "time squeeze" in recent years, where the working hours of many fulltime employees have either remained unchanged or risen (Veal, 2020). The unemployment rate in Bangladesh is declining due to the beneficial influence of various factors, such as technological advancements, economic changes, and social developments (Salam et al., 2021;Rahman et al., 2021). Consequently, there has been a rise in the number of employed women and parents in comparison to the preceding decade (Suppramaniam et al., 2019;Uddin, 2021). Therefore, there has been a notable growth in the demand for child care centers in Bangladesh over the past few years (Elsey et al., 2020). However, a significant amount of study has been done using child care facilities in Bangladesh. Therefore, the primary goal of this study is to defend the state of daycare services in Bangladesh. Along with the primary goal, the researcher will also look for factors influencing the daycare industry in Bangladesh and how daycare programs assist working parents. --- Theoretical Foundation Daycare centers have become an integral component of the typical childhood environment, where children may encounter elements that could impact their respiratory well-being. An essential element of this exposure is that it commences at a very young age (Nafstad et al., 1999). A child care center is a place where parents can enroll their children for supervision while they attend work, and these establishments provide care for groups of children who are often grouped together based on their age in appropriate classroom settings (Martucci, 2023;Adama et al., 2022; Cambridge dictionary, 2023). Both fathers and mothers experienced disruptions in their employment, but mothers were disproportionately affected (Fuller & Qian, 2021). Child care is of utmost importance and has the potential to the provide advantages to a significantly larger number of working mothers and families (Clarke-Stewart & Allhusen, 2005). Child care holds significant importance for families who are engaged in the workforce (Inwood & Stengel, 2020). Enhancing the capacity to effectively manage both professional and familial responsibilities can contribute to nurturing parent-child dynamics within the workplace (Kim, 2020). Working women who are also housewives face considerable obstacles as they navigate the balancing act between their professional responsibilities and family life (Ahmad et al., 2011). When selecting childcare options, parents prioritize the educational impact as their foremost consideration (Hossain and Islam, 2022; Lee et al., 2022). The COVID-19 pandemic has profoundly complicated various aspects of everyday life across society (Salam et al., 2022) and the work life balance was much harder at that time. Working parents often require daycare services for their children due to their busy schedules. However, it is crucial to address concerns regarding the safety, security, and quality of care provided by the daycare center. This study aims to investigate these aspects from a Bangladesh-specific standpoint by conducting a comprehensive literature review. --- METHODOLOGY: Similar to other forms of writing, traditional reviews are susceptible to subjective biases as they rely on the authors' intuition and personal experience. However, with the advancements in electronic databases, Systematic Literature Reviews (SLRs) can now be conducted with increased efficiency and transparency compared to previous methods (Kraus et al., 2020). Conducting a critical evaluation of published systematic reviews and meta-analyses can be beneficial to assess their strengths, weaknesses, and identify areas that necessitate further improvement (Moraschini et al., 2017). This work adheres to systematic review standards by conducting a comprehensive search for relevant information, analyzing complete articles on knowledge management procedures, and presenting original discoveries. Fig. 2 shows the systematic literature review process which is adopted from previous research (Talib et al., 2022). To demonstrate the search results and ensure the quality of the present literature review, a customized adaptation of the PRISMA flow chart was employed (Wells & Lang, 2016). Fig. 1 shows the PRISMA of the systemic literature, which was developed following the proper research guidelines (Page et al., 2021). --- Data Extraction and Synthesis A web data extraction system typically interacts with a web source to establish a connection and retrieve data from it, and the gathered data is subsequently organized in the most advantageous format and stored for future utilization (Ferrara et al., 2014). Utilizing synthetic data as an approach to safeguard privacy is effective because it does not contain information directly derived from the original dataset, resulting in a reduced loss of information (Hernandez et al., 2022). The research strategy comprised two phases, and these phases were adopted from the previous study (Attar et al., 2022). Initially, a com-prehensive compilation of literature related to daycare for children, daycare facilities, and child care services was undertaken. To ensure inclusivity across a wide range of academic articles, it was emphasized by (Preston et al., 2022) that multiple sources of scholarly research should be considered. In order to ensure a comprehensive review for the Systematic Literature Review (SLRs), multiple databases were utilized to verify that the majority of relevant literature had been examined. Furthermore, in order to enhance the comprehensiveness of the systematic study, the references of the selected citations were monitored to identify relevant articles. --- Analysis of Relevant Studies Over the past few years, numerous studies have been conducted in this field, contributing diverse and multidimensional insights to the existing body of literature. Consequently, nearly all of the studies were incurporated into multiple databases. Following a meticulous screening process, only selected studies were included in the literature review. --- CONCLUSION: In this article, we present a thorough assessment of the literature by incorporating the data synthesis findings from fifteen research studies conducted on indexed entities spanning the period from 2005 to 2022. In greater detail, the studies were categorized according to the research focus employed by the authors. Additionally, they were classified based on their source and publication time frame. Enhancing productivity within this emerging sector is increasingly vital. In Bangladesh, the accessibility of child care support remains a significant challenge for women in the workforce. The findings of this research will provide valuable assistance to working parents, various organizations, and the daycare sector as a whole. It is important to acknowledge the limitations of this study. Conducting a meta-analysis requires a substantial number of publications. Furthermore, conducting quantitative research is feasible only when all relevant aspects are thoroughly considered. --- ACKNOWLEDGEMENT: We would like to express our heartfelt appreciation to the Almighty Allah for granting us the opportunity to conduct this research. Furthermore, we extend our gratitude to all those involved in this particular aspect of the research study, whose contributions were the instrumental in its successful completion. --- CONFLICTS OF INTEREST: All authors of this research declare no conflicts of interest. --- REFERENCES: 1 Working women work-life conflict. Business

Creating a supportive and welcoming working environment is crucial for organizations to ensure employee job satisfaction. The main objective of this study is to advocate for the state of daycare services in Bangladesh. In addition to this primary goal, the researcher will investigate factors influencing the daycare industry in Bangladesh and explore how daycare programs benefit working parents. This research adheres to systematic review standards by conducting a comprehensive search for relevant information, analyzing complete articles on knowledge management procedures, and presenting original findings. The researchers extensively examined most of the topics and aimed to identify any gaps in existing research. The study highlights the growing dependence on child care services in Bangladesh, which poses challenges for working parents due to the prevailing family structure. Furthermore, the current child care facilities do not meet parents' expectations in terms of provided amenities. The outcomes of this research will provide valuable support to working parents, organizations, and the daycare sector as a whole.

that, under the worst circumstances, may lead to homelessness. These personal triggers include such crises as leaving the parental home because of conflict and abuse, marital or relationship breakdown, family violence, death of a spouse, leaving prison, leaving some form of socialor health-sector care, sharp deterioration in mental health, increase in alcohol or drug abuse, mounting debts or eviction from a rented or owned home. In today's economic uncertainty, these issues have become urgent and threatening. It is particularly timely, therefore, to present a special issue on homelessness, bringing together some of our country's leading experts on the topic. Employment is a particularly critical area to be understood by policy makers, practitioners, and scholars. It is an important segue out of homelessness and precarious employment, unemployment, or other issues associated with labor market integration which put people at risk of being homeless. And yet we know less than we should, from both theoretical and analytical grounds. The first article, by Micheal L. Shier, Marion E. Jones, and John R. Graham qualitatively analyzes the perceptions of employed individuals' experiences of homelessness in Calgary, Alberta-a population hitherto neglected in the literature. They are followed by an examination of some issues of specific impact to select homeless sub-populations. Unemployment of young people is particularly high in Canada, as in other Organization for Economic Cooperation and Development (OECD) nations. Karabanow, Hughes, Ticknor, Kidd, and Patterson therefore delve into youth perceptions about formal and informal employment in Halifax, Nova Scotia, Canada. Following them are John Coates and Sue McKenzie-Mohr, examining the trauma histories of homeless youth in the Maritimes using an adapted Trauma Symptom Inventory. A different and also under-researched area is immigration, and to the fore come anthropologists Alina Tanasescu and Alan Smart, who use interview and survey data collected from immigrants experiencing housing stress to better understand how this population might be assisted. Geographer Geoffrey Nelson takes a new look at a different secondary literature, providing the first major analysis of the transformative evolution from custodial forms of housing to supportive housing to the present supported housing, or "housing first" model. A vitally important stakeholder, and again one about which we do not know enough, is the media. As a corrective, communications scholars Barbara Schneider, Kerry Chamberlain, and Darrin Hodgetts examine the ways that four Canadian newspapers frame stories about homelessness in Canada-and show that all is not what one might first think. Concluding the edition is economist George Fallis, one of the country's eminent scholars on homelessness, who presents a history of Canada's welfare state as it pertains to housing policy. The interdisciplinary nature of the special issue is paramount. The following pages highlight the useful contributions that scholars, particularly those with an interest in theory, bring to the table. The special edition guest editors would like to thank Dr. Robert D. Leighninger, Melinda McCormick, and their team for helpful guidance at all stages in our process; to Micheal Shier and Heath McLeod, for leadership of the management of the copy editing of our special edition; to Sarah Meagher, who provided many months of leadership to the management of the special edition review and author submission processes; and to the authors, communities, and funders who were involved in the resulting dissemination. Not an unusual facet for a special edition: in several instances, and with the encouragement from the team at the journal, the coeditors were authors, and in each of these instances the double blind peer review process (as with all of the other articles) prevailed: authors were at all times precluded from any peer review decision making process. The special edition provides ample evidence that scholars can provide enormously helpful research into such issues of public policy as homelessness. Likewise, the work of Canadians can be of interest to readers from other countries. May the present special edition fertilize these prospects further; and above all else, may they contribute to our understanding of, and therefore solutions to, one of the great social problems of our time.

over 700 people gathered for more than three-days at 'Growing Home,' Canada's second national conference on housing and homelessness (www.nhc2009. ca) to explore causes and solutions to this urgent problem. Conference delegates included those who are experiencing or have experienced homelessness, their families, policy analysts, political activists, politicians, professionals, scholars, those in the affordable housing community, and concerned citizens generally. Over 140 academic papers and workshops were delivered by the country's leading researchers and homelessness-serving practitioners. There is an enormous scale of homelessness in advanced industrialized countries such as Canada. In a country of over 34 million people, between 150,000 and 300,000 are homeless, and various levels of government commit from $3 -$6 billion to supporting those on the streets. There are structural issues that can increase the risk of homelessness, including threats to income such as a rise in unemployment, low assistance levels for those with disabilities and seniors, lack of social housing and rent supports, insufficient affordable housing, and too many precarious jobs (involving job insecurity, low wages or high risks of ill health). Then there are events in a person's life

INTRODUCTION The school in modern times is characterized as a social environment in which the majority of students spend most of their time, because it is a space understood as a privileged place for learning, not simply of irrefutable educational themes, as well as of values and beliefs, which young people assimilate to confront themselves and live in society. in addition to developing critical thinking, self-esteem and security (BYDLOWSKI;LEFÉVRE;PEREIRA, 2016, p. 47). In view of this scenario, it is proposed to investigate the conceptions of the school community in relation to learning failure, thus seeking to understand how the social authors of the school community instigate with mediators with social vulnerability in the constructive resource in the researched school, using various fields of knowledge such as pedagogical praxis (FERREIRA, 2020, p. 86), pedagogical resources (SOSA; MANZUOLI, 2019), family influence (ARRUDA, 2019;BITENCOURT, 2019), school management (PASCHOALINO, 2018) and, in a global way, perceiving the circumstance of the subject who has blocks in reading and writing (AZEVEDO et al., 2019;SILVA and COUTINHO, 2019). The research was conducted in a municipal school from May 2019 to March 2020. It is extremely important to know the magnitude of the changes in order to understand the human being in its social context, to understand the path that the school needs to follow to support its pedagogical praxis, making it a conscious practice of the work that the mediators adjust to evolve, guiding in consideration the diversity and consequences coming from the most diverse realities, that surround the student and his/her family, in numerous significant references in the teaching-learning system (FERREIRA, 2020, p. 91). With the purpose of absorbing the problems of some teachers about the various factors that imply for social vulnerability (SOSA; MANZUOLI, 2019;BITENCOURT, 2019). However, it conducts an investigation that is necessary to cooperate with the study and find ways to improve the student's development and point out the following problems: What are the pedagogical praxis developed by the mediators of the researched school in relation to the students of the final years that indicate low school performance? How does the interaction between family and school take place for the progress of this student and how does the school community consider the most vulnerable in the face of learning adversities? How can the school contribute to circumventing or at least minimizing the gaps that will remain in development, and how to motivate students who live in a situation of social vulnerability followed by neglect and mistreatment so that they can overcome and achieve good school performance? It is hypothesized that the family plays an important role in the children's learning process, and its participation in the solution of these problems is very important. Another key point is that it is up to teachers and managers to know the reality of students to develop pedagogical practices and thus contribute to their development in learning, with this the school will have knowledge of the family structure, economic partner and the reality in which this student is inserted. However, based on the issues mentioned above, it is understood that for an improvement of the reality, it is also necessary that there are investments from the municipalities and the state to provide an opportunity to face this reality. (BITENCOURT, 2019, p. 72). Its general objective is to analyze the intervention strategies of teachers who teach in the final grades of elementary school with students in situations of social vulnerability in an educational institution of the municipal network. The specific ones: to verify the practices developed by the teachers of the final years to solve the difficulties of students who present social vulnerability; to investigate the relationship between family and school in the school context in the face of students who have low academic performance; Understand the management strategies for this student in the school environment. The object of study is justified by the low school performance, in view of the problems of social inequality presented by the students of the final years of the school researched, however it is essential to deepen the question to prove, in fact, what are the greatest obstacles that cause the various difficulties of the students in the daily school development and appropriation of knowledge. It is relevant to detect the changes that "occur in the student's life, to understand the path that the school needs to take to base its pedagogical practice, reaching the student in his most diverse realities", in order to offer the necessary support for the introduction of this student in society. (BITENCOURT, 2019, p. 81). In the same way as the methodology, a bibliographic, qualitative, exploratory research of a basic and qualitative nature is applied, with descriptive, cross-sectional statistics, because the data collected and analyzed allowed us to verify that both the school faculty and the management team seek to use attractive pedagogical practices with students who present social vulnerability, seeking to reconcile their family daily life. For data analysis and interpretation, the qualitative approach was chosen as an instrument for data collection, using questionnaires directed based on information to ten teachers of the final years of elementary school, the school manager and ten parents of students of the final years of the school field of research. In structure, the dissertation is divided into three chapters: The first addresses the following themes: The study of the terms mentioned points to a single denominator: these are individuals who are vulnerable because they are fragile and subject to risk factors. According to Prati, Couto and Koller: Social fragility can be externalized in the illness of one or more members, in present situations of drug use, domestic violence and other conditions that prevent or stop the healthy development of this group. Social vulnerability is a term used to characterize families exposed to risk factors, whether personal, social, or environmental, which help or add to the viability of their members to face psychological disorders (PRATI, COUTO and KOLLER, 2019, p. 404). However, social delicacy can manifest not only in a single family, but in an entire community, which is more regular. It is linked to situations of oscillation in the family environment, as well as the use of drugs, where individuals who go through this conjuncture point out weaknesses in their private talents (PRATI, COUTO; KOLLER, 2019). Thus, vulnerability is accompanied by extreme poverty, but this is not what defines it. However, it is called by the lack of perspective of changing the current condition in which it is situated, and is fixed to discovery, because this level of the population is located in more distant places and, more often, close to cities, in urban environments (KAZTMAN, 2005apud SILVA, 2017, p. 3). According to Silva, "populations affect such a great degree of fragility that they cannot have the ability to choose or deny what is offered to them" (SILVA, 2017, p. 3). In view of the infinite circumstances of social vulnerability that point to an extreme number of people who are exposed in Brazil, here is an explanation by the Institute of Applied Economic Research (IPEA), through the publication entitled "Atlas of Social Vulnerability in Brazilian Municipalities", about the intellect of social success. Conducting from various situations of social vulnerability to which a vast number of people are exposed in Brazil, we point out here an explanation by the Institute of Applied Economic Research -IPEA, through the publication entitled "Atlas of Social Vulnerability in Brazilian Municipalities", about the concept of social prosperity. In the same way, the conception of social abundance leads us to reflect on the definition of sociable vulnerability. The same "Atlas of Social Vulnerability in Brazilian Municipalities" points out that the fundamentals of "exclusion" and "social fragility" have been gradually manipulated, in Brazil and in the world, by researchers, managers and operators of social policies, in an effort to expand the capacity of the historically established conjunctures as poverty, tracking and issuing an expanded conception added to the one subordinated to the one subordinated to the inquiry of lack of income. In the same way, the principles of primordial nonconformist conveniences, multidimensional poverty and human evolution, exclusion and social vulnerability are "notions first of all political (even if they are not always perceived as such), which insert new aids of understanding in the face of the procedures of sociable development, and then of its monetary aspect" (BRASIL, 2015, p. 12). --- According to Bomtempo and Conceição: In the national panorama, there is a huge portion of the population in extreme social inequality. In these situations, the family as a child protection institution finds it increasingly difficult to perform this care. Situations of misery and impoverishment configure families and conjunctures that pacify interruptions and vulnerability of connection and dedication. Disaggregated families, with paradoxical conceptions, who find themselves in degrading socioeconomic circumstances, ensuring basic precarious care for children, create risk factors for the healthy growth of the immature (BOMTEMPO; CONCEIÇÃO, 2014, p. 495). In view of the references, there is a displacement in the prerogatives of the circumstance of vulnerability, since it is not integrated as an exclusive characteristic of the individual, but as a result of the arrangement of stipulated social and political agreements that will relatively affect citizens. School meals are the only alternative food for many poor children in situations of social vulnerability and exclusion from the school system. This part of the population has been surviving in extremely precarious conditions in terms of food, hygiene, health and education. Far from achieving better opportunities, since most of them have no education, a fact that makes it impossible for them to enter the job market. Such a condition leads to colloquial work, where many are exploited and work only to survive, taking away any chance of achieving a better social condition. One of the fundamental personalities of these families is the decay of schooling. The school is put in the background since what matters most is the need to guarantee an income and this is seen with greater concern (SOARES, 2017, p. 75). Social vulnerability is close to numerous social disadvantages, but it is essential to the loss of affective, relational and violence-related connections. The child's acquisition methodology begins even before he enters school, in view of this it is relevant to have an environment in which acquisition is supported, where adults encourage children to study. However, in vulnerable populations, few families have the capacity to take ownership of educational materials, time and attention for children (SILVA; RAPOPORT, 2015, p. 46). Long working hours have greatly reduced the time parents have to spend with their children. However, more than filling their physiological scarcities, students primarily need affection and attention. Consequently, in the distance of time, children's development is impaired (SUKIENNIK, 1996 apud CASARIN;RAMOS, 2017). However, their development is totally affected as a consequence of the precariousness of family relationships (CASARIN; RAMOS, 2017). It is believed that the experiences of children and adolescents directly afflict their life at school, as the lack of resources and tiny materials for survival constantly stimulate early entry into the world of work; There is the exploitation of child labor and a high rate of school failure and dropout. In view of this, they end up not having a professional vision and a project for the horizon (SILVA; RAPOPORT, 2015, p.78).

School in modern times is characterized as a social environment in which most students spend most of their time, as it is a space understood as a privileged place for learning, not simply an irrefutable educational theme, as well as values and beliefs, which young people assimilate to confront themselves and live in society, in addition to developing critical sense, self-esteem and security (BYDLOWSKI; LEFÉVRE; PEREIRA, 2016, p. 47). Faced with such a scenario, it is proposed to investigate the conceptions of the school community in relation to failure in learning, thus seeking to understand how the social authors of the school community instigate mediators with social vulnerability in the constructive resource in the researched school, using various fields of knowledge such as pedagogical praxis (FERREIRA, 2020, p. 86), pedagogical resources (SOSA; MANZUOLI, 2019).

INTRODUCTION Repeated pregnancy in adolescence is defined as a new pregnancy in the age group 10-19 years, being considered fast when a second delivery or a new pregnancy occurs within 2 years from the last pregnancy 1 . This is a matter of concern because it increases the risk for materno-fetal health 2 . In the United States of America (USA), approximately 12-49% of adolescent repeated pregnancies occur within 1 year of the previous pregnancy 3 , reaching 63% within 18 months. Among girls with repeated pregnancy, two-third reported that it was a unplanned pregnancy [4][5][6] . The younger the adolescent mother is, the greater the socioeconomic vulnerability and the materno-fetal complications 2, 6,7 . Experiencing another delivery before the age of 20 years may lead to unfavorable perinatal outcomes in a higher proportion than in the first childbirth. Repeated pregnancy in adolescence is more common in contexts of poverty, low education level, sexual initiation before the age of 15 years, early union, no use of effective contraceptive methods, and previous abortion or dead fetus birth [8][9][10] . As a single event, pregnancy in adolescence causes an important impact in the life of the adolescent and her family. Comparing with the first pregnancy, repetition leads to a greater risk of preterm birth, low-weight birth, greater perinatal and neonatal mortality, and child developmental disorders [5][6][7] . This reflects the lack of capacity of health systems to supply the basic needs of health education and social well-being of adolescents following the first pregnancy. Because of the effects throughout life, it is essential to identify the causes of repeated pregnancy in adolescence in order to develop appropriate prevention strategies to reduce its occurrence 9 . The aim of this study was to assess repeated pregnancy among Brazilian adolescents in the period from 2015 to 2019 and its association with marital status and educational level. --- METHODS This is a cross-sectional study conducted with data obtained from the Live Births Data System (SINASC), through the server of the Informatics Department of the Unified Health System (DATASUS) with the purpose of gathering epidemiological data on informed births in the national territory 11 . The following variables were used to perform this study: birth according to the mother's place of residence, birth according to region of the country, year of birth, maternal age, and number of pregnancies. The variable that assesses the number of previous pregnancies is named QTDGESTANT in the DATASUS database. The download of data from SINASC was performed from the DATASUS page for the years from 2015 to 2019 (Brazil, DATASUS). For each year and Federative Unity, there is a file in dBase File Compacted (*.dbc) format, which was converted into dBase File (*.dbf ) via batch script (.bat) using the application TabWin developed by DATASUS (Brazil, DATASUS). Since the database comprises millions of registers, it was necessary to use the Database Management System (DBMS) to analyze and manipulate such a large amount of data. The option was for DBMS open source PostgreSQL, version 11.8. Data were imported into PostgreSQL from DBF files by means of scripts developed in Python language, version 3.8. The study encompassed all women in the age group 10-19 years who had live births (LB) in Brazil in the period 2015-2019, with data available in the SINASC database (n=2,405,248). Data obtained included the total number of LB in age groups 10-14 and 15-19 years, to calculate LB rate of repeated pregnancies among adolescent mothers. The adolescents were placed in three groups: group 1: primiparas; group 2: with one previous pregnancy (second pregnancy); and group 3: with two or more previous pregnancies. There was also the assessment of sociodemographic data referring to marital status and education level of adolescent mothers, with the purpose of relating them to the prevalence of repeated pregnancy. Data were analyzed by the Epi-Info 3.5.4 software. The research project that resulted in this article was sent to Plataforma Brasil, received the number CAAE 04209418.1.0000.5259, and was approved by the Research Ethics Committee of Pedro Ernesto University Hospital of Rio de Janeiro State University (UERJ). --- RESULTS The total of repeated pregnancies remained stable along the years. In the age group 10-14 years, the decrease in the period was from 5.0 to 4.7%, whereas in the age group 15-19 years, there was a decrease from 27.8 to 27.3% (Table 1). Repeated pregnancy two or more times among all adolescents presented a slight decrease (from 5.9% in 2015 to 5.5% in 2019) with higher frequency in the age group 15-19 years (Table 2). Among adolescents aged from 10 to 14 years, in group 1 (primiparas), 19.1% were married or in a consensual union, and 63.6% had an education level lower than 8 years. In group 2 (second pregnancy), the rates were 31.1 and 73.3%, and in group 3 (two or more previous pregnancies), the rates were 35 and 70.1%, respectively. Among adolescents aged from 15 to 19 years, in group 1, 31.6% were married or in a consensual union, and 22.7% had an education level<8 years. In group 2, these rates were 38.4 and 38.0%, and in group 3, 42 and 51.7%, respectively (Table 3). It was observed that as the number of pregnancies increases, the same occurs with the rates of early marriage and low education level. Being married or in a stable union increases the chance of repeated pregnancy by 96% in the age group 10-14 years (p<0.001; OR=1.96; 95% confidence interval [CI] 1.85-2.09) and by 40% (p<0.001; OR=1.40; 95%CI 1.39-1.41) in the age group 15-19 years. Girls aged 10-14 years with an education level <8 years had a 64% higher chance of repeated pregnancy (p<0.001; OR=1.64; 95%CI 1.53-1.75), whereas in the age group 15-19 years, there was a 137% higher chance of repeated pregnancy (p<0.001; OR=2.37; 95%CI 2.35-2.38) (Table 3). --- DISCUSSION This is the first study to present data on repeated pregnancy in adolescence in the entire country, using official current data obtained from the full SINASC database of the Ministry of Health 11 . The available studies conducted until the present time are punctual and focused on the reality of the researchers' own states. Despite the decrease of 37.2% in the frequency of adolescent pregnancy in the past years 12 , repeated pregnancy does not occur in the same way. It can be verified that in Brazil, between 2015 and 2019, there was no significant decrease in repeated pregnancy. It is observed that the occurrence of repeated pregnancy remains a great challenge in Brazil, as well as in several other countries. In Uruguay, despite a 50% decrease in the rate of adolescent pregnancy (from 72 to 36‰) 13 , repeated pregnancy in adolescents aged<15 years is maintained at 20%, and as the age raises, there is an increase in the number of planned pregnancies 14 . In Chile, there was a decrease from 57.5‰ in 2010 to 26.5‰ in 2017 13 ; however, repeated pregnancy is an issue that has not yet been resolved and is a challenge for public policies for adolescent health 15 . In the USA, repeated pregnancy in adolescence decreased from 53.8 to 16.9% between 2004 and 2015 16 . In 2017, 16.3% of North-American girls in the age group 15-19 years became pregnant again during adolescence 17 . In Australia and Canada, the prevalence of repeated pregnancy in adolescence is of 33 and 15.2%, respectively 18 . In Uganda, repeated childbirth in adolescence has not decreased in the past 30 years, and the average number of live births among women aged<20 years remains at 2.2 7 . Available specific data for some states of Brazil reveal that in Piauí, the prevalence of repeated pregnancy within the period of 2 years after the end of a pregnancy was 25.9% in the capital and 35.4% in the hinterland 19 . A study conducted in Ceará presented 61% of adolescent pregnancy 5 years after the first pregnancy, and 40% of them had become pregnant more than once within this period 20 . Early marriage is an important cause of a new pregnancy, because it provides family structure, which in many cases leads to nonregular use of contraception methods, hence the occurrence of a new pregnancy. Brazil is ranked fourth worldwide in absolute numbers, with more child marriages. In the country, 26% of the female population marries before the age of 18 years 21 . The Federal Government published Law No. 13.811/2019, which prohibits the marriage of adolescents younger than 16 years, aiming to minimize this problem, but it is not possible to avoid consensual unions 22 . Often, marriage and maternity are the way in which those adolescents are inserted in adult life and have a more important role in their families, thus creating a vicious circle of poverty and repeated pregnancy. According to the World Health Organization, the problem of pregnancy in adolescence becomes greater as the adolescent's age decreases. The United Nations Population Fund showed that of 7.3 million pregnant adolescents worldwide, 2 million are aged less than 14 years. This situation may induce the aforementioned vicious circle of poverty and low education level, with a decrease of three times in the opportunity of achieving a university degree, and an income that is on average 24% lower than that of women who are the same age without children 23 . Confirming the findings of this research, Maravilla et al., in a meta-analysis, showed that continuing at school and having more years of education are protective factors for the prevention of repeated pregnancy in adolescence 9 . This situation was even more aggravated with the COVID-19 pandemic. It has been highlighted that schools were closed in 194 countries due to pandemic restrictions, thus increasing social inequality. In sub-Saharan Africa, approximately 1 million girls did not return to school due to pregnancy during the period of COVID-19 restriction measures 24 . Systematic reviews suggest that the most efficient strategies to prevent repeated pregnancy in adolescence are the promotion of access to highly effective methods, especially long-acting reversible contraceptives (LARC), which include hormonal intrauterine devices (IUD), copper IUD, and etonogestrel implants. This should be followed up by means of motivational interviewing conducted by skilled nurses, who provide individualized education on birth control options based on the adolescents' preferences, besides guiding them toward effective contraception 9,25 . The offer of LARC in the immediate postpartum results in a higher rate of permanence of its use at 3, 6, and 12 months, and the supply of LARC before hospital discharge increases the chances of effective contraception in the postpartum, significantly reducing repeated pregnancy in adolescence 3 . As limitations of this study, we point out the fact that it was conducted using SINASC data, which made it impossible to assess the interval between pregnancies, if it was a planned or unplanned pregnancy, if the new pregnancy was from the same partner, and previous abortion history. However, the finding of a high rate of repeated pregnancy in adolescence in Brazil highlights the dimension of the problem and the need for effective public policies for its reduction. --- CHECKLIST STROBE. --- AUTHORS' CONTRIBUTIONS

The aim of this study was to assess the rate of repeated pregnancy in adolescence and its association with early marriage and education level. METHODS: This is a cross-sectional study conducted by searching the Live Births Data System. The study included all adolescents in the age group 10-19 years with live births from 2015 to 2019 (n=2,405,248), divided into three groups: G1: primiparas; G2: with 1 previous pregnancy; and G3: with two or more previous pregnancies. RESULTS: Total repeated pregnancies remained stable, along the years. In the age group 10-14 years, the decrease in the period was from 5.0 to 4.7%, whereas in the age group 15-19 years, it was from 27.8 to 27.3%. Being married or in a stable union increases by 96% the chance of repeated pregnancy in the age group 10-14 years (p<0.001; OR=1.96; 95% confidence interval [CI] 1.85-2.09). In the age group 15-19 years, the chance of repeated pregnancy among the married or in stable union increased 40% (p<0.001; OR=1.40; 95%CI 1.39-1.41)). Girls aged 10-14 years with an education level of<8 years had a 64% higher chance of repeated pregnancy (p<0.001; OR=1.64; 95%CI 1.53-1.75), and among those aged 15-19 years, there was a 137% higher chance of repeated pregnancy (p<0.001; OR=2.37; 95%CI 2.35-2.38). CONCLUSION: Repeated pregnancy in adolescence in Brazil remains very high over the years. There is an association between low education level and early marriage with repeated pregnancies in adolescence.

Not only do their criticisms of Henrich's and Powell et al.'s (3,4) modeling assumptions miss their mark (2), but Vaesen et al. also ignore many other models that don't rely on these assumptions yet arrive at similar predictions. These other models variously include conformist transmission and explore these processes using non-Normal distributions, discrete-traits and networks, etc. (2,5). Of course, no one expects demographic/population variables to be the only things that matter, as cultural packages related to clothing or housing, e.g., will vary with latitude for reasons unrelated to demographics, risk or mobility. Vaesen et al are correct that these models assume that at least some individuals can sometimes assess the relative success or payoffs of different traits or individuals; but they are incorrect in claiming that there is little evidence for such learning. First, they ignore a vast body of laboratory evidence showing that infants, children and adults use cues of success, skill, or competence in learning (2,6). Second, Vaesen et al. also ignore work showing that (a) Hadza and Ache foragers acquire cultural information obliquely from broad networks (7) and (b) successbiases are well documented in traditional populations (2). Finally, the studies cited by Vaesen et al. do not support their claims about vertical transmission; instead, all support the two-stage learning process used by Henrich, Powell et al., and many others. Here, individuals initially learn from their parents, and then update only if they observe others who are more successful than their parents. Evidence from fisher-horticulturalists and foragers support this pattern and shows that second stage updating from non-parents is particularly prevalent in domains with high variation in skill/success. For example, Aka foragers learn from great hunters and prestigious shamans (2). Vaesen et al. ignore laboratory tests of these models (2). Using novel learning tasks, several experiments show how group size and interconnectedness influence the accumulation of skill, know-how and complexity, and some demonstrate the 'Tasmanian effect' (8). If the models are so poor, it's peculiar that they have withstood multiple experimental tests by independent researchers. Vaesen et al. cite studies by Collard that do not find a significant relationship between census population sizes and complexity. However, the theory predicts it is the size of the population that shares information-the effective cultural population size (3)-that matters, and if there is extensive contact between local or linguistic groups there is no reason to expect census population size to correspond to the theoretically-relevant population. Inappropriately, Collard used highly interconnected populations, and makes no effort to measure these interconnections or deal with the conceptual problems of using census estimates. Finally, Vaesen et al. ignore important findings linking population size to both linguistic complexity and innovation rates (2, 9, 10).

Understanding cumulative cultural evolution. Proceedings of the National Academy of Sciences of the United States of America, 113 (44). E6724-E6725.

Investigation and Analysis of Professional Women's Fertility Willingness A total of 1000 copies were distributed in this survey, and 925 copies were effectively recovered. From the data, we can clearly analyze women's desire to have children and the influencing factors. Published by Francis Academic Press, UK -40- --- Fertility of Professional Women at Different Ages It can be seen from Figure 1 that the majority of professional women aged 31-35 and 36-40 have given birth to one child, but there are also nearly the same proportion of women who have not given birth; The number of professional women who have given birth to one child between the ages of 26-30 and 41-45 is almost the same, but the number of people who do not want to have a second child between the ages of 26-30 accounts for 16%; In addition, 55% of women aged 20-25 have no children; The proportion of professional women aged 31-45 who do not want to have a second child is 14%. In addition, in the 925 surveyed samples, the proportion of women who would like to give birth to a second child as a boy is about 27%, 27.2% for those who would like to give birth to a second child as a girl, and 45.9% for those who would like to give birth to a second child whether it is a boy or a girl. With the continuous development of society, people have reduced the discrimination against the sex of the fetus. Those women, who have given birth to one child, hope to achieve the family structure of both children. In addition, 17% of professional women said they did not want to have a second child. Therefore, it is necessary to understand the influencing factors in order to ensure women's fertility [1]. --- Figure 2: Investigation into Women's Willingness to Have Boys or Girls --- The Impact of Occupational Differences on Women's Fertility --- Figure 3: Investigation into Women's Fertility of Different Occupations Figure 2 shows the impact of occupational differences on women's fertility. It can be seen from the data that more freelance women do not want to have a second child than professional women. Of the 336 freelance women, 70 do not want to have a second child, accounting for about 21%; Among 555 professional women, 126 do not want to have a second child, accounting for 23%. In Figure 3, compared with other occupations, the proportion of people who do not want to have a second child in these two categories is 25%. In addition, during the survey, it was learned that civil servants and female teachers are more likely to have a second child because of their better treatment for childbirth, while women who lack security may give up the idea of childbirth. At the same time, the economic pressure Published by Francis Academic Press, UK -41-and employment pressure have become the main factors that affect the fertility desire of women with general positions and salaries [2]. --- The Impact of Career Development on Women's Fertility --- Figure 4: Investigation on the Impact of Fertility on Women's Occupational Stability The most direct impact of female fertility is taking maternity leave or even resigning to take care of children at home. Some enterprises even dismiss pregnant women in violation of regulations. Therefore, the lack of maternity welfare system and potential unemployment risk have become important factors determining women's fertility willingness. According to the data, 50% of the respondents think that childbirth has a great impact on professional women, 30% of the respondents think that it has no great impact, and 20% of the respondents think that it has no impact, it was showed in Figure 4. The survey results show that most women believe that fertility has a greater impact on their career development, so the occupational risk brought by fertility is an important reason for the delay and even infertility of most women [3]. --- Factors Influencing Women's Fertility Willingness --- Age It can be seen from the survey that women of different age groups have a trend of low fertility at both ends and high fertility at the middle. The reason may be that the majority of professional women under the age of 30 are at the stage of hard work, which means they mainly consider working, with less consideration of having another child; Most professional women aged 31-40 are mature in work, marriage and mental development. Thus, they pay more attention to family life and childbearing; The physical function of professional women over 40 years old gradually decreased, the fertility risk increased, and the fertility desire to have more children was affected to a certain extent. At the same time, education also has the same important impact on women's willingness to have more children. --- Economic Conditions It is also very obvious that women's fertility willingness is restricted by economic conditions. From the above data, it can be seen that the number of women who are willing to give birth and work is relatively large, while the number of women who are willing to give up work is relatively small. It can be seen that professional women still care about whether they have a job and whether they have a fixed source of income. Therefore, the economic condition is also the decisive factor that restricts the fertility of professional women. --- Family "Bringing up sons to support parents in their old age" is a concrete embodiment of the impact of traditional Chinese culture on women's fertility. Studies have shown that traditional women have a strong desire to have children. However, with the impact of western new ideas on traditional Chinese culture, the traditional culture is weakening the idea of women's fertility willingness. However, the impact of western concepts on Chinese women's fertility intention is not always negative, such as women's concept of fairness in the family. This means that men must participate more in the family, and over-dependence on mothers in the family will give women more family burden. Although Western countries advocate fairness, women still have more responsibilities in the family than men under the influence of the society at that time. This means that women's marriage quality is relatively low, and their willingness to have children is relatively low. Therefore, the family has also laid a solid foundation for professional women's fertility. --- Countermeasures to Improve Women's Fertility Willingness --- Guarantee the Fertility Supporting System for Women of Childbearing Age The establishment of flexible working system is not only to meet the requirements of women for "getting to and off work on time", "eating on time" and "resting on time", but also to meet the requirements of women for "taking care of family" on the basis of meeting their psychological needs in the family. Every woman has special needs to take care of people or things. If professional women can't finish their work better because of the inflexibility and inhumanity of work schedule, they can't better fulfill their responsibilities to the family, which leads to the weakening of family functions and women's self-reproach. Professional women often face difficult choices when there are contradictions between work and family. Therefore, whether women choose to work or choose family, it is an infringement of women's legal rights and interests, and it is also an unfair manifestation of women. Therefore, the government should clearly establish a reasonable, humanized and flexible working system for female workers in accordance with the provisions of relevant departments, take into account the actual situation of women and increase the care for female workers, and regulate and determine it through legislation. Therefore, the implementation of the flexible work system needs the joint efforts of the government, enterprises and society, and the good implementation of the policy is also a key factor for the relevant government departments [4]. --- Increase the Proportion of Corporate Social Security Reimbursement In terms of the maternity insurance subsidies, According to the Social Insurance Law of the People's Republic of China, enterprises generally pay the maternity insurance expenses of employees at a proportion of no more than 5% of their total wages, and individuals do not need to pay. The payment of the national maternity insurance fund only needs to be borne by enterprises, especially some small and medium-sized enterprises, which are often in poor operating conditions due to the increased costs of enterprises. Through observation, it is found that many enterprises have reduced the number of female workers of childbearing age in order to reduce the operating costs, such as the adjustment of work positions during pregnancy and the strict commuting system. The government should also give preferential policies to women of childbearing age to balance the reproductive burden of employers. For the frequent occurrence of gender discrimination in units, we should improve the maternity leave and social maternity security system. In terms of medical insurance, relevant government departments should also increase the proportion of women of childbearing age. According to the actual situation, the process can be simplified, with special medical insurance for women to have two or three children, so that women can enjoy a more comprehensive and complete social security service system in the family, so as to alleviate the pressure of women of childbearing age in work and family, and promote the fertility of women in China and improve the fertility rate of women. ISSN 2616-5783 Vol.6, Issue 3: 39-43, DOI: 10.25236/AJHSS.2023.060307 Published by Francis Academic Press, UK -43- --- Strengthen the Supervision for Women of Childbearing Age Enterprises should implement the legal rights and interests of female employees in strict accordance with relevant laws. In the interview, it was found that some women of childbearing age will not bear any expenses during maternity leave except for their own medical reimbursement insurance and the minimum wage standard of three months, and the labor protection articles will not be distributed during maternity leave. In order to relieve the economic pressure, women have to go to work on time as soon as the maternity leave is over, and they have to give up breastfeeding. Therefore, these hidden gender discrimination and the deprivation of women's legal rights and interests reflect the lack of corporate responsibility. Therefore, the government should strengthen the supervision on the employment of enterprises and, if necessary, provide policy guidance so that women of childbearing age can dare to have, can have, and want to have children, and promote the supervision of the wage collective negotiation system, so as to improve women's wages and work. In addition, enterprises must implement parental leave and male paternity leave, and provide flexible policy support in the length of maternity leave, try to protect women's rights and interests during post adjustment and job transfer, and reduce the employment pressure of women of childbearing age at work. --- Conclusion To sum up, enterprises have a significant positive effect on the fertility intention of women of childbearing age. Therefore, the state and enterprises should protect women's legal rights and interests on the basis of protecting women's legal rights and interests. With the introduction of the family planning policy, the impact of fertility on women has become more and more important. Therefore, female fertility is not only the individual behavior of women of childbearing age, but also the behavior of a family and society. Only through the continuous and simultaneous efforts of the government, the country and the family can we build a harmonious family atmosphere and a good social environment. In order to promote the harmonious development of family and society, improve the fertility will of women of childbearing age, promote female fertility, and increase China's fertility rate, we need to fundamentally adjust China's fertility structure and promote the balanced development of population.

With the development of society and economy, women's willingness to have children is also decreasing. Women assume the double responsibilities of population and social reproduction in life, which also has a great impact on women's career development. Studies have shown that the comprehensive fertility rate of women of childbearing age in China in 2020 is 1.3%, which has reached the internationally recognized lowest level. In fact, the impact of female fertility on women's career development is mainly reflected in career stability, career income and other aspects. This study expounds women's fertility willingness in their career from three aspects: the survey and analysis of women's fertility willingness, the factors influencing women's fertility willingness, and the countermeasures and suggestions for women's career, so as to stimulate the positive effect of fertility on women and promote the coordinated development of population and society.

Introduction In January 2020, the World Health Organization (2020) declared the novel coronavirus disease a Public Health Emergency of International Concern, and on 11 March it officially became a global pandemic. In the absence of treatments and vaccines, many governments, including that of the United Kingdom, implemented a policy of social and physical distancing (UK Government, 2020). As of 27 April 2020, 157,149 people in the UK have tested positive for COVID-19 and, as of 26 April 2020, 21,092 have died (Public Health England, 2020). The effective management of COVID-19 in the United Kingdom depends partly on public compliance with guidance from Public Health England (PHE) that people limit physical contact with others. The United Kingdom population is diverse and there may be many social, economic and psychological factors which affect compliance with this and other PHE guidance. Psychological variables, such as political trust, and fear of COVID-19 are key, since they determine how people think and behave in this novel situation. Our research into climate change mitigation and HIV prevention (Jaspal, 2018;Jaspal, Nerlich & Cinnirella, 2014) has focused on the social, psychological, political and linguistic factors that impinge on the relationship between risk awareness and behavior change. In this commentary, it is proposed that tenets of the integrative model should be applied to communication strategies and to the design of policies and interventions in the context of COVID-19. --- Social representations of COVID-19 Social representations theory (Moscovici, 1988) can enhance one's understanding of how COVID-19 is communicated and with what effects for public awareness and understanding. Science communicators tend to use familiar and culturally accessible phenomena in order to substantiate their observations about COVID-19. This is referred to as anchoring. For instance, as a virus, COVID-19 has been anchored to HIV in media reporting (Yong, 2020), which promotes the erroneous perception that the two epidemics, and ways of dealing with them, are the same. Second, particular visual and linguistic 'tools' are used to describe the pandemic, which make it more psychologically tangible. This is referred to as objectification. For instance, war metaphors such as 'combat', 'fight', 'defeat', are employed to demonstrate governmental control, may foster a sense of collective action, but also justify fighting the 'enemy' at all costs (Sanderson & Meade, 2020). Together, anchoring and objectification engender social representations, that is, frameworks of meaning which shape how we think, feel and act in relation to the pandemic. They may initially be constructed in the media or in political rhetoric but later come to form part of everyday discussion. A key emerging social representation of COVID-19 is that social distancing is necessary in order to reduce disease incidence (Anderson, 2020). As the pandemic continues, more social representations will evolve and compete with one another, such as the wearing of masks. They will be debated with some being accepted and others challenged. Social representations that are disseminated by scientists are more likely to be accepted, while those associated with politicians may be less endorsed, especially if political trust is low (Osman, Fenton, Pilditch, Lagnado & Neil, 2018). Moreover, there are strong cultural differences, with mask wearing being generally accepted in the East but stigmatized in the West (Burgess & Horii, 2012). Social representations of key preventive measures in distinct social and cultural groups in the United Kingdom must be investigated and understood. --- Identity threat in the face of COVID-19 Identity process theory (Breakwell, 2015;Jaspal & Breakwell, 2014), a theory of identity, threat and coping from social psychology, can help us understand how individuals respond to emerging social representations of COVID-19. The theory postulates that identity is the product of the two identity processes: assimilation-accommodation and evaluation. Assimilation-accommodation refers to how people absorb and adopt new information (e.g. 'Like others, I am at risk of COVID-19') into their identity. Evaluation refers to the process of attaching meaning and value to it (e.g. 'COVID-19 is dangerous, but I am young and healthy'). The two processes are in turn guided by identity principles which include selfesteem, distinctiveness, self-efficacy, continuity and coherence. When the identity processes are unable to operate in accordance with the identity principles, identity is threatened, which can be psychologically traumatic. The social representation that social distancing is necessary will require people to change their behavior, lifestyle and identities in ways that may seem undesirable. Social distancing represents a loss of routine, changes to interpersonal relationships, and disconnection with particular spaces and places. It may therefore challenge an individual's sense of continuity because it disrupts the psychological thread between past, present and future (Murtagh, Gatersleben & Uzzell, 2012). Moreover, as some people resist social distancing, they may become the target of social stigma and be labelled as selfish and irresponsible. This social labelling process can undermine feelings of self-esteem. In short, this social representation as well as others emerging in the context of COVID-19 may lead to identity threat and people will be psychologically motivated to resist them. Non-compliance with mitigation measures will in turn increase disease incidence. --- Coping with change In response to identity threat, individuals engage in coping strategies, i.e. patterns of behavior which reduce identity threat. Some are adaptive (that is, challenging in the short term but effective in the long term), and others maladaptive ('quick-fix' solutions with limited effectiveness in the long term). The coping strategies operate at intrapsychic, interpersonal and intergroup levels (Breakwell, 2015). Denial is an example of a maladaptive strategy. For instance, in response to the potentially threatening representation of social distancing, some individuals may deny this and claim not to be at risk while downplaying the significance of their actions for disease incidence. This essentially removes the need for action. Indeed, in the United Kingdom, it has been noted that some individuals have defied the social distancing measures possibly because they reject the risk representation (Weinberg, 2020). By contrast, anticipatory restructuring and group mobilisation are adaptive. Anticipatory restructuring involves acceptance of the representation of social distancing and restructuring of identity so that one can take actions to mitigate its risk. For instance, one may plan online meetings in advance to maintain interpersonal connections so that one does not experience social isolation amid the social distancing policy. This enables identity to change so that one can take positive action in response to COVID-19. Group mobilisation, such as clapping, singing or music (Nerlich, Döring & Jørgensen, 2020), may provide feelings of belongingness. This can limit threat by creating a norm of social distancing, thereby rendering it less isolating. After all, people tend to seek consensus and, thus, being surrounded by like-minded others who share their beliefs can be a positive experience. --- Conclusions In this article, a broad theoretical framework -drawing on social representations theory and identity process theory -is described within which reactions to COVID-19 can be understood and predicted. In order to promote effective, enduring and sustainable change in the context of this pandemic, social representations of COVID-19 (and its mitigation strategies) must resonate among the diverse people one seeks to engage. Particular attention should be given to the processes of anchoring and objectification, as well as to the source of the representation that one wishes to embed in a community (i.e. who is disseminating it). These representations must not be construed as too threatening. Indeed, negative affect, such as fear, has only limited effectiveness in promoting positive behavioral change (Ruiter, Kessels, Peters & Kok, 2014) If they do threaten identity, there must be clear, discernible pathways towards resolving the threat. Self-efficacy is central to effective engagement with identity threat and positive behavioral change, as demonstrated in climate change research (O'Neill, Boykoff, Niemeyer & Day, 2013). Furthermore, intergroup strategies, such as the derivation of social support from group memberships, may be conducive to a 'team spirit' and, thus, be protective against threats to identity (Sani et al., 2012). It is vital to promote coping strategies that are effective and sustainable. It is only then that they will feel able and competent to engage with perhaps one of the greatest societal challenges in a generation -COVID-19.

This article describes an integrative social psychological framework within which human reactions to COVID-19 can be understood and predicted. It is argued that social representations of COVID-19 (and its mitigation strategies) must resonate among diverse communities, not be too threatening, and provide clear pathways for action and engagement.The novel coronavirus-19 (COVID-19) poses significant risks to both physical and psychological health. These risks can be mitigated through effective health communication using social representations that resonate among individuals and which specify clear pathways for action. The pandemic and its necessary mitigation strategies will inevitably challenge the core 'principles' of identity, such as continuity, self-efficacy and self-esteem. However, in order to minimize the severity and duration of identity threat, individuals must be supported to adopt effective, adaptive and sustainable coping strategies, such as anticipatory restructuring and the derivation of social support.

ENGAGEMENT OR ENJOYMENT? ATTITUDES OF OLDER ADULTS IN GROUP LUNCH VERSUS. LIFELONG LEARNING PROGRAMS Su-I Hou, School of Global Health Management & Informatics, University of Central Florida, Orlando, FL, USA, Oviedo, Florida, United States Purpose: This study examines aging attitudes among older adults who participated in the neighborhood lunch (NLP) and lifelong learning (LLP) programs. Methods: Older adults from an NLP and an LLP in the same county in Florida participated. An aging attitudes measurement originally developed by German researchers was used. Results: A total of 193 older adults participated, 43% from NLP. The mean age was 73.2 (SD=7.78) years. Data showed that LLP older adults endorsed higher on "would like to have responsibilities," "have a task," "do unpaid volunteer work," and "help others" (p<.001). NLP participants, on the other hand, endorsed higher on "no longer have to contribute to society," "want to enjoy life," and "finally want to rest and relax" (all p<.001). Exploratory factor analyses (EFAs) using principal component extraction methods and varimax rotation with Kaiser normalization showed a clear balanced 2-factor pattern, with total variance explained 60% (30% each). These two factors were consistent with the theory representing engagement versus enjoyment aging attitudes. Reliabilities of the twofactor scales were satisfactory, with Cronbach's alpha of .764 (CITC ranged: .457 ~ .660) for the engagement scale (4-item) and.634 (CITC ranged: .379~.499) for the enjoyment scale (3-item). Discussion: Current findings showed that LLP participants endorsed higher engagement, while NLP participants endorsed higher enjoyment towards aging. This tested aging attitudes scale consists of 7 items with two clear theoryconsistent factors among community-dwelling older adults. Results can help researchers quickly assess aging attitudes of diverse groups of older adults for tailored program and service development. Abstract citation ID: igad104.1182 --- A SYSTEMATIC REVIEW ON AGING IN THE COMMUNITY AND CULTURE AMONG CHINESE OLDER ADULTS Hao-Min Chen 1 , and Su-I Hou 2 , 1. Texas A&M Killeen,Texas,United States,2. School of Global Health Management & Informatics,University of Central Florida,Orlando,FL,USA,Oviedo,Florida,United States Chinese older adults face many barriers to healthy aging in community, such as increased financial burden, threatened place security, limited accessibility to medical services, language and transportation difficulties, daily housework and repairs challenges, etc. This systematic review aimed to examine and report the results current scholars have published in journal articles in the last decade (2010-present) on the influence of culture on Chinese older adults aging in community. Combination terms of "aging in community or aging in place," "Chinese," and "culture or cultural or ethnicity or identity or values" were used

online surveys and studies requiring personal interaction. Study one is a pilot instrument validation study collecting online survey data. Recruitment occurred locally through listservs and a research participation database from a large university hospital. Study two is a mixed-methods longitudinal design where survey and interview data are collected via phone or video calls. Participants for this study were recruited nationwide using multiple strategies, including social media. Both offer time-saving insights for dealing with fraudulent participation in research. For example, study one provides tips for planning how to manage spam/bots prior to data collection, including setting up filters to automatically weed out identified spam, creating automatic messaging included in the survey in the event it needs to be paused, and identifying potential problematic patterns in data that bypasses fraud detection. Study 2 emphasizes the importance of creating strong verification procedures for study eligibility when relying on participant reporting.

Superdiversity has garnered much attention as a term in the last ten years and has been applied and understood in many ways. The articles that compose this Monograph explore a variety of issues, some of them not necessarily correlated to migrations, including a meta-analysis of superdiversity in the literature (López et al., 2021), the applicability of "superdiversity theory" beyond migration studies (Kirwan, 2021), digital competencies and skills linked to social networks and diversity (Castillo and Gómez, 2021), children and citizenship in a superdiversity context (Ferreira, 2021), and new insights into potential superdiversity dimensions (Álvarez and Harris, 2021). The various conceptions of superdiversity are a likely result of both the lack of understanding of what the father of the concept tried to convey as well as the versatility that the term itself allows in its theoretical-practical application (Vertovec 2017). Regardless, it is evident that this term enables a (re)discussion and differentiation with other ideas that have been present in the social sciences for decades, such as multiculturalism, interculturality, diversity or intersectionality itself, bringing with it a triple vocation: descriptive, methodological, and practical (or policy-oriented) utility (Meissner and Vertovec 2015). In practical terms, sticking to the methodological domain, it is clear that there is no consensus on how to approach superdiversity in a standardized and homogeneous way in all cases. If the main objective of research in superdiversity is "exploring emergent social patterns and the architecture of social differentiation in contexts highly altered by international migration" (Meissner 2016, 24), then two common questions that arise when thinking about superdiversity, especially when it comes to operationalizing it, are: 1) What are the empirically anchored elements or variables that define social differentiation?; and, 2) Once defined, which elements constitute those with the greatest weight in the hierarchy of importance? That is, what are the empirically identified and demonstrable criteria that can be applied to define this hierarchy? Additionally, to what extent do these elements, their centrality and categorization, vary according to their usefulness? In other words, are there any viable differences if the research purposes are not the same (for example, if we are trying to conduct a characterization of the population rather than seeking evidence to propose public policies)? In summary, because of the multifaceted nature of the term, we are only able to provide and propose some potential lenses with which to explore and portray superdiversity in this Monograph. Although Vertovec himself briefly conceptualized the methodological aspect of superdiversity, that is, an exploration of some of the variables that must be considered and how to look at them (Vertovec 2010;2017;2007), "serious empirical applications remained rare" (Meissner 2016, 22). In fact, most of the analyzed research literature is based on qualitative studies even though, paradoxically, Vertovec himself used statistical data to justify the creation of the concept. Among the possible reasons for the predominant use of qualitative research to expand and justify superdiversity concepts, we highlight two possibilities: a) qualitative research is specifically designed to investigate the appearance of a new concept in an attempt to discover its differentiated dimensions through exploratory studies; b) the most scientifically viable ways, to date, to attempt to explore the sociological meanings, content, and interpretative richness of these differentiated dimensions are qualitative methods. Certainly, over the years, one of the objectives of furthering superdiversity research will be to move from exploratory and descriptive studies to more correlational and explanatory analyses which will allow for greater applicability of the concept and its dimensions on a larger scale, thus fulfilling the aforementioned policy-oriented vocation by Meissner and Vertovec. In order to accomplish this research objective, it will be essential to carefully define and select superdiversity's constituent elements so that they can be systematically analyzed and tested, with an acute awareness of the risk that this selection process may entail. Some methodological proposals to meet this objective have already been launched, such as the "Maximum variation sampling (MVS) or Respondent Driven Sampling (RDS)" (Goodson and Grzymala-Kazlowska 2017). The methodological door is still wide open, however, to welcoming new strategies that examine the "core" idea of superdiversity and that can overcome current methodological dilemmas, such as the "problem of data generalizability and relativism" (Goodson and Grzymala-Kazlowska 2017, 10). Being faithful to the notion of superdiversity requires the consideration of "all" the possible elements of differentiation that international migrations during the last two decades have contributed to diverse societies, including that individuals can also justifiably be studied as the unit of analysis in superdiversity research. Such a lens requires us to rethink the main variables / dimensions of certain phenomena (e.g., ethnicity, nationality, and gender) that have currently been prioritized and considered as "explanatory" and to put them under the scrutiny of scientific examination in order to (re)discover their potential weight within a contemporary social context. Over the years, there have also been some attempts to delimit the "radius of action" of the superdiversity term. As a result, we propose the intentional systematization of the term, based on six dimensions documented in table 1: (Vertovec, 2007(Vertovec, , 2010(Vertovec, , 2017;;Meissner and Vertovec, 2015;Nowicka and Vertovec, 2014;Aptekar, 2019;Grzymala-Kazlowska and Phillimore, 2018;Schrooten, Geldof, and Withaeckx, 2015;Boccagni, 2015;Meissner, 2015;Creese and Blackledge, 2018;Ozkazanc-Pan, 2019;Álvarez and Harris, 2021;Pride, 2015;Goodson and Grzymala-Kazlowska, 2017;Geldof, 2016;Robaeys, Van Ewijk, and Dierckx, 2018;Padilla, Azevedo, and Olmos-Alcaraz, 2015) Source: Authors' chart and data Obviously, this list needs to be expanded. However, it should be noted that an expanded list of differentiated factors will assuredly be accompanied with a greater probability of encountering problems when operationalizing the research. Likewise, such an approach may increase the likelihood of researchers to seek to study "respondents based on difference (…) rather than undertaking research within or between ethnic groups" (Phillimore 2015, 10) which could lead to a hierarchy of predefined variables. Because the ultimate diversity unit of analysis is the individual, and not the group, we propose that personality traits and their associated elements should be carefully considered in future diversity research (as referred to in table 1) because they are empirically well-grounded over time with enough consistency to provide increased understanding of differences between people. It will be up to future researchers to propose the correct research questions, guided by the data rather than by hierarchies of predefined variables, or by other selection issues and biases.

Superdiversity as a term has captured the attention of many researchers since its creation in 2007. However, the very characteristics of the concept have made its methodological operationalization not sufficiently clear, beyond being bridged by the great migratory movements of the 21st century. As a result, we find a considerable diversity of analytical approaches without being empirically clear what the dimensions and variables that should accompany those related to migratory flows. In this epilogue, methodological implications are critically discussed, especially those related to social differentiation factors and hierarchy of predefined variables. Also, future research implications are discussed.

Introduction The birth of the COVID-19 pandemic has transformed our working lives as Black, Asian and minority ethnic (BAME) medical professionals, particularly with the General Medical Council statement announcing that 'professionals may need to depart from established procedures'. 1 --- Hospital loneliness Vital signs and oxygen saturations supplanted the stethoscope as we upskilled, donning an astronaut-like visor. Consequently, communication became arduous, smiles were gone and words were muffled, inflicting loneliness on both healthcare professionals (HCPs) and patients. Bedside multidisciplinary ward rounds disappeared, replaced by remote rounds. Wards were piercingly quiet: no cheery nurses, no happy volunteers serving tea and no visitors. Patients were alone with only their illness as their companion. HCPs were also alone: no corridor chats, no mulling over cases during coffee breaks and no face-to-face teaching sessions or meetings. --- Loneliness in death Thanatophobia, the fear of death, emanated from patients' eyes. Some died alone, precipitously before their syringe driver arrived. We were 'breaking bad news' and then offering condolences within the same hour. On reflection, the sudden transition from good health to an unexpected death caused the most despair. Many of these patients had been whisked away unaccompanied in a frantic emergency. They spent their entire hospital stay alone, with relatives alone at home. The subsequent funerals were closed casket and deserted. Hence, attaining closure was difficult for grieving families. The increased BAME deaths have in part been attributed to multigenerational families living together and the difficult separation of patient and extended family appeared even more poignant. 2 --- Impact of loneliness, palliation and ReSPECT The social isolation of lockdowns has meant that mothers have given birth alone, schools have closed, workers have been furloughed, and older people and those with underlying conditions have shielded. This solitude will undoubtedly exacerbate mental health problems and other health problems, as patients are unwilling to attend healthcare services in addition to the postponement of some appointments. 3,4 Furthermore, the lack of culturally competent support is likely to add to the isolation in non-English-speaking people. Thus, we as HCPs should pre-empt these issues in a culturally effective manner. 5 e164 © Royal College of Physicians 2021. All rights reserved. --- OPINION Future Healthcare Journal 2021 Vol 8, No 1: e164-5 Most hospitalised patients had discussed their wishes on endof-life (EOL) care only after admission. This was documented using the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form. 6 However, EOL conversations are known to be difficult for both patients and HCPs and, until now, have taken place reactively. 7 The COVID-19 pandemic has shown us that the disease can be rapidly fatal and so patients would benefit from such conversations earlier and proactively by HCPs before they become critically ill. 8 --- Future planning In readiness for a subsequent wave, patients are risk stratified for COVID-19 and ReSPECT care-plan conversations have commenced with higher-risk patients. 9 But should all BAME patients have this ReSPECT care plan and should we consider communityhospice settings for our palliative COVID-19 patients? Until we find the definitive treatment and vaccine, we should focus our efforts in alleviating suffering by initiating and achieving 'shared understanding' of our ReSPECT conversations. 10

The birth of the COVID-19 pandemic has transformed working lives of British Asian general practitioners (GPs), such as one of the authors. The effects of the national lockdown and the subsequent loneliness have impacted every aspect of our lives and increased mental health problems. The added social isolation of local lockdowns, such as in Leicester, will undoubtedly exacerbate some health problems due to a lack of patient willingness to attend healthcare services and the postponement of some appointments. The lack of culturally competent support is likely to add to the isolation in non-English-speaking people. Thus, we should pre-empt these issues in a culturally effective manner. To prepare for subsequent waves, GPs are risk-stratifying patients for COVID-19 and have commenced ReSPECT care-plan conversations with higher-risk patients. But with the increased risk from COVID-19 to Black, Asian and minority ethnic patients, should this and other groups of patients also have a ReSPECT care plan? Is now the time to consider community-hospice settings for our palliative COVID-19 patients? This pandemic has uncovered a training need for healthcare professionals to feel more comfortable in discussing end of life as an integral consultation component. We should focus our efforts in alleviating suffering by achieving 'shared understanding' and 'negotiating management' of our ReSPECT conversations.

Close examination of family involvement and influence among Asian Americans is important because this group disproportionately underutilizes mental health services (Abe- Kim et al., 2007) and family influences their help-seeking (Okazaki, 2000). Although substantial demographic variation exists among Asian Americans, mental illness stigma, psychological disorder prevalence (Takeuchi et al., 2007), and mental health service underutilization (Sue, Cheng, Saad, & Chu, 2012) are considered fairly ubiquitous, allowing for exploration of recovery experiences across Asian American consumers. Most studies recruited Asian immigrants served by ethnic-specific programs. This study examined family involvement and influence in the recovery process of Asian Americans receiving community-based psychosocial rehabilitation services. --- Methods This secondary analysis used qualitative data from a larger project exploring sociocultural issues in a purposive sample of ethnically diverse adults receiving community-based mental health services. All eight Asian American (Chinese, Filipino, Japanese, Korean, Taiwanese, and Vietnamese) participants (four women) with schizophrenia (without current substance use disorders) and recruited by caseworkers were included. Participant ages ranged from 28 to 60 years and education varied from 6th grade to college, with most reporting 12 years of education. According to medical charts, length of illness ranged from 2 to more than 30 years and participants lived in supervised or supported community housing, took antipsychotic medications, did not currently experience positive psychotic symptoms, and received public assistance. Asia-born consumers spoke English as their second language. Semistructured in-depth interviews (approximately 1 hour) were audio recorded, transcribed, and translated (two Korean-language interviews) by bilingual master's-level research assistants. Participants provided written informed consent and HIPAA forms under protocols of the university's institutional review board and the county department of mental health's research committee. Data were analyzed using coding consensus, co-occurrence, and comparison (Willms et al., 1990). Transcripts were independently coded based on the interview guide and emergent themes. The final list of codes was constructed through a consensus of two investigators. Categories were further condensed into broad themes regarding family involvement or influence. --- Results and Discussion --- Family Involvement Although all participants initially described close family connections, none lived with significant others, except for one person living with a partner, and all reported only occasional family contact. These living arrangements are inconsistent with those among Asian Americans participating in ethnic-specific mental health programs (Bae & Brekke, 2002). Emotional support-The parents of the Asia-born participants were deceased. Descriptions of parental emotional support among the four U.S.-born Asians conveyed mixed messages, were brief, and lacked detail. One participant reported: "They are supportive. I call my parents every day. I ask them how they're doing and they ask me how I'm doing. We talk about five, ten minutes and that's it." Another participant reported perceived support, but actual support appeared limited: Sometimes I don't see them until maybe two or three months later because they have their own lives. They're really busy. But I know they love me and I know if I ever need their support, they be there for me, but they want me to learn how to grow up and be on my own too. Two U.S.-born Asian participants described their sibling involvement as limited or ambivalent. "My step-sisters, I hardly ever see them because they have their own lives." "My older sister, she's married and I hardly ever see her." In contrast, Asia-born participants appeared to have more consistent contact, stronger emotional ties, and more satisfaction with siblings' emotional support: I have my brother and sister over there [in home country], but I do not see them in 20 or 30 years. They are always saying "come back and we will take care of you. Do not live in America alone. Do not worry; we will take care of you. The nature of the relationships reflected ongoing, yet unequal, dependent ties between siblings and participants. An Asia-born participant illustrated the caregiving sibling role. "My brother wants to watch me close to him, so that I don't fall into something else. If he doesn't watch me, he doesn't know how I am doing, so he prefers working with me." Financial support-All participants mentioned receiving financial support from family members: "My mom helps me with that; she says, 'I'll pay you.'" "They come and visit me at [the hospital], and they brought me money and goodies to relax me." Asian American cultural norms generally promote instrumental rather than emotional social support. Providing financial assistance (Kung, 2003), often reflecting feelings of obligation is common among Asian Americans. --- Family Influence on the Recovery Process Participants reported that psychiatric care, but not the experience of mental illness, was openly discussed with select family members. One participant said: "We don't discuss the personal problem. … [My family asks] 'How are you feeling? Are you sure you took all your medication? We worry about you.'" Families' view of medication reportedly varied. One participant said, "They [sisters] have me take the medication. Ahh, they are telling me to take the medication." In contrast, another participant noted: "My parents didn't want me to take medication. … They thought there was nothing wrong with me. They told me to stop taking the medication." Participants described family involvement regarding hospitalization. One participant said: "They gave me the best doctors, the best hospitals and they're very supportive." In most regards, families reportedly deferred care responsibilities to professionals, especially psychiatrists. One consumer noted, "They [brothers] come and visit me at the hospital, but they let the doctor take care of me. They did not interfere." Respect for authority figures combined with limited health literacy may contribute to dependence on professionals for most healthcare decisions. --- Conclusions and Implications for Practice Participants' explanations for the relative lack of family involvement in their daily lives could be an effort to preserve family honor. Importantly, participants did not verbalize desire for more family involvement. Participants seemed more concerned about potential negative relational consequences of seeking more support (Kim, Sherman, & Taylor, 2008) and becoming a burden to their families. Further, findings revealed patterns of low-intensity and unequal dependent relationships between participants and some family members. Family involvement was largely related to care, rather than improving quality of life from involvement in education, employment, religious activities, or community engagement. English-speaking Asian American consumers may not appear to need cultural modifications to treatment. Thus, subtle sociocultural issues and potential cultural strengths may be overlooked. Despite inclusion of consumers varying in acculturation and ethnicity, the sample size was small and may not be representative of all Asian American consumers in community-based care. Nonetheless, these descriptive findings informed suggestions for providers. • Assess past and current family involvement and influence of consumers with limited family contact; families provide lifelong perspectives on consumers' recovery preferences (Simich, Maiter, Moorlag, & Ochocka, 2009). • Go beyond consumers' initial comments and explore the nature and extent of family support. Conforming to cultural values, consumers may not initially report limited family support; exploration reveals perceptions of family involvement and influence. • Use windows of opportunity (e.g., hospitalizations) to reengage families in the recovery process. For Asian Americans family is a safety net and likely to provide care during crises. • Assess positive and negative family influence on recovery. Family can be supportive yet impede recovery by focusing on symptoms rather than meaningful quality of life. Families need not be present to affect perspectives of Asian Americans receiving recoveryoriented services. Research should explore how families affect recovery processes and outcomes, considering practical issues such as duration, intensity, and circumstances of family involvement. --- Author Manuscript Lee et al. Page 6

Objective-Family involvement is important in the recovery experience of culturally diverse adults with schizophrenia. However, little is known about the influence of family among consumers purported to have close family ties without regular contact. This study explored Asian American consumers 'views about family relationships and participation in their recovery. Methods-Secondary analysis of qualitative data from a larger project was conducted to explore family-related themes of eight Asian Americans receiving services from recovery-focused programs in urban Southern California. Results-Most consumers described their family support as adequate while simultaneously reporting limited family involvement. Asia-born and U.S.-born Asian consumers varied in describing family support, suggesting providers consider nativity in culturally responsive service delivery. Conclusions and Practice Implications-Families need not be present to affect the perspectives of Asian Americans receiving recovery-oriented services. The extent of family influences on recovery, beyond the initial determination of current family contact, requires further exploration.

exploiting temporal variation in the timing of COVID-19 exposure across participants interviewed from 2018 to 2020 together with the geographical variation in COVID-19 severity at the provincial district level. Overall, the DID estimates showed that the COVID-19 pandemic could significantly increase trust in doctors after controlling for multiple covariates (adjusted β: 0.053, 95% CI: 0.028-0.078). Stratified analyses showed that the effect was only in females and the more educated ones but not in their counterparts. In addition, the COVID-19 pandemic showed a positive effect on trust in doctors among 65-79-year-olds (0.082, 0.056-0.109), but older adults over the age of 80 showed significantly reduced trust in doctors (-0.236, -0.418--0.055). Our findings confirm the association between the COVID-19 pandemic and trust in doctors among older Chinese people. Hospitals and other medical organizations should pay more attention to improving older adults' trust in doctors and building a better physician-patient relationship to face the future pandemic. Puzzle activities in dementia patients have been associated with improvements in mood and cognition across a number of studies. Our research team designed and developed Jigsawdio, a digital technology that provides an innovative and interactive multisensory solution which supports memory recall in patients with dementia through the completion of personalized, audio-visual jigsaw puzzles. This device builds on the benefits derived from traditional puzzles by integrating salient audiovisual stimuli aimed at evoking nostalgia and encouraging reminiscence. The purpose of this study was to assess pre-and post-intervention effects of Jigsawdio use after six weeks among older adults with mild to moderate cognitive impairment. Using a single arm, twice weekly intervention, nine persons participated in the Jigsawdio program study. The Montreal Cognitive Assessment (MoCA) was used to measure changes in cognitive function and recall on the first and last days of the intervention. A paired t-test was used to investigate the group mean differences in cognition before and after participation in the intervention program. We found a significant group mean difference between the post-assessment and the baseline assessment MoCA scores of participants. This study presents suggestive evidence of cognitive benefits and feasibility of the technology in older adults with dementia.

We used data from the Hispanic Established Population for the Epidemiological Study of the Elderly to examine the relationship of financial strain and interview language to high depressive symptoms among Mexican Americans aged ≥75 years without history of depressive symptoms at baseline over a 12-year period (2004/05-2016; N=1157). Participants scored < 16 in the Center for Epidemiologic Studies Depression Scale at baseline. Measures included age, marital status, years of formal education, body mass index, social isolation, church attendance, self-reported medical conditions, cognitive and physical function, pain, falls, disability, and hand grip strength. We used a generalized estimating equation model to estimate the odds ratio (OR) and 95% confidence interval (CI) of depressive symptoms as a function of financial strain and interview language over time, adjusting for all covariates. We found that participants experiencing financial strain and interviewed in Spanish had greater odds of experiencing high depressive symptoms (OR=2.48, 95% Cl=1.37-4.48) compared to those who were not experiencing financial strain and selected be interviewed in English.

to disparities in risk, morbidity, and mortality from not only COVID-19 but also many other conditions. The structures, policies, and practices that advantage some and disadvantage others so that race and ethnicity are consistent predictors of a cycle of unequal access to care, unequal access to educational and employment opportunities, and disproportionate exposure to health risks, as evident in the COVID-19 pandemic. Generations of Black individuals, Indigenous individuals, and those from other racial and ethnic minority groups have lived this cycle for decades with little to no hope for change. Their resulting lack of faith in a system that has so consistently demonstrated little or no regard for their well-being should come as no surprise. In fact, the blanket of mistrust that has been used to explain disparities in vaccine uptake is masking underlying fundamental inequalities in the system of vaccine distribution. Those of us who work in and with historically marginalized communities see strong evidence that equality does not equal equity. Equality means giving everyone the exact same resources, whereas equity involves distributing resources based on the needs of the recipients. Giving everyone equal access (eg, through online scheduling) has exacerbated inequities in vaccine uptake. When you prioritize equality over equity, you get the results we have seen throughout the COVID-19 pandemic. Disparities grow wider and wider when we consider unequal access to broadband and internet, computers, time to visit online vaccine distribution sites to find an appointment, and the ability to drive hours across county and state lines for an appointment. We must develop and use strategies that provide equitable (not only equal) solutions to address the disparities we are witnessing. 5 --- Stop Using Vaccine Hesitancy as an Excuse In the news and across public health and health care, attention has focused on individuals' current reluctance to receive the vaccine. The term vaccine hesitancy puts the focus on the individual. In fact, what I have seen, as a physician and community-engaged researcher, is vaccine deliberation, as individuals weigh the pros and cons of the evidence of vaccine efficacy, loved ones lost in the pandemic, and an overwhelming history of racism in medicine and science. Many Black and Indigenous populations as well as those from other racial and ethnic minority groups are cautiously waiting to see for themselves whether the vaccines are safe-by talking with family members, observing the side effects experienced by loved ones who have received the vaccine, weighing information from trusted sources and local leaders, and talking with health care professionals. In addition, an old adage applies here: "When I know that you care, I'll care about what you know." So, when health care systems make shifts that demonstrate trustworthiness and a commitment to equity, more people will likely agree to the take the vaccine and more will cautiously say yes. It is all these sources of information and inputs, assessed over time, that lead some to agree and others to decline. Our role as health care professionals is to stay engaged in these conversations with our friends, family, patients, and communities as they sort these sources of information in their decisionmaking. --- Focus on Equity in Vaccine Distribution We need structures, policies, and practices focused on ensuring Black and Brown communities and the clinical settings that serve those communities receive enough doses of the vaccine in a timely manner. 6 In addition, we need to use strategies that ensure those who are most in need in historically marginalized communities are given preference and provided support to both access appointments and travel to them. Mobile units and pop-up clinics, preferably cosponsored by trusted local community organizations and/or individuals, are 2 examples of structural approaches to advance equity in distribution. 7 --- Use High-Touch Rather Than Hi-Tech Approaches Current online vaccine appointment scheduling shows the deep digital divide between those who may not have access to or feel comfortable with the internet and those who can successfully navigate health information technology. Vaccinations are an extremely important factor in mitigating the COVID-19 pandemic. However, the digital chasm between what needs to be done and the health care system that provides the solution is widening. We need high-touch (ie, person-to-person) practices, particularly in Black and Brown communities, to bridge the digital divide. In communities with the highest risk of infection, local community health workers have demonstrated their expertise in getting more people tested and connecting them with the care they need. 8 This same trusted workforce needs to be mobilized to address current vaccine uptake disparities and institutionalized to continue meeting the needs of historically marginalized communities. --- Partner With Trusted Organizations With Ties to Historically Marginalized Communities Much has been written about having trusted voices as part of a marketing campaign to improve vaccine uptake. Indeed, this is a useful practice but falls short of a true partnership. True partnership requires ensuring leaders and organizations in communities are fully engaged with and remain an integral part of the planning and implementation of the solutions. True partnerships are more than images of an individual who looks like the target population with their sleeve rolled up getting a vaccination. Partner organizations must be shoulder to shoulder with health care professionals and public health colleagues as we continue to fight for the lives of every person in this country. Addressing disparities in vaccine uptake requires a multipronged approach centered on the needs of historically marginalized communities. The approach must recognize that vaccine deliberation is rooted in structural racism and be designed to clearly demonstrate the trustworthiness of medicine, public health, and our health care system.

Vaccine hesitancy and mistrust of medicine and science dominate current discourse around disparities in who is currently receiving COVID-19 vaccines, a potentially lifesaving prevention strategy. Mistrust of medicine and science is based in a long and sordid history of unethical practice and research on African American, Latinx, Indigenous, and Asian American populations in this country. [1][2][3][4] However, current concerns about vaccine uptake are a glaring symptom of a much deeper problem-structural racism. The underlying condition of structural racism is a significant contributor Author affiliations and article information are listed at the end of this article.

INTRODUCTION We have previously argued that, whilst WOs share certain architectural features with systems in the Search and Web Analytics space, the inherent nature of "Observation" in the Web Science sense is more than simply a sub-set of these tools. We will not further rehearse this argument, which is outlined in the earlier paper [1], save to summarise that in order to establish the differences in usage/application of WOs rather than the structure of Observatories [2] (which might physically be largely indistinguishable from other forms of repository or analytical platform) the research started with a discourse/narrative analysis which was performed on the current literature for Observatories and Observatory-shaped objects. 1 This resulted in an initial vocabulary of 17 processes focused around the implementation/execution of WOs, which we have gone on to validate and expand through a process of individual and focusgroup interviews of academic and business users during the period 2012-2015. --- THE NEED FOR REVISION In our initial work the focus was purely on elicitation of usage patterns (and to some extent problems/challenges) of WO systems and resulted in a basic workable model (see fig 1 .) of processes for discussion/validation with practitioners. --- Figure 1 -Unstructurd early model of WO processes This initial view however did not capture any grouping/structures/sequencing of the processes and also suffered with a number of fundamental issues that we address in this paper: • Firstly that the WO is treated as existing in a sociotechnical vacuum with external factors (whilst perhaps implied) are not elucidated/enumerated. • Secondly that the model does not make social elements of the social machine sufficiently explicit • Thirdly the non-linear, emergent effects resulting from these process flows were ignored • Finally that no method of implementing this type of analysis is suggested Permission to make digital or hard copies of all or part 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 components of this work owned by others than ACM must be honored. Abstracting with credit is permitted. To copy otherwise, or republish, to post on servers or to redistribute to lists, requires prior specific permission and/or a fee. Request permissions from Permissions@acm.org. Thus we offer here a substantially improved version over the initial model which we have termed e 5 and which forms part of the larger DNA model. --- METHOLODOLGY The general approach to this work has been the development of a grounded theory according to the constructivist variant preferred by Charmaz [3] and thus, by definition, this model is substantive, focusing largely (though not exclusively) on academic research subjects. The wider research will also engage with business and government/non-profit participants in the future. It should be noted that the A section of the DNA methodology focusses specifically on this issue of differing perspectives and Archetypes and will form the subject of future papers/articles. --- Restructuring the model Our initial action was to group the original 17 processes into a notional "black box" comprising three activities around the discovery, assembly and delivery of data and sources. --- Figure 2 -WO processing model Following the analysis of additional theoretical concepts from focus groups and individual interviews our focus was drawn to the idea that many of the challenges and factors brought up by participants were exogenous (either external to and/or unexplained by) this pure "processing" model of WO. We therefore include both external factors that might influence WO from an eco-system perspective and also those emergent factors that might result from the use of WO that would in turn feed back into the eco-system. --- Exogenous factors The study of additional (non-process) facets of external forces and resulting (emergent) properties more than triples the size of the original model and also caused a number of the original processes to be refined/re-assigned. Under the external model we elected to assess/categorise the processes according to the established PESTLE 2 Under the emergent factors we elected to assess/categorise the processes according to the idea that an effect should be exogenous in the sense of not-explained-by-the-model and may also broadly decompose into a PESTLE structure. e.g. We might consider that revenue/profit resulting from license fees for WO services would not be an unexplained/exogenous factor (i.e. it results directly from the processing model), whereas the formation of community-lead de jure processes/standards potentially subverting the original specifications of the WO designers would be considered exogenous as they are not directly explained by the mere existence of a processing model. --- The e 5 model Adding in these two additional perspectives, the e 5 model presents a more flexible view of WO operation as it recognizes the potential impact of inbound factors beyond the control of WO builders as well as outbound factors and effects (both intended and unintended), which may result from WO interactions and interoperations. The model extends the processing section as follows: Figure 3 -Revised e5 process model --- RESULTS Following the collection and analysis of the additional focus group and interview material the process vocabulary (now expanded to a vocabulary of various 30 factors and 32 processes was re-cast as follows: --- Table 1 -e5 factors and processes Space constraints do not permit the reproduction of formal definitions/diagrams of each process in a short paper format but a visual representation and brief description of each process/factor is available for review/comment on-line at http://bit.ly/1bjQf9P. --- Future Work As the grounded theories for this work continue to evolve we propose to consider the instrumentation and implementation of WO processes (just 3 of the 5 e5 groups since exogenous factors are not something that can be implemented but perhaps can be measured/evaluated). Whilst we can visualize process definitions using existing notations such as BPMN, UML and others we are particularly keen to look at mobilizing these process in a way that can measured and interwoven both with (semi) manual processes and also cross-platform interactions. To this end we are starting to consider platforms, which combine both work-flow and manual steps and so the next step is implement a number of processes as a proof of concept including inter-system communication using lightweight protocols such as LSC [4] . In the wider context, as intimated above, the process perspective is only one of three in the DNA method and so there is further work to look for correlations and groups between functional aspects, process aspects and motivational aspects. --- CONCLUSIONS A model of socio-technical systems, social machines and Observatories needs a broad model of interactions comprising both a technical/processing vocabulary as well as a social/ecosystem context from which to operate. With so much research focusing on the emergent properties of the Web it seems inadvisable to propose a model, which does not allow both elements to be included in the analysis. Whilst we are not suggesting that every social machine or observatory will be materially affected by every external factor, nor that each system will employ every processes listed, we do suggest that a core vocabulary of processes is useful for broader social machine analysis and that these findings represent a substantial improvement over the original WO process model. Ultimately we are looking for a set of useful techniques and perspectives that move us closer to an evidence-based (grounded) theory of the operational factors for a broad range of social machines.

In this paper, we describe extensions to the process model first described in the paper "From Search to Observation" based on additional field interview work. This process model forms part of a triad of perspectives under the banner of a methodology known as DNA, which looks at structure (Definition), process (Nature) and motivations of actors (Archetypes) for Web Observatories (hereafter WO) and more generally the class of Social Machines. We discuss the rationale for the model enhancements, enumerate and summarise the changes and close with an introduction to future work around use of open source tools and languages for implementing and analyzing social machine processes using this model. The additional perspectives we are now considering are an extensive revision to the model (which now addresses more than three times the number of factors in the previous model) and hence a revised paper is called for in this space.

Introductions The last decade has witnessed a growth of user driven social media online applications blogging, social networks and channels for media distribution. Even kids are growing today with information technology access Internet is not only a mass media but more than that a 'multifaceted mass medium' in the sense that it contains many different configurations and communications (Morris and Organ 1996) [1] . Social Media marketing is a tool by the usage of social networking platform to get people attention. Social networks offer an atmosphere in which users can connect on the internet which has an important effect on the idea of customer socialism (Vinod Chandwani, 2016) [2] . This technical transition had a major impact on conventional marketing, introduced new age for advertisers; the social media changed the relations between marketers and stakeholders entirely. Due to enhancing use of internet, retailers are taking advantage to enlarge their business capacities and to expand their revenues. Amazon, e-Bay, Dell.com, Ez Mall etc. developed a series of business opportunities that expanded consumerism worldwide. Consumption never remains static for a long time in the modern advanced societies where shifting needs occur quite often. The dynamic nature of human needs makes consumption a dynamic character. The definition of what constitutes a 'necessity' is changing and the distinctions between luxuries and necessities are blurring (UNDP, 1998) [3] . In the present scenario, the pronounced tendency to consume has become indispensable part of one's life and individuals are assessed based on their materialistic lifestyles. In this way we are moving towards consumerism. Consumerism refers to the consumption of goals at a higher rate. It is appreciated in western countries but not in India as we Indians are known for our spiritual values not for material wealth. --- Related Studies Karve, Sunil and Shilpa C. Shinde (2013) [4] in their paper "Effectiveness of Social Networking Sites (SNS)" have made an endeavour to make sense of the encounters of the web clients with respect to internet based life and have likewise attempted to discover the example of SNS utilisation of buyers. The scholars express at online networking has turned out to be very much famous. Social networking sites have changed the manner in which individuals invest their energy on the web and make their purchase decisions Liu. et al. (2013) [5] conducted a study of online shopping of Chinese customers. The findings of the study have shown that detailed information is necessary because purchase decision is only based on the information available online Design and content of website would be attractive to improve customers satisfaction. Website transaction capability is necessary element to complete a transaction Safko and Brade (2009) [6] state activities, practices and behaviours among communities of people who gather online to share information, knowledge and opinions using conversational media. Conversational media are web based applications that make it possible to create and easily transmit content in the form of words, pictures and audios. This media creates a wide market for customers. Naidu Geetanjali et al. (2013) [7] analyse the influence of social media on purchasing division of students in Raipur. According to survey result, 75% of young population uses internet for sharing their opinions, views and comments on numerous websites. People use social media weekly to collect information about the product they want to purchase. --- Study Area --- Objectives of The Study  To analyse the interests of consumer households of Meerut district towards social media.  To find out factors motivating consumers to purchase things using social media.  To make people aware of negative side of social media. --- Research Methodology The study is an empirical study based on household survey of consumers living in Meerut District. Primary data based on Income, expenditure family size, occupation structure and consumption was collected through schedule based on structured questionnaire. The rural and urban households selected by stratified random sampling with the help of suitable designed schedule. The number of samples were quality divided in rural urban population. Ratio of population in urban is 51% and 49% in rural area as per 2011 census (https://www.cenusindia2011.com). 500 consumer households were surveyed. In order to know the impact of social media on consumption the main variables were demographics, web graphics, online shopping, place of purchasing daily needs, motives of purchase, branded/ nonbranded, purchases, use of smart phone, purchase of fashion outfits etc. --- Descriptive Statistics Descriptive analysis was conducted to understand the demography of the population. The sample comprises of 48% of female and 52% of male respondents. The sample were well educated as 48.4% has their degree in UG, PG or in Ph.D. and 35.2% sample were high school and intermediate education (refer table below). The average age of the sample was 44. According to age groups, highest number of respondents belongs to the 39-48 with 47% followed by age group 49-58 (25.8%), age group 29-38 (10.4%). In terms of occupation, most of the respondents were Self-employed (43%) followed by Agriculture (28.2%), Government jobs (14.8%) and Private jobs (14%). Thus, the respondents were selected from varied age, education and occupation. Respondents are representatives of their respective households. Hence the samples were exhaustive enough for fulfilling the objective of the study. The summary of descriptive statistics is presented in Table followed by supporting graphs and charts. --- Factors to decide which site to purchase Respondents were asked about their decisions to purchase their daily needs. They replied that they are most influenced by Special discount offers, advertisements, friends and relatives etc. Conclusively It can be said that consumption is an economic activity but sustainable consumption is our fundamental and moral duty besides consumption, saving and investment are equally important. If we plan to save and invest the money, it will create employment opportunities for others and out country will be a Self-reliant economy.

Social Media is a tool by the usage of social networking platforms to get people's attention. This motion now influences the way we use the internet and has produced common sites like Facebook, Youtube, Instagram and Twitter where users are communicating, creating and posting information. When the knowledge regarding a product/ service/ brand/ business is posted by a person, it is shared by many people in social media. Social media acts as a peer group and gives way to the demonstration effect introduced by Duessenberry (1949). He wrote that consumer's behaviour is strongly influenced by demonstration effect. People imitate their friends, neighbours and colleagues for their purchase decisions. Now in the era of social media demonstration effect is expanded. Consumers imitate whatever they see at social media platform. People are moving towards consumerism. Resulting from enhancing use of social media, Consumerism refers to the consumption of goods and services at a higher rate. Our Indian culture doesn't support consumerism as India is known for its spiritual values not for chasing material wealth. Moreover consumerism is enhancing global warming, industrial pollution and depleting natural resources. The present study is an attempt to explore how far social media has influenced consumer behaviour in Meerut District.

xxi --- Preface This book presents the state-of-the-art in research and empirical studies in the field of Natural Language Processing (NLP) for the semantic analysis of social media data. Because the field is continuously growing, this third edition adds information about recently proposed methods and their results for the tasks and applications that we covered in the first and second editions. Over the past few years, online social networking sites have revolutionized the way we communicate with individuals, groups and communities, and altered everyday practices. The unprecedented volume and variety of user-generated content and the user interaction network constitute new opportunities for understanding social behavior and building socially intelligent systems. Much research work on social networks and the mining of the social web is based on graph theory. That is apt because a social structure is made up of a set of social actors and a set of the dyadic ties between these actors. We believe that the graph mining methods for structure, information diffusion or influence spread in social networks need to be combined with the content analysis of social media. This provides the opportunity for new applications that use the information publicly available as a result of social interactions. Adapted classic NLP methods can partially solve the problem of social media content analysis focusing on the posted messages. When we receive a text of less than 10 characters, including an emoticon and a heart, we understand it and even respond to it! It is impossible to use NLP methods to process this type of document, but there is a logical message in social media data based on which two people can communicate. The same logic dominates worldwide, and people from all over the world share and communicate with each other. There is a new and challenging language for NLP. We believe that we need new theories and algorithms for semantic analysis of social media data, as well as a new way of approaching the big data processing. By semantic analysis, in this book, we mean the linguistic processing of the social media messages enhanced with semantics, and possibly also combining this with the structure of the social networks. We actually use the term in a more general sense to refer to applications that do intelligent processing of social media texts and meta-data. Some applications could access very large amounts of data; therefore the algorithms need to be adapted to be able process data (big data) in an online fashion and without necessarily storing all the data. This motivated us to give three tutorials on Applications of Social Media Text Analysis at EMNLP 20151 , on Natural Language Processing for Social Media at the 29th Canadian Con- --- xxii PREFACE ference on Artificial Intelligence (AI 2016) 2 , and on How Natural Language Processing Helps Uncover Social Media Insights at the 33rd International Florida Artificial Intelligence Research Society Conference (FLAIRS 2020). Also on this topic, we organized several workshops (Semantic Analysis in Social Networks (SASM 2012) 3 , Language Analysis in Social Media (LASM 2013 4 , and LASM 2014 5 ) in conjunction with conferences organized by the Association for Computational Linguistics 6 (ACL, EACL, and NAACL-HLT). Our goal was to reflect a wide range of research and results in the analysis of language with implications for fields such as NLP, computational linguistics, sociolinguistics and psycholinguistics. Our workshops invited original research on all topics related to the analysis of language in social media, including the following topics: • What do people talk about on social media? • How do they express themselves? • Why do they post on social media? • How do language and social network properties interact? • Natural language processing techniques for social media analysis. • Semantic Web / ontologies / domain models to aid in understanding social data. • Characterizing participants via linguistic analysis. • Language, social media and human behavior. There were several other workshops on similar topics, for example, the Making Sense of Microposts (#Microposts) 7 workshop series in conjunction with the World Wide Web Conference 2012 to 2016. These workshops focused in particular on short informal texts that are published without much effort (such as tweets, Facebook shares, Instagram-like shares, Google+ messages). There has been another series of Workshops on Natural Language Processing for Social Media (SocialNLP) since 2013. For example, SocialNLP 2017 was in conjunction with EACL 2017 8 and IEEE BigData 2017 9 , and SocialNLP 2020 had two editions, one in conjunction with TheWebConf 2020 and one in conjunction with ACL 2020 10 . The intended audience of this book is researchers that are interested in developing tools and applications for automatic analysis social of media texts. We assume that the readers have basic knowledge in the area of natural language processing and machine learning. We hope that this book will help the readers better understand computational linguistics and social media analysis, in particular text mining techniques and NLP applications (such as summarization, 2 http://aigicrv.org/2016/ 3 https://aclweb.org/anthology/W/W12/#2100 4 https://aclweb.org/anthology/W/W13/#1100 5 https://aclweb.org/anthology/W/W14/#1300 6 http://www.aclweb.org/ 7 http://microposts2016.seas.upenn.edu/ 8 http://eacl2017.org/ 9 http://cci.drexel.edu/bigdata/bigdata2017/ 10 https://sites.google.com/site/socialnlp2020/ PREFACE xxiii localization detection, sentiment and emotion analysis, topic detection and machine translation) designed specifically for social media texts. Besides updating each section in this third edition, we added a new section on keyphrase generation from social media messages and one on neural machine translation in Chapter 3 and three new applications in Chapter 4: rumor detection, recommender systems for social media, and preventing sexual harassment. We discuss the new methods and their results. The number of research projects and publications that use social media data is constantly increasing. Finally, we added more than 50 new references to the approximately 400 references from the second edition.

Synthesis Lectures on Human Language Technologies is edited by Graeme Hirst of the University of Toronto. The series consists of 50-to 150-page monographs on topics relating to natural language processing, computational linguistics, information retrieval, and spoken language understanding. Emphasis is on important new techniques, on new applications, and on topics that combine two or more HLT subfields.

Introduction Unlike other forms of donation, blood donation is a unique and noble form of helping that could be perceived as doing a small favour for strangers. Interestingly, in certain cases, donating blood is valued as an anonymous gift of life as donors have no idea whom they are helping and blood recipients do not know whom to thank for the gift (Beyerlein, 2016). Often, it is acclaimed as an altruistic action (Alessandrini, 2007;Sudgen and King, 2021;France et al., 2022). At an individual level, blood donation provides donors with meaningful personal experiences for being socially useful. Hence, the experiences offer individuals a social identity as a blood donor that could enhance their self-esteem for performing the social role (Belda Suarez et al., 2004;da Conceicao et al., 2016). Whereas at a societal level, blood donation denotes a collective form of helping which it is perceived and practiced as a religious duty as well as moral and social responsibilities (Abdel Gader et al., 2011;da Conceicao et al., 2016;Nyambiya et al., 2020;Chen et al., 2021;Hossain et al., 2022;Ayob et al., 2022). --- Literature Review Irrespective of religious backgrounds, individuals' religious values and their altruistic attitude could motivate them to express their concern for others via various means including blood donation. Among the Muslims, blood donation is regarded as a religious duty. In Saudi Arabia for instance, the fatwa (religious ruling) proclaimed that Muslims can donate blood with the intention to save the life of needy patients. Thus, they believed it is a religious duty that must be carried out for the preservation of life (Abdel Gader et al., 2011). In a study conducted by Ayob et al. (2022) in Malaysia, it was observed that young donors regarded an act of donating blood as a sacred duty that is performed with a good intention to save others' lives. In addition, one's intention to donate blood could be associated with the elements of religious teachings. In a study by Chen et al. (2021) in China, it was observed that the instrumental elements of Buddhist teachings such as the pursuit of moral perfection, the cultivation of the virtues of unselfishness, benevolence and understanding, and the laws of karma could influence the intention to donate blood among Buddhists blood donors. They indicated that Buddhist religious elements were positively associated with moral attentiveness which later could promote higher intention to donate blood among them. Among blood donors in Australia, blood donation is carried out as a voluntary work. They felt obliged to contribute to the community where they can and gain personal satisfaction from volunteering. This highlights that blood donation practice and volunteering are mutually reinforced (Alessandrini, 2007). Furthermore, blood donation is a right thing to do to save a life, thus could reinforce a sense of social responsibility among donors (Shaz et al., 2006). For instance, Jaafar et al. (2023) in their study observed that young donors reflect their concern towards the virtues and needs of other individuals through donating blood. Similarly, Yao and Wu (2023) in their study in China among university students found that these young donors believe that donating blood could not only help others but could also save lives. They regarded it as a good deed and a noble charity that should be done voluntarily without any compensation. In a pluralistic society like Canada, family solidarity is generally salient among the Black communities in Montreal. They felt obliged to one another due to family ties. Despite acknowledging blood donation is crucial to save a life and they do it for a common good and a civic duty, Black communities would be inclined to donate blood to their family members or community rather than total strangers (Tran et al., 2013). In another instance, among Brazilians, blood donation is practiced to mainly keep life and ward off death. It is believed that by giving blood, it could save lives, help live and strengthen the lives of others (da Conceicao et al., 2016). In Zimbabwe, donating blood is both a religious and social responsibility for it could save others' lives. By donating blood, it enhances blood's availability in the blood bank as well as enhances accessibility to those who are in need. By donating, donors do not only save others' lives but also could enhance their health too (Nyambiya et al., 2020). Understanding blood donation practice and its underlying socio-cultural perceptions among the younger population is crucial to the functioning of the health system. This is to ensure blood supply is adequate to address the health needs of the population. Thus, this study aims at exploring the socio-cultural perceptions towards blood donation practices among young blood donors in Selangor. --- Research Methods A qualitative study was carried out at the International Islamic University Malaysia (IIUM) to examine young donors' perceptions towards blood donation practices. A convenient sampling technique was employed to select the informants for the study. They were approached during the two-day blood donation drive held at the university to obtain their consent to participate in the study. They were also briefed about the objectives of the study prior to obtaining their consent. After obtaining their consent, informants were interviewed face-to-face for data collection. The interview sessions were held informally in a semi-structured way, but guided by the interview schedule. The interviews were conducted on campus at the convenient time and place of the informants and lasted for approximately 20 minutes on average. Questions on informants' socio-demographic data and perceptions towards blood donation practices were applied, audio-recorded and later transcribed verbatim. Thematic content analysis technique was used to analyse the data obtained from the study. The interview transcripts were read and read to gain an understanding of the issue and classified into dominant themes representing the socio-cultural perceptions towards blood donation practices among the informants. --- Results and Discussions --- Informants Demographics Profiles Nine (9) young donors aged between 21 and 24 years old involving both local and international students were selected as informants for the study. Out of nine informants, seven were male and two were female students in their undergraduate programme from various disciplines. The informants' demographic profile is presented in Table 1. 1 represents informants' demographic profiles. It was observed that most of the informants interviewed were first time donors. They reported having to find out their blood type during the blood donation drive. As young donors, informants in this study held a positive view towards blood practice. The discussion that follows below will describe several themes generated from the data obtained in this study in relation to socio-cultural perceptions on blood donation practice. It was observed that young blood donors in this study perceived blood donation practice as a good thing to do to help others. This includes perceiving blood donation practices as moral and social responsibilities. --- Theme 1: Moral Responsibility One of the informants, Malik, a 21 years old blood donor perceived blood donation as a form of sadaqah (charity) that can be performed to help others. In one of the interviews he said: …it is like giving 'sadaqah' (charity) to others, you are doing something good to the person. You help others who are in need. Indeed, the word 'donation' itself implies doing a good thing, not limited to donating money only. In another instance, Hakimi aged 21 described the following in one of the interviews: I do not have money to help poor people but fortunately, 'alhamdulilah' I am a healthy person, so I can donate blood to those who need it. Often donating money is central in the concept of donation. However, this is not the case among young blood donors in this study. For them, the concept of donation is not limited to donating money for a good cause, but also includes non-money gifts. They perceived that their good health permeates good to others. By donating their healthy blood to others without expecting anything in return promotes the feeling of happiness for the blood donors. Thus, it is evident that young blood donors in this study exhibited altruistic behaviour. --- Theme 2: Social Responsibility The act of donating blood among young donors in this study could be perceived as one of the ways to contribute to the community. This includes helping others to overcome fear and save lives. In one of the interviews, Faz aged 24 mentioned that his intention to participate in a blood donation drive is to help save others' lives. He described his intention as follow: Young people like me have the best quality of blood. The best thing that I can do now (in a healthy state and have the best quality of blood) is by helping a person who is in a critical condition in a hospital and in need of blood. Similarly, Alya aged 21 also perceived blood donation as a social responsibility and a way to contribute to her country. She mentioned that: Donating blood is one of my contributions to the country. When I was in my secondary school, I came across a poster published by the National Blood Bank stating that the country is in shortage of blood supply. I wanted to donate, believing it is a good deed to be performed as a citizen. Unfortunately I was underage, thus I was not eligible to donate. Now I am 21 and this is my 3rd time donating. As for Wan, aged 21 narrated that his experience of overcoming his fear of needles could be a motivational factor to help others in overcoming their fear too. He described that: One of my friends wanted to donate blood but she fears needles. I did feel the same way previously, but managed to overcome the fear in my first blood donation attempt. It was like enhancing my self-confidence too. For this reason, I felt responsible to help her to overcome her fear too by persuading her to participate in a blood donation drive as a blood donor. The above discussions highlighted that donating blood is not only to help patients who are in need of blood for their health problems, but also could help others to overcome their psychological conditions like fear through blood donation procedure. It was observed that the blood donation procedure itself could hinder the process of recruiting potential blood donors. --- Conclusion The foregoing discussions had demonstrated that donating blood has become a common practice among younger population particularly the university students. These young blood donors looked forward to donating blood for it provides a means for them to contribute to society. They felt socially and morally responsible to help others who are in need. This positive attitude is crucial in ensuring the blood supply in the country is sufficient for its shortage would bring disruption in providing the necessary health care to the population. Tran, N. Y. L., Charbonnear, J., & Valderrama-Benitez, V. (2013). Blood donation practices, motivations and beliefs in Montreal's Black communities: The modern gift under a new light. Ethnicity & Health, 18(6), 508-529. Yao, X & Wu, Y. (2023). Experiences and perceptions of Chinese university students toward blood donation: A qualitative analysis, SAGE Open, 13(1), 1-10. --- Ethics Approval and Consent to Participate Research Ethics Committee approval was neither mandated nor emphasised prior to the commencement of data collection. However, all informants were furnished with sufficient information regarding the study before obtaining their consent to voluntarily participate in the study. Confidentiality and anonymity were maintained to protect informants' privacy. --- Conflict of Interest The authors declare no conflicts of interest in relation to the research, authorship, or publication of this paper.

This is a qualitative study examining the socio-cultural perception toward blood donation practice among young blood donors. Understanding blood donation practice and its underlying socio-cultural perceptions among the younger population is crucial to the functioning of the health system. This is to ensure blood supply is adequate to address the health needs of the population. To address the issue, nine (9) young blood donor aged between 21 and 24 years old were approached during a blood donation drive held at the International Islamic University Malaysia. These young blood donors were selected through a convenient sampling technique. Guided by a semi-structured interview schedule, face-to-face interviews were conducted on campus to capture informants' perceptions toward blood donation practice. Thematic analysis technique was used to analyse data obtained from the study. It was found that young blood donors in this study perceive blood donation practice as a good thing to do to help others. This includes perceiving blood donation practice as moral and social responsibilities. Contribution/Originality: This study contributes to the existing literature by empirically demonstrating the positive attitudes of young blood donors on blood donation practice, highlighting the roles of university students in spreading good message about blood donation.

Background: Parenting is marked by intense emotional and health information needs for individuals and families. Understanding how digital technologies are used by new parents may allow public health organizations to tailor digital health information resources and delivery methods to better meet needs. --- Methods: A qualitative descriptive study was conducted to understand new parents' experiences with digital technology during their transition to parenting. Individuals in Ontario, Canada who had become a parent in the past 24 months were recruited to participate in a focus group. Participants were asked to describe the technologies used to support their parenting and how they were used to support self and family health. Focus group data were subjected to thematic analysis using inductive coding. --- Results: Focus groups were conducted with 26 heterosexual female participants. Participants primarily used digital technologies (smartphone, social media) to seek information on maternal, foetal, and infant health and establish social and emotional supports. Parental health information work was gendered and categorized by 2 dominant themes. First, '''Let me know when I'm needed''' typifies fathers' limited health information seeking and reinforces mothers as lay information mediaries. Second, ''Information Curation'' captures participants' belief that gender biases built-in to digital parenting resources reified the gendered nature of health information work for new parents. --- Conclusions: While parents regularly use digital resources for health information seeking, the gendered nature of such digital resources reinforces gendered divisions of health work. --- Key messages: Digital technologies tailored to new parents actively reinforces gender norms. Public health organizations have an opportunity to engage with new parents to identify how digital information resources can be created that support equitable division of health information work. --- Abstract citation ID: ckad160.1234 The association between self-perceived stuttering and social participation among older adults --- Aims: Social participation is important for general health and quality of life among older adults. Currently, research concerning the association between stuttering and social participation among older adults with larger data sets is scarce. The aim of this population-based cross-sectional study was to investigate the association between stuttering and social participation among older adults in southern Sweden in 2012. --- Methods: Participants were 8518 inhabitants of the Region Ska ˚ne in 2012, aged between 55 and 80 years. They were recruited from --- Background: The utilisation rate of operating theatres is one of the indicators of efficient management in a Hospital. Our analysis focuses on the percentage of room utilization for planned activity. The aim is to compare the results of the manual planning carried out by the Surgical Scheduling Office (SSC) with the one carried out automatically by the testing of a Decision Support System (DSS) management application based on the automatic analysis of factors involved in the creation of surgical scheduling. --- Material and Methods: The study took place at the Hospital 'Alta Valdelsa' in Poggibonsi, Tuscany, Italy. It first saw the collection and cataloguing over a period of one month (Nov 2022), for each speciality, of the operating notes made by the SSC, taking into consideration the indications of the respective referring surgeons. From the surgical work pathway management system (ORMAWEB), the actual average operating times over the same period were then collected for each specialty. Finally, for comparison, the DSS worked out the best room scheduling according to an algorithm based on waiting lists, priorities, and operator surgical times. --- Results: Following the manual planning of 143 scheduled operations, the planned utilization of the operating theatres was in most cases confirmed by the reality of the occupied room times extrapolated from ORMAWEB, with slight differences due to patient-dependent modifications. Out of a total of 350 hours available for surgical specialties, the manual operating notes predicted room occupancy for only 196 hours and 40 minutes, with a utilization rate of 56.3%. The DSS application, on the other hand, produced a possible schedule with a room occupancy of over 90%. --- Conclusions: The study shows that the efficiency of the operating theatre could be significantly increased if the SSC were supported by a DSS application that uses totally objective criteria in the selection of patients to be operated on the waiting list. --- Key messages: The use of new applications in surgical path management can improve the efficiency of the operating theatre. Increased utilisation of surgical rooms results in better rationalisation of available resources of the Hospital. --- Background: Current dynamic consent software available is not all tailored for public health research and lacks the appropriate data governance framework and mechanisms to be compliant with public health research requirements. This paper presents the UML modelling of the Dynamic Consent for Public Health (DC4PH), a dynamic consent platform being designed for the Canadian public health domain Methods: The proposed platform incorporates data governance and public health stakeholders' requirements into its design and is based on state-of-the-art standards and solutions. Diagrams created in UML reflect the mapped requirements and demonstrate the capabilities of our dynamic consent proposed data structure. We also incorporated private ledger entities in our modelling to provide an immutable log of dynamic consent for stakeholders and improve transparency and trust between them. --- Results: A series of UML assets were created based on previous mapping of the public health research domain, public health principles, and data governance requirements. Use case diagrams for each type of user of the platform, state diagrams of key business objects vital for the platform's enhancement of traditional consent, and state diagrams of the actor's possible states. Flowchart of the core platform's functionalities, such as the dynamic consent approval process. And a class diagram of the proposed platform that incorporates all the previously mentioned domain mapping and binds it with optional private ledger properties. --- Conclusions: This work offers a comprehensive and extensible UML design that is being used to develop the DC4PH platform. The paper concludes that the design has the potential to improve the efficiency and efficacy of informed consent collection in public health research projects of small or large scales while also being capable of complying with data governance requirements, healthcare standards, and ledger technologies. Key messages: Dynamic informed consent still lacks appropriate scrutiny over the underlining data structures utilized to store and manage dynamic consent. Our work proposes a design in Unified Modelling Language (UML), of dynamic informed consent based on public health's domain mapping, data governance and public health research requirements.

Population aging poses challenges to high quality health and social care for older people in Europe. The Horizon 2020 ValueCare project (www.projectvaluecare.eu) develops, implements and evaluates an Information and Communication Technologies (ICTs) supported integrated health care solution. ValueCare aims to increase health-related quality of life of older people in Europe by a co-designed digital solution with end users. The project has seven pilot sites with unique social and cultural backgrounds: Athens,

Introduction Imagine a researcher who is trying to understand how a particular population subgroup on social media might react to an event that hasn't happened yet and that they are not currently discussing. This task has a variety of applications such as estimating public opinion, planning marketing campaigns, and identifying potential risks and opportunities. This is not a straightforward task. The researcher must first find the group in question, and they typically do not know the terms that the group uses to describe themselves or their interests. However, large language models like GPT-3 can generate potential keywords for identifying content created by the group in question since these models are trained on vast amounts of text data and are likely to have ingested interactions from the group. Once the researcher has identified potential terms, they must be able to verify them against actual social media conversations to see if they are being used by the group or "hallucinated" by the model. If the terms are relevant, the researcher needs to download, store and clean the appropriate posts, removing any irrelevant or redundant information. Finally, small language models like GPT-2 can be finetuned on these posts to create a model tailored to the group's language and context. Because the desired opinions and beliefs are not explicitly in the text, but are latent in the model, the model can be used to generate artificial text simulating how the population might react to the hypothetical event. This scenario illustrates how language models can identify and understand population subgroups on social media, even when the desired information is not explicitly present in the text. Such models can provide valuable insights into the thoughts and behaviors of these groups, allowing researchers to make more informed decisions and predictions. To address this scenario, we have developed a Python toolkit for using large language models to identify and analyze relevant data from social media platforms. Our applications facilitate understanding and analyzing population subgroups online, enabling researchers and practitioners to gain insights that would not be possible through traditional methods. --- Background Query term identification is the process of identifying relevant terms and phrases for describing a particular topic or concept. However, this process is often ad-hoc and deeply reflects the researcher's awareness and bias [11,2]. Other approaches rely on query logs and cannot be used for recommending important words based on a domain where the user has little prior knowledge or experience [9]. This can lead to a lack of consistency and reproducibility. In recent years, there have been attempts to create tools to help researchers determine the optimal keywords for search in social media in disciplines such as information retrieval. These tools often use various techniques, such as natural language processing [4] and machine learning [13], to analyze large datasets and identify relevant keywords. For example, some researchers have used topic modeling algorithms, such as Latent Dirichlet Allocation (LDA), to identify the most common themes and topics in a dataset [5]. These themes can then be used as keywords to search for relevant content. Other researchers have used sentiment analysis to identify the sentiment associated with specific keywords, which can be useful for understanding how different groups of people feel about a particular topic [13]. There have also been efforts to develop keyword generation tools specifically for social media platforms, such as Twitter [1]. These tools often rely on machine learning algorithms to identify patterns in the language and behavior of users, and use this information to suggest relevant keywords for search [12]. While these tools have had some success in helping researchers identify relevant keywords, many of these tools rely on supervised learning techniques, which require large amounts of labeled data for training [10]. This can be difficult to obtain, particularly in domains where there is limited available data or where the language used is highly specialized. Additionally, these tools (e.g. LDA) may be limited in their ability to capture the complexity and nuance of human language and behavior, which can be important for understanding social media conversations and other phenomena. Alternatively, transformer language models such as BERT and GPT are trained on vast amounts of data from a wide range of sources, including books, articles, and social media posts, and as a result, they have a broad understanding of language and context. This can make them useful for sociology research, such as addressing query term identification by generating lists of slang terms or other specialized vocabulary that may be difficult to find using other means [8]. These large language models could potentially further be used to analyze the retrieved data, but they may not be tailored to the specific needs and concerns of examining a particular subgroup. To address this, smaller language models such as GPT-2 can be quickly fine-tuned on corpora that are specific to a target domain [6]. This allows the models to capture the language and context of particular social subgroups, enabling a new form of computational sociology. By repeatedly prompting these finetuned models to produce a large volume of responses, researchers can gain insight into the language and behaviors of these groups in a more nuanced and detailed manner than via traditional means [7]. --- Application Pipeline Overview The Keyword Explorer Suite is a toolkit for understanding online populations, consisting of a set of Python applications that work together in a pipeline, where each app produces outputs that are used in subsequent applications. The suite includes a graphical user interface (GUI) that allows the user to explore the data in an interactive environment. The pipeline consists of: keyword exploration and validation, continues with data collection, then data cleaning and refinement, and concludes with model training and exploration. These parts of the pipeline are discussed in detail below: --- Keyword Exploration and Validation Keyword exploration uses the KeywordExplorer app (Figure 1a), which lets the user prompt the GPT-3 using the OpenAI API to produce lists of keywords. Prompts are generally of the form: "xxxx: ¡newline¿ 1)". Here, ¡newline¿ is a line break and xxxx is a string such as List slang terms that have been used to refer to COVID-19:, or Create a list of hashtags that are important on Black Twitter. As an illustrative example we will be using Here's a short list of exotic pets. Each time the model is prompted, slightly different responses will be generated, and can be evaluated. For this query, the responses started with "1) Bats, 2) Monkeys, 3) Snakes," and went to "9) Tarantulas, 10) Scorpions, and 11) Sugar Gliders." When prompted in this form, such responses from the GPT-3 are easily parsed using a regex. Once applied, an unadorned list is produced that can be passed to Twitter or Wikipedia to evaluate the keywords based on the usage of each keyword over time. With the default parameters we retrieve count data for 10 days in the past to the current date, though these are easily edited. Submitting these words to Twitter returns the total usage over that period (Dec. 17-27, 2022) to be Monkeys (36,772), Snakes (29,830), Bats (21,156), Alligators (3,258), Tarantulas (689), and Sugar Gliders (196). To further evaluate the applicability of the keywords, the app can launch a series of tabs in the default browser for each of the keywords across the defined timeframe. This can help to find times when the context switches, as in the case for "Birds" during 2014, when the Baltimore Orioles baseball team, referred to as "The Birds," had a particularly good season. --- Data Collection Once the keywords are validated, they are passed into the TweetDownloader app (Figure 1b). This app allows the user to submit the keywords individually to the Twitter API and sample the relevant tweets over a defined period. The number of tweets per keyword per day can be adjusted so that they are the same for each day or proportional with respect to the largest number of tweets for any particular keyword. The TweetDownloader app also allows the user to also filter for language, location, and other criteria. The results are saved to a MariaDB relational database, which allows sophisticated queries and analysis. The database stores data and time information, which supports downstream chronological sampling. Users can apply daily and overall limits for each keyword corpus. --- Data Cleaning and Refinement TweetEmbedExplorer (Figure 1c) filters, analyzes, and augments tweet information. Augmented information can then be used to create a train/test corpus for finetuning language models such as the GPT-2. For any keyword, user information associated with the ID of each post can be collected and placed in its own table in the database, allowing more sophisticated queries. Using the OpenAI text embeddings API, the embeddings for each tweet can be stored in the database. These can be projected to 2D using a combination of PCA and T-SNE. Once dimension reduction has been performed, clustering can be performed interactively using DBSCAN [3], and outlier clusters can be marked "excluded." The next step is to produce a corpus for finetuning a GPT-2 model. Finetuned models have been shown to accurately predict, for example, the vegetarian preferences of Yelp reviewers when all vegetarian data has been excluded from the test/train data [7]. This means that a model finetuned on a set of tweets that may not contain the explicit information about a certain subject may still be able to generate tweets that are likely to contain that information in some cases. We use a process we call "meta wrapping" that creates text that has metadata in it in addition to the tweet, e.g.: Each entry in the string is wrapped by [[ and ]]. All elements within the meta wrapped string are separated by ||. The "text:" element precedes the posting, the "created:" tag precedes the data the post was created, and the "location:" tag contains the coordinates of the tweet or the poster if available. For model convergence validation, there is a substring of the form "probability: xxxx", where xxxx can be "ten", "twenty", "thirty", or "forty." The likelihood that a line will have the appropriate string reflects the probability of the random number generator hitting that value. As a sanity check, if the generated data does not match these percentages, insufficient finetuning can clearly be diagnosed. --- Model Training and Exploration ModelExplorer is a tool that allows users to interactively explore finetuned GPT-2 models (Figure 2). These models are finetuned on tweet corpora generated from TweetEmbedExplorer. It allows the user to provide a set of comma-separated probes along with model hyperparameters and then generate a series of predictions from the model. Text that is output from the model is parsed, displayed in the text output area of the tool, and if desired, stored in the database for further analysis. In the example in Figure 2, probes regarding Ivermectin and Paxlovid were used. The results show that there was a maximum deviation of 4% with respect to the target percentages, so the finetuning sanity check was passed. --- Conclusions We presented a Python toolkit for gaining insight into population subgroups. 1 Our pipeline begins with using large language models to generate potential keywords for exploring population subgroups, which are then validated using historical usage trends on social media platforms. The resulting data is then analyzed and clustered using a combination of GPT-3 embeddings and manifold reduction. Finally, the posts are used to generate corpora that can be used to fine-tune language models and identify latent information. We plan to use our toolkit to study COVID-19 racism.

We have developed a set of Python applications that use large language models to identify and analyze data from social media platforms relevant to a population of interest. Our pipeline begins with using OpenAI's GPT-3 to generate potential keywords for identifying relevant text content from the target population. The keywords are then validated, and the content downloaded and analyzed using GPT-3 embedding and manifold reduction. Corpora are then created to fine-tune GPT-2 models to explore latent information via prompt-based queries. These tools allow researchers and practitioners to gain valuable insights into population subgroups online. (a) KeywordExplorer (b) TweetDownloader (c) TweetEmbedExplorer

Introduction Transmasculine individuals (TM; assigned to the female sex at birth but who live their lives as men or within the masculine spectrum) who have a cervix may be at a higher risk of cervical cancer [1][2][3]. Research has documented that TM patients are screened less and therefore, have lower odds of being up-to-date with cervical cancer screening compared to cisgender women (persons whose gender identity correspond to the assigned sex at birth) [4,5]. Some of the drivers for this disparity include stigma and discrimination in health care interactions, barriers to access cancer screening, lack of representation in the national cancer statistics, and lack of tailored cancer screening programs [6]. Latinxs are a particularly vulnerable group as they have the highest incidence of cervical cancer among all ethnic groups in the United States (US) [7]. Thus, Latinx TM (LTM) could be at an even higher cervical cancer risk as they lie at the intersection of two health disparity populations (gender and ethnic minorities). Healthcare providers (i.e., physicians, advanced practitioners, nursing staff) are in a key position to foster cervical cancer prevention efforts [8][9][10][11]. However, research has documented that when interacting with healthcare providers, LTM often feel stigmatized and are provided with substandard levels of care [12,13]. These negative experiences can often lead LTM to avoid seeking healthcare altogether [13]. Furthermore, despite some provider's intentions to provide high-quality healthcare to LTM, their lack of training and knowledge about LTM-specific healthcare needs, such as cervical cancer, might lead them to interact with patients in ways that can be perceived as negative [6,[14][15][16][17]. For example, research has documented how offering a self-swab option for human papillomavirus (HPV) testing (as opposed to provider-collected) can be a patient-centered behavior that increases cervical cancer screening among this population [5,18]. Nevertheless, the team did not find any research effort to date assessing patient-provider clinical interactions with LTM via direct observation. This is an important gap, as interviews or self-report measures can only provide a limited understanding of cervical cancer prevention behaviors during patient-provider clinical interactions. Considering this, the objective of this study was to examine cervical cancer preventive behaviors among medical students during simulated clinical interactions with an LTM. --- Materials and Methods --- Design and Procedures This study is part of a larger project examining barriers and facilitators for LTM cervical cancer screening. The research was approved by the Ponce Health Sciences University Institutional Review Board (1903007737). To address the purpose of this study, the team implemented Standardized Patient Simulations (SPS), self-reported measures, and observational techniques. SPS are simulations of clinical interactions with actors portraying the role of a patient, which are routinely used in medical schools to examine medical student's competencies. The total sample consisted of 37 third-year medical students, all of which were already scheduled to participate in their third-year SPS evaluations. Participants were recruited by availability and met the following criteria: (1) 21 years of age or older and (2) in the third year of medical school. The SPS program staff informed potential students about the study. Those interested were provided with an orientation and proceeded to complete the consent form and sociodemographic questionnaire before engaging in an SPS simulation with an LTM. The SPS case script, jointly developed by the research team (researchers, LTM, and SPS staff), presented an LTM with a chief complaint of pelvic pain and irregular bleeding. The actor had to (1) uniformly present the chief complaint and symptoms, (2) report a double mastectomy (if prompted), (3) disclose gender identity (if prompted), (4) report current testosterone use (if prompted), (5) report history of cervical cancer in the family (if prompted), and (6) report no previous history of HPV vaccination or screening (if prompted). These interactions lasted for approximately 20 min in which medical students had to (1) obtain the patient's medical history, (2) discuss identified symptoms and risks, and (3) recommend treatment and testing. An LTM actor trained by the SPS staff in the study's script performed all cases. This LTM SPS was interspersed among their other scheduled SPS cases. All participants were aware they would engage in an observed SPS with a LTM at some point during their SPS rotations. All SPS interactions were video recorded in order to be analyzed later using the behavioral measure described in the next section. --- Measures Sociodemographic Questionnaire-The team developed this self-report questionnaire to address participant's demographic information such as age, gender, income, marital status, etc. Cervical Cancer Preventive Behaviors Inventory (CCPBI)-This observational inventory was developed by the research team based on their previous research [19,20], establishing observational measures for SPS with the input of LTM participants and consultants. The CCPBI includes 38 nonverbal and verbal behaviors that can be enacted during a clinical interaction with an LTM. It assesses behaviors that are relevant to any interaction with a patient (general behaviors), and behaviors applicable to LTM (gender affirming behaviors and cervical cancer preventive behaviors). A trained observer assesses all behaviors using a three-point scale with the following values: manifested, unsure, and not manifested. --- Data Analysis Given the descriptive nature of this study, the team used one-way frequency tables to describe the sample and the general, gender-specific, and cancer-specific behaviors. --- Results --- Sample Characteristics The total sample consisted of 37 students in their third year of medical school. Participants had a mean age of 36 years (SD = 2.0) and consisted mainly of single (67.6%), heterosexual (89.2%) cisgender females (54.1%) who lived in an urban area (97.3%). Participants identified themselves as Catholics (37.8%) and reported an annual income equal to or lower than $50,000. Participants had not received any type of training focused on transgender health issues (Table 1). --- One-Way Frequency Analysis The documented clinical skills in the SPS with LTM evidenced a concerning scenario. Findings suggest that while some general behaviors were manifested (i.e., answered the patient's questions (100%); discussed family history of cervical cancer (94.3%); asked about current gender identity (74.3%)), others more specific to cervical cancer prevention among LTM were largely absent (i.e., exploring the patient's reasons for avoiding visits to the doctor (77.1%), asking if the patient preferred to collect the sample by himself (85.7%); exploring potential discomforts the patients might have experienced in the waiting room (100%)). A more detailed description of these behaviors is presented in Table 2. --- Discussion In this study, the team aimed to examine medical students' cervical cancer preventive behaviors when interacting with an LTM by using SPS and observational techniques. The findings suggest an alarming scenario in which medical students seem to lack important clinical skills for engaging in cervical cancer prevention efforts with LTM. The main finding is that medical students in this study did not manifest key behaviors to address cervical cancer prevention when interacting with a LTM. Despite previous evidence emphasizing the importance of gender affirming behaviors in clinical interactions with LTM [13,20,21], some participants did not ask about the patient's chosen name or pronoun, and used gendered language throughout the clinical interaction. Furthermore, none asked about potential concerns/discomfort while in the waiting room area. In addition, key cervical cancer preventive behaviors recommended by guidelines and recent research evidence [6,[22][23][24][25][26] were not exhibited, such as asking about hysterectomy, checking for specific symptoms linked to cervical cancer, and asking if self-sample collection for screening was preferable. This could be related to the reported lack of training focused on transgender-related health issues. However, it could also point towards another interesting finding-that most trainings and guidelines focus on education through knowledge acquisition and attitude change, assuming that it will foster better behaviors in clinical interactions with LTM. Thus, these descriptive findings from actual behaviors in clinical interactions echo recent research arguing the need for surpassing the general Lesbian, Gay, Bisexual, and Transgender (LGBT) awareness and sensitivity training taught in medical schools by focusing instead on separate transgender-specific content, clinical skill building, and measured outcomes [14,27]. However, it is also important to highlight that these findings are mixed. For example, some participants did demonstrate gender-affirming behaviors (i.e., asking about current gender identity and avoiding making discouraging comments about hormone use). Similarly, some cervical cancer preventive behaviors were enacted by medical students, such as discussing family history of cervical cancer and referring to cancer screening tests. Despite these findings, this study has several limitations to be noted. First, the team did not examine real patients, which does not allow for an examination of patient outcomes. Second, the small sample size and lack of control group limits the generalizability of the study findings. Third, participants were aware they would not encounter actual patients, which can prompt them to change their behaviors. Thus, the findings should be interpreted with caution. However, despite these limitations, this study addresses an important gap in the research literature, by focusing on actual observed behaviors rather than relying on self-report measures to better understand cervical cancer preventive behaviors for LTM and can serve as the basis for future research in the area. --- Conclusions Observed behaviors in clinical interactions between medical students and LTM were mixed, with some recommended behaviors being neglected and others enacted. Further research efforts addressing the limitations in this study are needed to better understand behaviors in clinical interactions with LTM as well as how to improve them. --- Data Availability Statement: Data is contained within the article. --- Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. --- Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Latinx transmasculine men (LTM) can be at a particularly high risk for cervical cancer as they lie at the intersection of two health disparity populations (gender and ethnic minorities). Previous research using self-report measures has documented how negative interactions with providers are a key barrier for cervical cancer screening among LTM. However, no research to date has examined, via direct observation, cervical cancer preventive behaviors in clinical interactions with LTM. Thus, the objective of this study was to examine cervical cancer preventive behaviors in clinical interactions between medical students and an LTM. The team implemented standardized patient simulations (simulations of clinical interactions with actors portraying the role of a patient), self-report measures, and observational techniques. A total of 37 medical students participated in the study. The results were mixed with some key behaviors neglected (i.e., asking if the patient preferred to collect the HPV test sample by himself), while others were enacted (i.e., checking family history of cervical cancer). Further research is needed to better understand behaviors in clinical interactions with LTM as well as how to improve them.

Introduction The concept of sexuality can be dated back to our ancestors, who laid much emphasis on the care of self and the act of procreation, emerging population and health concerns have led to the re-thinking and re-identification of the relationship between sexuality and human activity and behavior, slowly then has undergone many changes within the past forty years. The emergence of the sexual revolution has also impacted greatly sexual orientations, patriarchy, sexual relations, reproduction, and family formations. Against this backdrop, this paper will examine the origin of the concept of Early sex education, how it evolved in Nigeria, and how well it is fairing in Nigeria. In doing this, the paper will highlight some conceptual perspectives of sex education, and identify its definition, its content, and structure. Conclusions will be drawn and practical ways of moving sexuality education forward in Nigeria will be suggested. --- Early childhood In human life, children are the most valuable assets. They have extraordinary potential so they become active, dynamic, enthusiastic people who want to know what they see, hear, and feel. Therefore early childhood must be nurtured, guided, and directed so that the child's potential develops in a positive direction and benefits. Children according to Nigerian government law are in the 0-18-year age range, and according to UNESCO, early childhood is in the 0-8-year age range. Early childhood can be seen from the path of formal education, playgroups, kindergartens, and elementary schools. Informal age education can be through family education and environmental education. Parental education style is essential in developing the personality of children and adolescents. --- Sexuality Education Sexuality education has been given various definitions by various schools of thought. AHI (2003) described sexuality education as "a planned process of education that fosters the acquisition of factual information, the formation of positive attitudes, beliefs, and values as well as the development of skills to cope with the biological, psychological, sociocultural and spiritual aspects of human sexuality." That is, learning about the anatomy, physiology, and biochemistry of the sexual response system which determines identity, orientations, thoughts, and feelings as influenced by values beliefs, ethics, and moral concerns. It is the interactive relationship of these dimensions that describes an individual's total sexuality (SIECUS, 1995). Also, sexuality education teaches us that, religious principles, beliefs, rules and regulations, and ethical considerations affect our everyday interactions just as our culture, role models in our families, and our friends impact us as well. Sexuality education is simply the art of learning how to conform to a certain art of living by being able to reason, examine and monitor oneself in clearly defined terms. In Nigeria as well, traditional forms of sex education existed in kinship systems and coming-of-age ceremonies where the youth were tutored about manhood and womanhood. Its essence was purely biological and culture-specific. There were various methods of contraceptives which included virginity, herbs, breastfeeding, the ring, and abstinence; most of which were strictly meant for the married and kept a secret. Issues on sexually transmitted diseases were also of great concern but were barely discussed while the contraction of them was a big shame and stigma. The socialization process of the child remained strictly the only way of acquainting the child with issues like family relationships and public manners with very little room for self-expression. As school education expanded, people began to question moral viewpoints about virginity and abstinence and wondered about the credibility of rigid moral standards and myths that surrounded sexual issues. The fast pace of domestication encouraged rapid improvement in communication, transportation which had a tremendous effect on sexuality issues in Nigeria. The use of telephones and letters helped to promote interpersonal relationships. The print media intensified and popularised the notion of flirting, dating, and a variety of sexual behaviors. Intimate relationships developed from social activities such as dancing, singing, and local drama sketches. Despite these changes, information on sexuality was still kept in the dark, not openly discussed, and was perceived as dirty or evil, particularly by religious leaders who often viewed morality as being determined by a higher order from above (Adepoju, 2005). The mundane views about early childhood sexuality were kept intact until recently when it came to light that early childhood experiences are related to sexuality. Today, conservative morality about sexuality is beginning to diminish with people gradually coming to terms with the fact that sexual knowledge can serve as a great weapon against ignorance. Evolution of Sexuality Education in Nigeria Initial efforts to introduce sexuality issues in the Nigerian educational system were done through the introduction and institutionalization of population education which was considered as a potential way of tackling the problem of rapid population growth and its consequences for socio-economic development in the country. The need to inform young people about the causes and consequences of uncontrolled rapid population growth has become paramount hence the National Population Policy of 1988 which was recently revised and officially launched in February 2005, was put in place with emphasis on population education as a potential vehicle to translate the population policy into action. Also, among health and educational professionals in Nigeria, the feeling is widespread that the health of adolescents is at risk. This burgeoning adolescent group who constitute more than 12 percent of the population of Nigeria and whose number is expected to rise sharply over the years are often prone to unplanned sex, unwanted sex, unsafe abortion, sexual coercion, sexual violence, sexually transmitted infections, and even HIV because they are uninformed, or poorly informed, about the implications of their reproductive behavior and health risks especially from under-age sexual practices and other anti-social practices. Over the years, the federal government, donor agencies, and non-governmental agencies have put forward initiatives to address population problems and issues. The Federal Ministry of Education and the Nigerian Educational Research and Development Council (NERDC) have been involved in curriculum and instructional package development and teacher training for school-based population and family-life programs. Drawing from practical experiences, the Directors of National Education Programmes in African countries drew up general principles upon which African population and familylife education programs were based, as follows: 1. The contribution that population education can bring to the socioeconomic development of the community and the nation. 2. The importance of both individual decision-making on population matters and the role of the family in collective decision making. 3. The importance of understanding the social and cultural context in which population education contents are to be integrated. 4. The fact that low rates of school enrolment and high rates of drop-outs should lead to greater recognition of out-of-school programs. 5. The need to sensitize the decision-makers in Africa on their countries' population situation and problems (UNESCO, 1985). Udo and Viederman (1979) argued that the definition of population education should include components such as: 1. Population education is part of a total social learning process that can assist learners to better regulate their lives and their environment. 2. Population education, being a problem-centered process, could enable learners to define their own and their communities' population-related problems. 3. Population education is concerned uniquely with the population interactions and interrelationships between the individual and the communities in which she lives. 4. Population education is oriented towards the improvement of the quality of life of both individuals and society, both now and in the future. --- Islam and Early Sex Education Sex is instinctive to organisms and is a basic human need, sex functions to be able to carry on children. The fulfillment of sex requires rules or norms so that humans do not fall into deviations and destruction. Islam has clear and detailed rules in the Sharia so a Muslim must understand and apply them every day to be protected from loss and misery. Sex education can be started as early as possible so that children are better prepared to face physical changes during puberty with all the consequences and can protect themselves from exploitation and sexual abuse. --- Conclusion Early Sex education in Nigeria is still understood to be limited to the guidance of knowledge protection about children's reproduction. When in fact the Sharia and Education have been explained as a series of manners that must be built by a family related to the relationship of men and women both inside and outside the home. In this case, parents play an active role in educating children and instilling these social customs and values. The teacher also plays a role in helping parents do the same thing in the school environment. Therefore, the role of educators is very urgent to socialize the understanding that Early sex education in a different perspective which includes the ways mentioned above so that parents and the community understand Early sex education is not limited to the guidance of knowledge about the reproduction of men and women.

The focus of this study was to investigate the impact of Early sex education in Nigeria. The results revealed that there are Outbreaks and Haigh rates of sexual embarrassment like Firebreaks in the forest, problems, misuse of sex, high teenage pregnancies and abortion, and inadequate information on sex. Sex education is a vital aspect of the health education curriculum. It provides factual knowledge to assist parents and teachers, children and adolescents to avoid sex-related problems. The knowledge also includes ways of helping children develop self-respect, sexual understanding, define the values of interpersonal relationships and strengthen communication skills in sex and education. This promotes a wholesome and stable sex life. Parents and teachers must acquire a scientific, social, and psychological understanding of the need for sex education. The sexual revolutions among contemporary youths recommend sex education as an imperative for adolescents that should be protected from the harmful effects of deviant sexual behaviors.

I. INTRODUCTION 1.1 Background Social innovation, broadly defined as the process of developing and implementing novel solutions to address societal challenges, has gained significant attention in recent years (Murray et al., 2010). As global issues such as climate change, poverty, healthcare disparities, and education gaps become increasingly urgent, social innovation has emerged as a promising approach to drive positive change (Phills et al., 2008). This paper provides a comprehensive examination of social innovation, aiming to deepen our understanding of its foundations, methodologies, impacts, and challenges. 1.2 Research Objectives This research paper has the following objectives:  To explore the conceptual frameworks and theoretical foundations of social innovation.  To analyze the key actors, stakeholders, and networks involved in social innovation processes.  To examine the methodologies and tools used in social innovation projects.  To assess the impacts and outcomes of social innovation initiatives.  To discuss the challenges and barriers faced by social innovators.  To identify future prospects and areas for further research in the field of social innovation. 2. Theoretical Foundations of Social Innovation 2.1 Defining Social Innovation Defining social innovation is a complex task due to its interdisciplinary nature. Scholars have proposed various definitions, but common elements include novelty, social value creation, and the active involvement of stakeholders (Westley et al., 2017). We examine prominent definitions and conceptual frameworks to provide a comprehensive understanding of social innovation. 2.2 Historical Evolution of Social Innovation Social innovation is not a recent phenomenon; it has historical roots in movements like the civil rights era, the cooperative movement, and grassroots activism. Tracing the evolution of social innovation helps us contextualize its contemporary significance. 3. Theoretical Foundations of Social Innovation 3.1 Defining Social Innovation Defining social innovation is a complex task due to its interdisciplinary nature. Scholars have proposed various definitions, but common elements include novelty, social value creation, and the active involvement of stakeholders (Westley et al., 2017). We examine prominent definitions and conceptual frameworks to provide a comprehensive understanding of social innovation. 3.2 Historical Evolution of Social Innovation Social innovation is not a recent phenomenon; it has historical roots in movements like the civil rights era, the cooperative movement, and grassroots activism. Tracing the evolution of social innovation helps us contextualize its contemporary significance. --- II. METHODOLOGY  Design Thinking Design thinking is a human-centered approach that has gained popularity in social innovation. We discuss its principles and application in problem-solving.

Social innovation has emerged as a critical driver of positive change in contemporary society. As the world faces complex challenges ranging from environmental sustainability to social inequality, understanding the nature, processes, and impacts of social innovation is crucial. This research paper aims to provide a comprehensive review and analysis of social innovation, examining its theoretical foundations, practical manifestations, and the role it plays in addressing pressing societal issues. Through a multidisciplinary approach, we explore the various facets of social innovation, shedding light on its conceptual frameworks, key actors, methodologies, and outcomes. Moreover, we delve into the challenges and future prospects of social innovation, emphasizing the need for continued research and collaboration to unlock its full potential.

INTRODUCTION An estimated 1.6 million children, or nearly 1 in 45 American children, experienced homelessness in 2010. 1 Although a national economic downturn and an increase in housing foreclosures contribute to family homelessness, additional adversity and risk factors often contribute to this complex problem. Children affected by homelessness may experience a variety of challenges to their health because of difficulty accessing health care, inadequate nutrition, education interruptions, trauma, and family dynamics. By recognizing these challenges, pediatricians can help improve the care of these children in practices and communities. --- DEFINING AND MEASURING HOMELESSNESS The US Department of Education defines a homeless individual as "(A) an individual who lacks a fixed, regular, and adequate nighttime residence . . . and (B) includes (i) children and youths who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative accommodations; are living in emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement; (ii) children and youths who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings …; (iii) children and youths who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings; and (iv) migratory children who qualify as homeless for the purposes of this subtitle because the children are living in circumstances described in clauses (i) through (iii)." 2 Measuring the homeless population is difficult, and there are no definitive counts of homeless persons in the United States. The US Census Bureau does not currently attempt to estimate the total homeless population; however, the US Department of Housing and Urban Development collects data on shelter usage and makes point-intime estimates of homelessness. The 2011 Annual Homeless Assessment Report to Congress estimates that approximately 1.5 million homeless people used an emergency shelter or transitional housing during 2010-2011, and on a single night in January 2011, 636 017 people were homeless. From 2007 to 2011, the number of children in shelters increased by 1.9% and families with children comprised 35.8% of the total sheltered population in 2011. In addition, from 2007 to 2011, the number of families that moved from stable housing arrangements to the shelter system increased by 38.5%. 3 These estimates did not include homeless persons who were unsheltered or living temporarily with other families. The incidence of homelessness in the United States in a given year is thought to be much higher. --- RISK FACTORS Although all populations experience homelessness, some populations are disproportionately affected. Major risk factors for homelessness among parents include unemployment, substance abuse, mental illness, previous military service, and a previous history of domestic violence or physical or sexual abuse. 4 An analysis of homelessness in a national cohort of US adolescents revealed that poor family relationship quality, school adjustment problems, and victimization during adolescence were each independent predictors of homelessness in adulthood. 5 Among homeless youth, a sexual orientation other than heterosexual and a history of foster care placement and school expulsion are all potential predictors of homelessness as well. 6,7 Racial and ethnic minorities are significantly overrepresented in the sheltered homeless population. In 2011, 71.9% of sheltered families were racial minorities. 3 Recognition of these risk factors is an important part of understanding and supporting homeless children and families. Homeless children and families often experience a number of negative exposures and life events that create a cumulative risk for poor health outcomes. For example, children who live in poverty, are exposed to violence, or experience food insecurity also have poor health care service attainment, increased emergency department utilization, and overall poor health outcomes, independent of housing status. 8,9 However, these risks can be additionally compounded by homelessness. A series of studies on adverse childhood experiences has shown that multiple toxic stressors that begin in childhood can have long-term adverse effects on a child' s neurobiological make-up, cognitive ability, mental health, and ability to manage stressors as an adult. 10,11 It is therefore important to understand and address these stressors both separately and in totality. --- HEALTH EFFECTS OF HOMELESSNESS Homelessness and housing insecurity negatively impact child health and development in many ways. Homeless children have shown higher rates of acute and chronic health problems than low-income children with homes. Cross-sectional surveys conducted in the 1990s reveal increased rates of multiple infectious, respiratory, gastrointestinal, and dermatologic diseases and otitis media, diarrhea, bronchitis, scabies, lice, and dental caries. 12,13 Both the prevalence and severity of asthma are markedly increased among homeless children, and homeless children suffer from higher rates of accidents and injuries than low-income children with homes. 12,14 In an evaluation completed in a schoolbased health center, homeless children were 2.5 times more likely to have health problems and 3 times more likely to have severe health problems than children with homes. 15 Children without a stable home are more likely to skip meals, worry about the availability of food, and consume foods with low nutritional quality and high fat content. 16,17 As a result, they suffer from high rates of malnutrition, stunting, and obesity. 8,18 Homeless children are at an increased risk of abuse, exposure to violence, and psychological trauma. Emotional distress, developmental delays, and decreased academic achievement are all more common in this population. [19][20][21] Speech and language deficits lead to significantly decreased literacy rates in school-aged children. 19,21 Homeless children may experience frequent moves that interrupt their education and impact school performance. In a study in elementary school students, homeless children scored lower on math and reading achievement tests than low-income students living in homes. 21 A study in homeless adolescents who received crisis services at a homeless shelter revealed just 34% of those students attained a high school diploma or general equivalency diploma (GED) by 18 years of age. 22 Unaccompanied homeless and runaway youth differ from homeless children in families. They are more often separated from their families and more frequently exposed to violence and exploitation. Unaccompanied homeless youth are more likely to engage in highrisk sexual behaviors, have teenage pregnancies, engage in drug use, experience mood and anxiety disorders, and face violence than youth with homes. 23,24 ACCESS TO HOUSING Homeless families face many barriers to accessing appropriate housing. In the 2012 Hunger and Homelessness Survey conducted by the US Conference of Mayors, 64% of the surveyed cities reported that shelters turn away families with children experiencing homelessness because of lack of available beds. 25 Access to shelters is challenging in urban settings and rural communities. Although homeless families are more likely to be sheltered than individuals, age and gender restrictions in many shelters often lead to family separations. Homeless mothers are also more likely than housed mothers to have their children separated from them by the child welfare system. 26 --- ACCESS TO HEALTH CARE Children and families in unstable housing often receive fragmented health care and rely on the emergency department as a primary source of care. 27 Some of the barriers that prevent homeless children and families from accessing optimal care include the following: difficulty obtaining affordable, accessible, and coordinated health care services; frequent and unpredictable changes in living circumstances that prevent timely presentation for care, follow-up, and communications with health care providers; inadequate access to storage places for medication and medical supplies; and potential exposure to violence or fear of violence that limits freedom. Despite these barriers, pediatricians can support homeless children. By partnering with community resources and making changes in practice, pediatricians have the opportunity to help families establish a stable source of quality health care, improve family dynamics, and obtain housing and needed services. Addressing these barriers has been shown to have a positive effect on the health outcomes of those who have experienced homelessness. 21,22,28,29 --- RECOMMENDATIONS The following recommendations address how pediatricians can help improve the health of homeless children through practice strategies. 1. Pediatricians should help homeless children increase access to health care services by promoting and, when possible, facilitating Medicaid enrollment to eligible children and families. 2. Pediatricians should familiarize themselves with best practices for care of homeless populations and the management of chronic diseases in homeless populations. 3. Pediatricians should optimize acute care visits to best resolve patient concerns and provide comprehensive care when possible. For example, pediatricians can update immunizations if a patient is significantly behind rather than having him or her schedule a separate appointment. 4. Pediatricians should seek to identify the issues of homelessness and housing insecurity in their patient populations. Pediatricians can use methods such as routine screening on intake and making note of frequent address changes or a history of scattered care provision. 5. Pediatricians should seek to identify underlying causes of homelessness in specific families and help facilitate connection to appropriate resources. This may include asking sensitive questions about unemployment, intimate partner violence, substance abuse, and sexual and gender identity issues. Supporting families to address these difficult issues in addition to their housing needs is critical to improving child health and development. Homelessness is a complex issue that presents a number of challenges for children and families. Pediatricians can support all children who are impacted, by implementing practice-level strategies and engaging in advocacy to promote their health and well-being. --- STAFF Camille Watson, MS

Child health and housing security are closely intertwined, and children without homes are more likely to suffer from chronic disease, hunger, and malnutrition than are children with homes. Homeless children and youth often have significant psychosocial development issues, and their education is frequently interrupted. Given the overall effects that homelessness can have on a child' s health and potential, it is important for pediatricians to recognize the factors that lead to homelessness, understand the ways that homelessness and its causes can lead to poor health outcomes, and when possible, help children and families mitigate some of the effects of homelessness. Through practice change, partnership with community resources, awareness, and advocacy, pediatricians can help optimize the health and well-being of children affected by homelessness.

INTRODUCTION A decision to disclose that one's perceived gender feelings are not the same as the ones assigned to them by birth is a tough one and is often either neglected or completely shattered and put away by the societal norms especially in developing countries like India, Pakistan, Bangladesh, and other countries of south Asia. Very few individuals illustrate the courage and stand up for their decisions, which is influenced by the complexities of family honour, tightly integrated family network, social obligation to get married, and prevalent religious beliefs in the society. 1 All these not only pull back the individuals potential but also deprive them of their self-respect and basic human rights. 2 Gender incongruence (GI) is defined as a condition in which the gender identity of a person does not align with the gender assigned at birth. If GI causes significant distress or problems in functioning lasting for at least 6 months it is described as gender dysphoria (GD) (DSM-V). This case study advances understanding of how gender dysphoria can lead to personality disorders like paranoid personality disorder and how removing the taboo and accepting the individual with their perceived gender is the need of the hour. --- CASE REPORT We present the case of a 24-year-old boy, who presented to the emergency department by police as he was found on the footpath with a bleeding wrist. to calm him down so that wrist could be sutured. His blood pressure (BP) was noted to be a 142/95, respiratory rate (RR) after haloperidol was 18 bpm, pulse rate-102 and he had a temperature of 38.2, complete blood count (CBC), and fasting blood sugar (FBS) were in normal limits. Following that day, his family was contacted who informed the doctors that he never wanted to be a boy ever since he understood the reality of his gender and has runaway from home earlier as well because he feels he doesn't belong there. "All he wanted to do was wear short dresses and put some make-up with false eye-lashes and nail paint". It was noted that the boy's siblings and friends at school made fun of him and he felt too distressed about his feelings. His family always thought he would out-grow such feelings and kept educating him about the ideal behaviours of being a boy. They even supressed his feelings of dressing up like a girl and were embarrassed of him each time he wore short skirts and shaved his legs. They also reported that they were ashamed to talk about this with their family doctor so they started to ignore him assuming he will soon out-grow this behaviour when he understands that he's not being accepted in the family. 16 As his peer group at school never missed a chance to make fun of him which led to dropping out school in his 11 th grade. Ever since then he felt he was not accepted in the society. Family also informed that the boy has had trust issues and paranoia since the past 8-9 years and that he doesn't talk to anyone about his feelings as he thinks everyone is going to harm him in some way and he perceives every act of kindness by his family as an act of planning against him. On obtaining such history a diagnosis of gender dysphoria was made and the it was understood that the boy has also developed a paranoid personality disorder secondary to gender dysphoria. The boy was referred to a transgender specialist, endocrinologist for treatment and psychiatrist for psychotherapy and counselling. --- DISCUSSION Developmental traumas in which the individuals are made to question the validity or reality of their experiences by caregivers are believed to play a role in the eventual development of paranoia, leading the individual to constantly question what is "really" going on in their world and to anticipate danger and shame in their everyday interactions. 3 Failure to provide support by a sense of understanding the individual can lead the child to doubt their perceptions, making the child vulnerable to later developing psychosis. 4 Another prominent influence in the development of paranoia may be the experience of humiliation and shame during childhood. 5 Individuals experiencing paranoia constantly question surface experiences, seemingly on the lookout for the potential to be humiliated. They end up perceiving others as being enraged and threatening towards their own self, leaving the individual to constantly expect maliciousness from others and to adopt a hypervigilant stance against perceived threats in their social world. 6 In recent years, the number of children and adolescents seeking help with GI and GD has increased sharply and especially in children not all persons with GI represent with symptoms of GD. [7][8][9] In early childhood, gender disparities and preferences start out small and generally ignored by the family as it is thought that child will out-grow such behaviour. Children are developmentally on track, and are just as likely to participate in school as they were doing up till now and like all the other students around them. Among those who do not out-grow such explorative behaviour and get distressed by their body changes at the time of puberty start facing problems with activities of daily living and lack a full potential of further growth and development. [10][11][12] --- Challenges in management Sadly, just a few numbers of patients of GD/GI in India are able to make a visit to the psychiatrist as they have always faced rejection and have been supressed by the societal norms to discuss the need of any treatment or proper counselling. Such individuals struggle daily for their identity and lose their self-respect along with their dignity. All this eventually leads to morbid disorders like obesity due to binge eating in stress, low self-esteem, high blood pressure, depression and social isolation along with personality disorders. and increased rate of mortality in this population. Although some resourceful patients who can get treatment and are able to obtain proper therapy and hormonal treatment, some individuals who can't obtain treatment from their health care specialist due to societal taboos seek surgical treatment options from local practitioner and have been subjected to "inferior surgical techniques and post operation care with outcomes anecdotally reported as "horrifying". All this leads to increased probability of a poor outcome, with an increase in morbidity and mortality including post-operative suicide. 21 --- CONCLUSION The onset of adolescence can bring significant barriers and stress to the individuals who do not perceive their gender as the one assigned to them. Gender norms and discrimination heighten their risk of unwanted pregnancy, HIV and AIDS, malnutrition, and risky behaviour like attempt to suicide and running away from home as in our discussed case. 13 All this asks for a passionate and friendly paediatrician, an adolescent medicine specialist and a child and Adolescent Psychiatrist along with psychologist who can adequately diagnose the condition and give appropriate treatment during the early years of GI/GD. 14 Adequate guidance to the patient as well as the family in the best way possible is required to make the society understand the need to accept the individual in a way in which they want to be accepted. 15 Special attention is needed regarding the language in which the child or adolescent is addressed to. Words with a gender statement such as "boy," "girl," "son," "daughter," "he," and "her" can be experienced as uncomfortable for both children with GI and their parents. It is important to be aware of these emotions and to take a step towards gender-sensitive work by asking how someone wants to be addressed. The assessment procedure in children and adolescents is similar. All this can be possible at a tertiary level of care as in a gender affirmation clinic. 16 --- Funding: No funding sources Conflict of interest: None declared Ethical approval: Not required

While trying to take the vitals of the patient and asking for history he was very incorporative and kept on shouting on the staff saying "you are all the same". "Nobody can ever understand me and I don't trust anyone of you" repeatedly. Measures to calm him down by offering food and drink items failed and he tried escaping the emergency department by hitting the staff while getting abusive. He was restrained and was administered Haloperidol injection

INTRODUCTION Family and marriage issues are an important part of all societies. In our society, this issue is given importance at the level of state policy. Because tomorrow's successors will grow up in the family.President Mirziyoyev. Sh.M. also expressed the following comments on this issue: "constantly paying attention to the health of mothers and children, providing employment, taking into account the living conditions of women, their place and influence in our social and political life we consider ourselves to be the most important task to continue the state policy on increasing" [1]. Based on this, in today's rapidly changing world, it is important to study family and marriage relations, which are an important part of our national mentality. In this article, we focused on the attitude of today's youth to the family, and the analysis of their thoughts about the "ideal family". The term ideal (from the Greek symbol, idea, concept) is the highest example, perfection of something, event and phenomenon. In general, this term is understood differently in different fields. In particular, morally ideal -perfect human qualities, human relations; aesthetic appearance, character, description, mature in all aspects. "Ideal" is a real existence, the highest manifestation of beauty. It consists of our perfect, completely subjective concepts of life [2]. Based on this, what characteristics should an ideal family have? The characteristics of an ideal family differ in different periods and regions. There is no clear criterion for what an ideal family should look like. Because, as many people as there are on earth, their views on the ideal family will be different depending on their nature and outlook. A type of family that is considered ideal for one person may not be ideal for another. This varies depending on their age group. --- LITERATURE REVIEW --- VOLUME03 ISSUE11 DOI: https://doi.org/10.55640/jsshrf-03-11-05 Pages: 23-27 Family and marriage issues have always been one of the topics in the focus of researchers in various fields. In particular,AR Lemekhova analyzed the relationships between girls and boys and touched upon the characteristics of ideality in these relationships, and LP Ilarionova studied the aspects of interpersonal adaptation in family relationships [3]. The works of VA Sukhomlinsky should be mentioned separately. He expressed his thoughts about the formation of ideal family ideas in teenagers based on the family he is growing up in. . Norotkov NZ, Kordon SI, Rogova IA "Family: everything starts with love. (Semya: vsyo nachinaetsya s lyubvi) Most of this work is written on the basis of sociological surveys of Russian teenagers [4]. In addition, VI We can cite Barsky marriage harmony, VA Baltsevich, SN Burova, DK Arapbayeva. --- RESEARCH METHODOLOGY The article is written based on the methods of ethnology -ethnographic field research, observation, and the comparative analysis of the results of questionnaires received by the youth of Jizzakh region. --- ANALYSIS AND RESULTS As mentioned above, people's views on the "ideal family" are different in terms of age. For example, 17-20-year-olds' ideas about the ideal family are more likely to be love, love, which is connected with their emotional feelings. People of this age idealize their partners and relationships. In this place, Let's look at AR Lemekhova's analysis of the relationship between girls and boys. He examines the relationship between girls and boys and describes it in three ways: 1. Harmonious type -in this type, girls and boys have enough moral concepts and have a developed emotional culture, that is, they can control their feelings. they look at love, the opposite sex, and family life somewhat clearly and correctly assess the situation. 2. Family romantic type -on the contrary, feelings play a leading role, love, relations between the sexes are taken away from life, they are extremely idealized, and when they collide with the existing existence in life, all their imaginations are shattered and they become mentally depressed. Too idealized feelings disappear. 3. Spiritually poor type -young people misunderstand love. In love, they cannot see the spiritual closeness, the importance of the spiritual factor, and as a result, they encounter many obstacles. [5]. Adolescents' ideas about the ideal family have something in common with the second type of attitude above. 24-25-year-olds and older people have different opinions about the ideal family. As a proof of ideas, we will analyze the ideas of some young people about the ideal family. One of the middle-aged respondents said that an ideal family means a family in which a couple understands each other correctly, solves problems with good words, calmly, and where love always reigns in the family. Another informant said that in an ideal family, both husband and wife should be responsible for the stability of the family, the man should be the head of the family and be determined, and in any situation, family problems should be solved mutually. He also mentioned that parents should always make time for the family. In comparison, 23-25-year-olds and middle-aged adults are more intellectual than emotional in their ideas about the ideal family. [6]. Modern young people include the need to have their own budget and nuclear family among the features of their ideal family. In our society, two-generation families are the main form of family. However, in foreign countries, we rarely meet the two-syllable family type. Nevertheless, they have a lot of family disputes and divorces. At this point, we will mention the opinions of foreign youth about the ideal family. This is mainly the opinion of German youth over 18 about the ideal family: • In an ideal family, first of all, all family members believe in the same religion, parents are married, good communication is established between all family members, and both men and women have permanent jobs. it is noted that he should be able to spend time with his children and raise them well. • According to another respondent, in an ideal family, everyone should understand each other, establish good communication and healthy relationship between family members, solve all problems together, and in general, everyone should feel happy in the family. • First of all, everyone in the family should be able to express their opinion freely if they support each other. There should also be respect for the decisions of others, mutual trust and open communication. Most importantly, in an ideal family, each member of the family should play an important role and take responsibility in the family. Only then did he express his opinion that this family would be an ideal family. The above ideas are the ideas and thoughts of young people who have not yet started a family about an ideal family. These thoughts of theirs may have been formed based on the environment in the family where he lived. That is, they are satisfied with the relationship of their parents and have made it their ideal, or they are dissatisfied with the environment in the family, so they do not want to build a similar family in the future. In 1978-79, Russian researchers conducted surveys of several Russian families on this very issue. According to him three out of four teenagers want to be like their parents. 41.3% of girls and 34.9% of boys want to be like their mother (respectively 9.8% and 22.4% like their father). According to the results of interviews with class leaders, mothers set a more positive example for their children than fathers. Because, in 96.9% of cases, mothers do not have negative manifestations in their behavior, while this indicator is only 75.2% of fathers. Among schoolchildren in the group of delinquents, fathers have more and more often negative deviations in their behavior than in other surveyed families: they drink and quarrel [7].As VA Sukhomlinsky said: "Where the father educates himself, children will educate themselves." If the father does not have a clear example, any words about the child's self-education will remain mere words" [8]. So, how the ideas of the "ideal family" of young people who have not yet started a family are formed depends on their own family. it also depends on the environment. Now we will analyze the opinions of foreign young people who have started a family about the ideal family: • In order to be an ideal family, there should be certain rules in the family and everyone should follow them fully. • Finding a solution to the problem together, doing some kind of exercise together at least once a week, the couple understanding each other, having trust. • A 27-year-old German married woman informant described the ideal family with words such as a house, a good husband, children, work and health [9]. If we look at the ideas of German youth about the ideal family, there is a lot of emphasis on the fact that each member of the family has a place and their opinions are taken into account. They also want to be married, have many children, and have a family gathering at least once a week to do something together. Through these thoughts, we can find out what kind of families they have. Therefore, young people in Germany are often not married, and rarely do family members get together and spend time with children. These features are characteristic not only of Germany, but also of many western countries. This can be explained by the fact that the tendency against "detocentrism" appeared in the second half of the 20th century. The socio-political emancipation of women and their involvement in more social production activities has made women's family roles, including motherhood, less important for some. Modern western women do not want to be only "faithful husband, wife, loving mother" and cannot be anymore. Women's self-respect now includes other bases besides motherhood -not only because of professional achievement, social independence, the fact that they touched the earth, but also the social position they have achieved. Some traditional tasks of mothers -functions related to child care and education -are now taken over by other specialists -pediatricians, nurses, educators, special social institutions, i.e. kindergartens. This does not eliminate the value of maternal love and the need for it, but it changes the nature of maternal behavior. [10].As a result of such factors, specific family characteristics have been formed in western countries. Unfortunately, such features are visible in some Uzbek families, in particular, children are left to fend for themselves as a result of the constant employment of parents. Also, the fact that many parents leave their children to work abroad also leads to the formation of dysfunctional families. The concept of a dysfunctional family is the exact opposite of an ideal family. --- Conclusion and recommendations Summarizing the above information, the characteristics of the ideal family are a concept that changes according to space and time. Also, each person's views on the ideal family differ depending on the environment, worldview, age and status. It gains commonality in some aspects only when it is taken at the level of a certain nation. For the Uzbek people, the ideal family is built on the basis of mutual love and respect, trust, mutual support, understanding in different situations and moving in the same direction, dreams, goals and interests. --- Years Total

This article analyzes the opinions of today's youth about the "ideal family". Also, the views of foreign youth on the "ideal family" were analyzed in comparison with the views of Uzbek youth on this issue.

Introduction Across Canada, there is a growing call for a National Dementia Strategy to improve public awareness, reduce stigma, and effectively support people living with dementia and their families. Recently, the Canadian Academy of Health Sciences (CAHS 2019) released a report emphasizing the need to overcome stigma and improve quality of life for people affected by dementia. Despite this growing call, there is a paucity of evidence-based research to reduce stigma and support people with dementia living outside of large urban centres. More research is needed to better understand the unique needs of rural and remote people affected by dementia. In developing a National Dementia Strategy, it is essential to recognize that Canadians live in diverse communities. We believe that a national strategy needs to be built from the ground up and not imposed from the top down. Only through the development of evidence-informed research and collaborative partnerships, can we ensure that the needs of all people affected by dementia are addressed. --- The case of Saskatchewan: where rural and remote still matter In Saskatchewan, over 19,000 individuals live with dementia, and an estimated 60% of those individuals reside in their own homes (Kosteniuk et al. 2015). Rural communities are disproportionately affected by dementia as older adults in the province tend to reside in rural communities (Morgan et al. 2009). Outmigration of youth along with increasing life expectancy have contributed to Saskatchewan's aging rural population. For example, older adults comprise 22.4% of the population of towns and 21.7% of villages, compared with 14.7% of cities (Morgan et al. 2009). By 2038, dementia is expected to cost over $35.9B in health and caregiver costs in Saskatchewan, and it is projected that community care will become the dominant mode of dementia care by 2028 (Smetanin and Kobak 2009). Addressing dementia supports is essential for improving health outcomes, quality of life, and savings for the health system. In rural and remote communities in Saskatchewan, people with dementia and their caregivers who are currently accessing limited available resources are doing so at the point of crisis (Morgan et al. 2009). These seniors face unique barriers to accessing dementia care that are compounded by limited finances, information, and transportation, as well as issues related to geographic distance (Forbes and Hawranik 2012). While only 18.9% of the Canadian population live in rural areas, this number rises to 33% in Saskatchewan (Statistics Canada 2011). This is complicated by the fact that the province has a low population density and covers a large geographic area. As the bulk of dementia supports and services exist in urban settings, this means rural and remote residents must either travel to access services or forego them. With the recent elimination of the Saskatchewan Transportation Company (a publicly owned intercity bus service), and the end of Greyhound Inc.'s western bus service, Saskatchewan no longer has any widely available road transportation service between communities. This makes access to dementia care for people in rural and remote communities even more difficult. Subsequently, the restricted availability of dementia care resources is expected to continue and may decrease social inclusion and impact the well-being of seniors with dementia and that of their care partners. For this population, the already challenging navigation required to access these supports will only increase. Age is the greatest risk factor for developing dementia, and the number of Saskatchewan residents aged 65+ is rising. Currently, 15.5% of the rural population in Saskatchewan is comprised of older adults aged 65+ (Moazzami 2015). Population aging statistics show that older adults (65+ years old) now outnumber children (0-14 years old), and older adults are projected to increase to almost 25% by 2031 (Statistics Canada 2017). While rare, an estimated 2-8% of all dementia cases in Canada are young-onset dementia that occurs before the age of 65 (Alzheimer Society of Saskatchewan 2019). By 2038, an estimated 25,800 Saskatchewan residents will have dementia (Smetanin and Kobak 2009). A recent study found that dementia and cognitive impairment are more prevalent among rural seniors than urban older adults (Weden et al. 2018). In Saskatchewan, seniors are more likely than younger persons to live in rural areas (Morgan et al. 2009). However, access to dementia services in rural and remote communities remains a substantial challenge (Standing Senate Committee on Social Affairs, Science and Technology 2016). The unmet community needs of rural and remote people with dementia have severe consequences, including depression, shame, spousal hiding, social isolation, and suicide (Alzheimer Disease International (ADI) 2016). Recently, a Leger survey for the Alzheimer Society of Canada found that almost 50% of Canadians would not want others to know they had dementia (Alzheimer Society of Canada 2017). Currently, a lack of dementia knowledge perpetuates stigma of dementia, especially outside of large urban centres (Forbes and Hawranik 2012). However, if these needs continue to go unmet, there are substantial implications that impact early dementia diagnosis, health service utilization, interactions with health providers, and caregiver burden. There are significant consequences and an urgent need to reduce stigma and improve supports for people with dementia and their families. Some examples of consequences related to unmet needs of people affected by dementia include adverse health outcomes, social isolation, and care partner burnout (Alzheimer Disease International (ADI) 2016). However, with proper supports, people with dementia are able to remain within their own homes longer, and as many as 90% stay within their communities (Standing Senate Committee on Social Affairs, Science and Technology 2016). --- Evidence-informed research and collaborative partnerships: a way forward Supporting rural and remote people with dementia requires local input and innovation, and the development of evidenceinformed research to address not only the biomedical determinants but also the social determinants of health such as education and culture. In particular, research is needed to examine the complex interactions between the different determinants of health to better address issues of social inclusion and stigma for rural and remote people living with dementia. Further research is also required to identify and assess the effectiveness of interventions for reducing dementia-related stigma. The vast majority of services and programming for people living with dementia and their care partners will be financed by provincial governments and delivered by agencies of, or working on behalf of, those governments. What services get delivered where and how will depend on the specific configurations of need within and across each province. Any national strategy must take into account that these configurations of need will differ significantly across the country and be adaptable to those different circumstances. Rural and remote people face unique barriers to accessing dementia care and supports, ranging from limited finances to inadequate public transportation. Despite these challenges, recent literature suggests that local knowledge and ingenuity within rural communities has led to creative solutions (Bacsu et al. 2017). Subsequently, collaboration with older adults affected by dementia can help to facilitate awareness, lived-experiences, and local insight to improve the quality of life for people with dementia and their families. Furthermore, partnerships with organizations such as the Alzheimer Society of Saskatchewan (ASOS) and the Rural Dementia Action Research (RaDAR) Team provide education, information, networking, knowledge-exchange opportunities, and interventions to support people with dementia across the province. Some examples of ASOS interventions include a Dementia Friendly Communities initiative, a Warning Signs campaign, a Dementia Friends program, and a Dementia Helpline. The RaDAR Team provides a telehealth-assisted interdisciplinary Rural and Remote Memory Clinic to support people affected by dementia. In developing effective strategies to support rural and remote people affected by dementia, it is essential to engage in partnerships and collaboration. In moving forward, research is needed to examine ways of effectively engaging people with dementia in collaborative research, especially in rural and remote communities. --- Conclusion In Saskatchewan and most provinces across Canada, urgent action is required to support people affected by dementia, especially in rural and remote communities. While our discussion draws on Saskatchewan as a case study, other jurisdictions face similar situations across Canada. Addressing dementia-related stigma and improving supports for people with dementia is necessary to optimize cognitive health promotion, facilitate preventive interventions, and support early dementia diagnosis in rural and remote communities (World Health Organization 2012). The CAHS (2019, p. 2) report provides compelling evidence highlighting the need for a national strategy to provide a "central vision" and direct resources to meet the needs of people with dementia and their caregivers. However in developing a National Dementia Strategy for Canada, addressing the unique needs of rural and remote people affected by dementia must be identified as a key priority. It is critical that this strategy is collaborative and built from the ground up. Moreover, it must reflect the realities of rural and remote people affected by dementia in a wide variety of community contexts. As such, further research is needed to build an evidenceinformed knowledge base to address issues of dementiarelated stigma and better understand the unique needs of rural and remote people affected by dementia. Only through the development of collaborative partnerships and evidenceinformed research can we ensure that the needs of rural and remote people affected by dementia are addressed. --- Conflict of interest The authors declare that they have no conflict of interest. Publisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

A number of organizations such as the Canadian Academy of Health Sciences have identified the growing need for a National Dementia Strategy in Canada to improve the quality of life for people with dementia. This commentary highlights the necessity of addressing stigma, social inclusion, and supports for people affected by dementia, specifically those living in rural and remote communities. Drawing on Saskatchewan-based examples, we discuss the importance of recognizing the unique needs of rural and remote communities in developing a National Dementia Strategy for Canada. We believe that a national strategy needs to be built from the ground up and not imposed from the top down. Only through the development of evidence-informed research and collaborative partnerships can we ensure that there is equitable access to services and supports for people with dementia in rural and remote communities.Des organismes comme l'Académie canadienne des sciences de la santé ont défini le besoin croissant d'une stratégie nationale sur la démence au Canada pour améliorer la qualité de vie des personnes qui en sont atteintes. Dans ce commentaire, nous soulignons la nécessité d'aborder la stigmatisation, l'inclusion sociale et les mesures de soutien aux personnes touchées par la démence, surtout en milieu rural et éloigné. En citant des exemples de la Saskatchewan, nous expliquons l'importance de reconnaître les besoins particuliers des milieux ruraux et éloignés dans l'élaboration d'une stratégie nationale sur la démence

Introduction Medicine use for headaches is common among adolescents and a considerable part of the medicines used are over the counter medicines. [1][2][3] In these age groups, unsupervised medicine use for headaches can be problematic: Adolescents know very little about medicines for headache 1 and they may use it inappropriately, e.g. to treat general discomfort 4,5 or to quickly alleviate pain-related discomfort in a time pressured life in modern families. 6 Further, medicine use for aches in adolescence is predictive of medicine use in young adulthood, i.e., inappropriate medicine use may continue over the life course. 7 Therefore, it is important to know the prevalence, demographic patterns and trends of self-medication with medicines for headache. There are few published studies about socioeconomic variations in self-medication for headache among children and adolescents. Two studies from Germany 8 and the Netherlands 9 show that the prevalence of self-medication for headache is highest in high socioeconomic groups and a study from Denmark show the opposite pattern. 10 It is unknown whether the socioeconomic patterning of medicine use for headache is stable over time. Therefore, the aim of this paper is to examine the association between socioeconomic background and self-reported medicine use for headache among adolescents, and how this association changes over time. --- Methods --- Design and study population: The analyses applied data from seven Danish contributions to the international cross-sectional Health Behaviour in School-aged Children (HBSC) 11 study in 1991, 1994, 1998, 2002, 2006, 2010 and 2014. Each survey included all children in the fifth, seventh, and ninth grade (11-, 13and 15-year-olds) in random samples of schools, drawn from complete lists of public and private schools. The total response rate (participants as percentage of all students enrolled in the participating classes) was 88.4%, n=31,660. This paper includes participants with full data about all applied variables, n=26,685. --- Data collection and measurements: The participants answered the internationally standardized HBSC questionnaire 11 at school. The study does not include data about the specific medicines but it does include self-medication with both prescription and over the counter medicines. The dependent variable was measured by the item "Within the past month, did you take any pills or medicine for headache?" The response categories were "no", "yes once" and "yes several times", dichotomized into no and yes. There is little available information about the validity of adolescents' self-reported medicine use. A study by Andersen et al. 12 found a fair agreement between adolescents' self-report and parents' information, gamma correlation = 0.67, Kappa coefficient = 0.41. A study by Gobina et al. 2 found a systematic relationship between frequency of pain and use of medicines which also suggest that the measurement is valid on population basis. The independent variable socioeconomic background was measured by the questions: "Does your father/ mother has a job?", "If yes, please say in what place he/she works (for example: hospital, bank, restaurant)" and "Please write down exactly what job he/she does there (for example: teacher, bus driver)". The research group coded the answers into OSC from I (high) to V (low). The research group coded this information into occupational social class (OSC), from I (high) to V (low) with an additional category VI for parents outside the labor market, living from social welfare transfer income. Each student was categorized into high (I-II), middle (III-IV) or low (V-VI) OSC. The coding instruction was consistent across all seven waves of data collection. Jobs change over time but the coding reflects two general features which are more stable than occupations: 1) required educational qualifications and 2) the control (over capital or people) connected with the occupation. Several studies have shown that children in these age groups are able to provide valid information about parent's occupation. [13][14][15][16][17] The analyses included four control variables, sex, age group, survey year, and frequency of headache, measured by the item "during the past six months, how often have you had headache (response categories: almost every day; more than once a week; about every week; about every month; rarely or never). Statistical procedures: Time trends were tested by the Cochran-Armitage test for trend. The analyses of social inequality in medicine use for headache included 1) absolute social inequality (per cent difference between high and low OSC) and 2) relative social inequality by logistic regression analyses, i.e. odds ratio (OR) and 95% confidence interval (CI) for medicine use by OSC, using high OSC as the reference group. The logistic regression analyses applied multilevel modelling because of the cluster sampling (SAS, PROC GLIMMIX). The analyses were adjusted for sex, age group, survey year and frequency of headache. The final step was inclusion of an interaction term between survey year and OSC to examine whether the social inequality in medicine use changed over time. --- Ethical issues: There is no formal agency for approval of population surveys in Denmark. Instead, the research group asked the parents' representatives (school board), the school leader, and the pupils' council in each of the participating schools to approve the study. The pupils received oral and written information that participation was voluntary and anonymous. From 2014 the Danish Data Protection Authority has requested notification of such studies and has granted acceptance (Case No. 2013-54-0576). --- Results Table 1 shows the study population by survey year, sex, age group, OSC, pct. with medicine use past month and pct. with headache at least monthly. The proportion of participants who used medicine for headache within the past month was 40.5%, showing a significantly increasing trend from 32.3% in 1991 to 42.8% in 2002 (Cochran-Armitage test for trend, p<0.0001) and very little change 2002-2014. The proportion who reported having headache at least once a month was 48.1% with some variations across survey years. Table 1 and Figure 1 here Figure 1 shows the trend in high, middle and low OSC. There was a similar trend in all three OSC groups with an increase from 1991 to 2002 and stability thereafter. The trend was significantly increasing in all three OSC-groups from 1991 to 2002, all p-values <0.001. Table 2 shows the prevalence of medicine use for headache: 36.2% in high, 41.5% in middle and 44.8% in low OSC, p-value from chi 2 -test <0.0001. The difference in percent between low and high OSC in the seven surveys varied across survey years with no clear trend which suggests that the absolute social inequality in medicine use for headache was persistent from 1991 to 2014. --- Table 2 here Table 2 also shows the relative social inequality in medicine use for headache. In the total study population, the OR (95% CI) for medicine use was 1.25 (1.18-1.32) in the middle and 1.43 (1.33-1.54) in low OSC. These figures did not change much when adjusted for sex, age group, survey year and frequency of headache. There was a similar pattern of increasing OR for medicine use with decreasing OSC in all seven surveys and the OR for medicine use was significantly higher in low than high OSC in five of the seven surveys. These data suggests that the relative social inequality was persistent from 1991 to 2014. The interaction of survey year and OSC on medicine use was insignificant, p=0.9416. --- Discussion Main findings: This is the first study to examine trends in social inequality in adolescents' medicine use for headache. The proportion of adolescents who used medicine for headache was increasing from the 1990s to 2002 and stable thereafter. This trend was similar in high, middle and low OSC groups. There was an increasing medicine use for headache with decreasing OSC, even after adjustment for sex, age group and frequency of headache. This social inequality did not change substantially between 1991 and 2014. The finding of a social gradient in adolescents' medicine use for headache corresponds with a study from the same HBSC-project in 2001 10 but is in contrast with two studies from Germany and the Netherlands which showed that children's medicine use for headache was highest in higher socioeconomic groups. 8,9 There is a need for studies which enhance the understanding of this socioeconomic patterning of medicine use for headache. --- Methodological issues: The main strength of the study is the design with seven comparable surveys conducted during a 23 year period, all adhering to the HBSC research protocol regarding sampling, data collection and measurements. 11 The available studies about the validity and reliability of the two main variables, OSC and medicine use, suggest that the data quality is good. [12][13][14] An important limitation is that the study lacks data about which kinds of medicine the participants used but only has data about behaviour, i.e. whether the participants had used medicine for one specific symptom, headache. Another limitation is that the study lacks data to interpret why there is a social inequality in medicine use for headache and why this social inequality is persistent. --- Implications: The high prevalence of medicine use for headache combined with insufficient knowledge about medicines among adolescents 1 call for more health education about the proper use of medicines. The conflicting findings of a socioeconomic gradient in adolescents' medicine use for headache calls for more studies about the social patterning of medicine use, e.g. studies in other countries and study populations. Further, there is a need to identify the processes which contribute to this social inequality and a need to study the reasons for the increasing medicine use for headache among adolescent. New findings could inform future health education about medicine use for headache. --- Conclusions: There was an increasing trend in prevalence of medicine use for headache from the 1990s to 2002 and stability from 2002 to 2014. There was an increasing medicine use for headache with decreasing OSC in all survey years and this social inequality was persistent from 1991 to 2014, both in terms of absolute and relative social inequality.

Background: Socioeconomic variation in adolescents' medicine use behaviour is an understudied issue.To examine the association between socioeconomic background and medicine use for headache among adolescents, and how this association changes over time. Methods: Data stem from the Danish part of the international Health Behaviour in School-aged Children (HBSC) study 1991-2014 with data about parents' occupational social class (OSC) and self-reported medicine use for headache, n=26,685. The analyses show absolute social inequality (percent difference between high and low OSC) and relative social inequality (odds ratio for medicine use by OSC). Results: In total, 40.5% used medicine for headache in the past month. There was a significant increase from 32.3% in 1991 to 42.8% in 2002 (test for trend, p<0.0001) and very little change 2002-2014. This pattern was similar in high, middle and low OSC. The prevalence of medicine use for headache in high, middle and low OSC was 36.2%, 41.5% and 44.8% (p<0.0001). The OR (95% CI) for medicine use was 1.25 (1.18-1.324) in middle and 1.43 (1.33-1.54) in low OSC.

Background: Violence against healthcare workers increased sharply during the COVID-19 pandemic, and this trend seems to continue. This development is exacerbating workforce stress and healthcare workers' physical and mental health risks. The attacks are not limited to the workplace and have spilled-over to social media and the private sphere. A transsectoral and multi-professional governance approach may help us to better understand the complexity and different forms of violence. Four major target groups and forms of violence can be identified for non-conflict settings. These include attacks against frontline healthcare workers and migrant and minority groups, and gender-based or sexual violence. The threats go beyond the individual healthcare worker and affect healthcare and the retention of the workforce and, finally, the institutions of the healthcare state, their representatives and the humanitarian values of societies. --- Objectives: This panel workshop aims to critically discuss violence against healthcare workers as both a public health crisis and a political problem. The goal is to highlight the need for action and explore policy solutions. We argue that public health can and should play an important role in raising awareness and improving the prevention of violence and the protection of healthcare workers. Public health provides an appropriate framework and policy platform for connecting different stakeholder groups and establishing coordination across sectors, professional groups, and policy areas. The workshop adds new evidence and burning questions to the healthcare workforce debate: (1) What do we know about violence, and how do frontline healthcare workers experience the threats? (2) What do healthcare workers need, and what is known about existing policy responses? (3) How can we raise awareness of the problem and stand up against violence? (4) What can management and policy do, and how can they join forces? The panel opens with an introduction by the organisers, including a brief overview of the problem and the presentation of a comprehensive framework for research and governance action. Then two important frontline professional groups, young doctors and paramedics, provide deeper insights into the dayto-day experiences and threats. Reflections on the policy solutions from an international perspective of management (EHMA) and policy (WHO Europe) follow. The moderated panel sets the scene for an interactive discussion with the audience in the second part. The workshop connects key stakeholders in the field and explores new solutions to respond more effectively to violence against healthcare workers and to build connections to the broader 'Time to Act' healthcare workforce debate. --- Key messages: Violence prevention must become a health policy and management priority to improve individual protection and wellbeing, as well as the retention of the healthcare workforce. Action against violence towards healthcare workers must be taken on all levels of governance and against all forms of violence, including gender-based and racialised violence.

literature was uneven across different continents. Findings revealed that transport workers faced a heightened risk of exposure due to crowded work settings, job demands, and inadequate use of personal protective equipment. Systemic and structural inequalities were identified among transport workers.This study provides insights for policy and practice interventions that address the unique needs and challenges faced by workers in the industry, including how to promote social equity and justice during pandemics. There is a need for more qualitative and mixed-methods research approaches to obtain a more comprehensive understanding of the topic. Given the global nature of risks for respiratory infections and the global transport sector (which is a significant transmission point for societies), more research is required in non-traditional contexts outside US, Canada, EU, and UK.

Turning from organized labor to the more revolutionary movement, we see open enmity toward the church. At best it is regarded as but a luxury for the well-to-do. But more often there is extended to it active opposition as an institution standing as sponsor for the social maladjustment of our time. The radical labor literature of our country breathes this note of hostility from the first page to the last. Victor Berger, the leader of the Socialists in Milwaukee, told us the other day that the workingmen of Milwaukee are no longer Lutherans, are no longer Catholics, belong no more to their various churchesbut are very good Socialists. He seemed to think that he was putting in antithesis two incompatible positions. This is but one instance of the way the intelligent workingmen, who are turning for help to an economic movement, are at the same time abandoning the religious movement in the feeling that the ideal of a better condition for men on earth is so divorced from the ideal of the church, that fealty to the one implies severance from the other. And why should this be? Certainly the withdrawal of large numbers of workingmen from the church is not due to any hostility to religion. As John Mitchell, the prominent labor leader, had told us -this withdrawal "is not a protest against religion itself, but is attributable to an impression that there is, on the part of many of our churches, an absence of sympathy with the ideal of the working people and with the movement through which they are striving to ameliorate the conditions under which men live and work." We must agree, I think, that the church has lost its influence among the masses of the people largely because to-day, as at so many previous periods of its history, it has departed from that primitive Christianity which, let us never forget, had its inception among the outcast and lowly; because it has merely an academic interest in those " that labor and are heavy laden"; because it is not standing as a rebuke to the social iniquities about us; because it is not insisting upon a literal application to our social and economic life of the injunction: "Thou shalt love thy neighbor as thyself." We know that a few ministers who have insisted upon a literal interpretation of that precept in every-day life have thereby lost their pulpits. To-day we are conscious as never before of our membership in the social organism. One feels that infidelity to that organism is the great infidelity and that according as the church faces the social chaos about it will it be of service to its time. And how is our own Society meeting these social problems? We know that Friends have acquired a reputation for the probity of the individual so that the very word "Quaker" has come to be synonomous with all that is straightforward and upright. We younger Friends, who have done absolutely nothing ourselves, must feel that adverse criticism of our Society on our part would be most unfitting -that if we can but carry on unsullied the character which has been handed down to us, we shall, indeed, have done well. And yet, perhaps, we may all consider together where in our Society can be strengthened. The Friend, we know, is reputed as one whose individual conscience is keenly alive, but whose social conscience is atrophied. We are told that we are so introspective, so absorbed in developing our own characters into perfect flowers that we have no time for the great social movements that are bent on making such development possible for all. As we look at the placid, comfortable attitude with which Friends regard the social ills about them, it seems indeed a far cry to the aggressive vigor with which the early Friends challenged the evils of their time. Should those pioneers come amongst us to-day with their titanic energy, their insistent zeal, I think they would feel that we were not of their kin -and we undoubtedly would look askance at them as fanatics. There is no religious body which has more splendid principles and traditions of democracy than has ours. But to-day, though we cling in large measures to the simple speech and simple dress, I think we have forgotten the spirit of democracy of which that speech and dress were but the token. Let me give an instance. The needs of a certain reform movement were being laid before a friend whom I know. This Friend is most punctilious as to plainness of speech and garb. Yet her first question was: "What sort of people are taking this up -what is their social caste -are they ladies?" This is an extreme case perhaps. There are probably few who would have asked such a question. And yet, in this exaggerated form, we can see how we are, possibly, clinging to the letter which killeth and losing the spirit which maketh alive. When we go into reform circles to-day, we find that it is no longer to Friends that these workers are turning for help. In those circles we are regarded as conservatives, as reactionaries. Sometime ago an organizer of a reform agitation was planning to carry her campaign into a certain city. There were many Friends in that city and I offered to give her their names as, theoretically at least, Friends stand for this movement. She thought an appeal to them not worth her while however. "I know all about Friends," she said, "they will hold a conference or two and talk a great deal, but as to the active, aggressive work necessary to push this through, they will be of no use." This verdict may have been unjustified; but the fact that such a view is held, and I know widely held, is reason for thought. At the beginning of our Society we were as a whole poor, without influence, and with not much education. To-day we are considerable in numbers; we have greater influence, leisure, wealth, a better education than ever before. Then, why should we be so impotent compared to the early Friends? We are nowhere so numerous or so influential, I suppose, as in this State of Pennsylvania, and yet there is probably no State which is more under the domination of the criminal elements. This State, at the last census, had over thirty-three thousand children under sixteen at work in manufacturing industries alone. This was the State which, of the six leading industrial States, had the greatest illiteracy among its children between the ages of ten and fourteen. As we realize these and kindred facts, we must feel that we are not measuring up to our work, to our opportunities. We can hardly believe that the character of Friends to-day is different from that of the members in early times-that to-day they are any less eager to work than in those far off days. A Friend wrote to me once: "I so wish that I had been born in the anti-slavery period so that I could have taken part in that great campaign." Many seem to cherish such a feeling. But these are just as stirring times in which we live today, and the need for workers is just as great, did we but know it. Not long ago I came across a description by a distinguished English woman of a visit to a Friends' meeting and community. She was impressed most of all, she said, by the happiness of the people; but, she added, they seemed to have no realization whatever of the conditions which made such happiness impossible for the majority of people in the neighboring city. This, it seems to me, puts the whole case succinctly. It is simply that we are, to a great extent, unaware of the social conditions about us. With unsparing devotion, the individuals are pouring out their service in behalf of their own immediate circles -but with society as a whole, they are not in contact-they do not know its needs. Could we but take them into the mills where children are toiling at an age when they ought to be living with fairy tale; could we but taken them into those factories, for instance, where women are employed at machines of such a character that three months of the work means the forfeiture of the power of motherhood; could we but place them face to face with the grim realities surrounding them, it would mean, in many cases, the awakening of the social conscience, the birth of an overmastering desire that such injustice to the individuals, such injustice to the race, should cease off the earth. Our discussion to-day is in relation to Woodbrooke. I have read that John Wilhelm Rowntree said, not long before his death, that the next ten years would show whether the Society of Friends in England could still be of service and had a future before it. With the view of enabling it to be of greater usefulness he was instrumental, I understand, in founding Woodbrooke. As we look at our Society here, the same means of increasing its power comes to our mind. There is some talk of a Woodbrooke in America. As to the practical aspect of the question I know nothing, but, if it be possible, I wish that we could have such an institution -not for academic work, for that we can get at the universities; not for technical training in social work, for that we can get at the Schools of Philanthropy, -but as a place that would take us, young and old, for a little time and give us the first impulse for service, give us the necessary inspiration and vision. A friend in Philadelphia, a woman of about thirty-five I should think, told me that after she left college, her life had been absolutely empty. She was eager to use her energy but knew of nothing to do. About six months ago she met a person who is working devotedly for a certain reform. This chance meeting with an individual, whom she has never seen but that once, has transformed her life. She has thrown her splendid gifts into this same movement and all this ability and power which were being lost to society have now been drafted into its service. What that accidental meeting unconsciously did for this woman a Woodbrooke might consciously attempt to do for our members. It might be able to draw into the service of humanity vast areas of untapped energy at present going to waste. We read that in the early times Swarthmore Hall was a kind of central altar fire to which the Friends from all over the kingdom turned, and where the flame in their souls was enkindled anew. What Swarthmore Hall was to our founders we might hope that a Woodbrooke would become to us, helping us to be worthy of the great traditions which we have inherited, making us more valiant soldiers in humanity's cause than ever before-a central fire enkindling anew the life in our Society. 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Any inquiry into the condition of the churches to-day must consider the gulf existing between the church and the working class. We hardly realize, I think, that by a great section of the proletariat our religious organizations are regraded as the stronghold of hypocrisy and oppression. We hardly realize the bitterness that that these workers fell toward us as they repeat once again: "Woe unto you, scribes and Pharisees, hypocrites! for ye devour widows' houses, and for a pretence make long prayers. Therefore, shall ye receive the greater damnation." For something like forty years those two schools-the one which lays stress on economic forces and the other, represented by the churches, which lays stress on moral forces-have been growing farther apart and understanding each other less and less. We find the president of American Federation of Labor, for example, saying that his associates have come to regard the ministers and the churches as the apologists for the wrongs, indeed the defenders of the wrongs committed against the people.

State funded opera houses in Germany are becoming increasingly a target of public criticism. The combination of certain factors -for example diversification of urban audiences, digitalization, changes in aesthetic demands etc. -raises questions of institutional legitimacy and thus a certain state of crisis. My research has shown that opera houses develop systematic strategies to counter these kinds of transformative powers on the one hand and the related fundamental institutional criticism on the other: participatory formats can be determined as one of these strategies. Participatory formats can not only be seen as an artistic development within the portfolio of events that music theatre houses offer in addition to its main events, i.e. opera performances, but also as strategic action to gain new audiences, meet cultural-political demands and generally opening up to a divers urban society. What measures are being developed and in what way do these measures raise questions of actually cultural participation? How can these measures be realized within the structural and aesthetic requirements of an opera house? Interdisciplinary implications. Opera and music theatre as contemporary performative practice can no longer be explored by looking at musical scores only. Bringing musicology, performance studies and social sciences (and esp. its methods) together has the potential to explore the many interdependencies between institutional structures, social participation and artistic demands that contemporary music theatre is so heavily characterized by.

Disciplinary background A. My research has its origin in performance studies understanding opera and music theatre as performative phenomenon -with special consideration of instrumental and vocal practice.Exploring contemporary music theatre practice in Germany, I see a necessity to involve theories and methods of social sciences and educational theory to fully understand institutional influence on aesthetic products and production.

INTRODUCTION Fertility control preferences and maternal healthcare have become a major concern for health professionals, development workers and policymakers. Existing evidence suggests poor fertility control and maternal healthcare among the major obstructions in ensuring better health and social status of women. 1 In Pakistan, approximately 30,000 women die every year because of healthcare issues during pregnancy. 2 Despite this, the rate of progress in this area is slow. 2,3 There is no significant change in fertility preference trends over the years as the recent available statistics show that above than 50% of couples still consider four or more children as ideal family size. 3 However, women still reported difficulty in accessing professional healthcare (21-35%) and almost 50% reported 'no access to professional healthcare facility at the time of delivery'. 3 This is a concern as access to better health care is both related to women's life expectancy and empowerment. It is important to understand the barriers which result in low access to health care; one way to look at it is the extent to which women exercise their choice in family planning and if it is determined by having more say in other matters as well. It would be interesting to look at the pattern of decision making and mobility, for instance, and whether it explains in any manner both fertility preference and the access to better health care for women. Literature shows that increased autonomy leads to better access to maternal healthcare, [4][5][6] at the same time some studies suggest contradictory findings by demonstrating that the rates of independent mobility are very low in women and movement freedom is not a significant predictor for access to maternal healthcare. 7,8 It is important, therefore, to understand patterns of women's autonomy in context of family system and impact of social and cultural values. It is a prevalent practice in Pakistani society that women when step out of house are accompanied by either a male family member or another woman. This is due to both a safety measure against untoward harassment and also to keep the image of a "good woman". Moreover, in household matters women rarely make decisions independently 3 a common phenomenon in a collectivistic culture, with some positive outcomes on access to maternal healthcare and fertility control preferences. 7,9 The joint decision-making in household matters and accompanied movement does not mean absence of autonomy in the context of Pakistani society and therefore this study takes both individual and joint decision-making as indicator of high autonomy in contrast to conditions where household decisions are solely taken by husbands or other family members. This study investigates the pathway that explains the access to maternal healthcare and fertility preferences for Pakistani women and whether their decision making along with selected other demographic variables helps determine it. --- METHODS The data was obtained using stratified sampling. A two-stage stratified sampling technique was used in PDHS-2012-13 survey. In the first stage, 248 urban areas and 252 rural areas were chosen by employing a probability proportional to size sampling scheme with an independent selection in each sampling stratum. In the second stage, a systematic, sampling technique was used to select households from each sample point with a random start. A total of 14,000 households were chosen for data collection. Further details of data collection may be taken from Pakistan Demographic Health Survey (PDHS) 2012-2013. 3 The data used in the analysis consisted Women's maternal healthcare: Women who gave birth in the last five years were inquired about receiving maternal healthcare for most recent birth, including number of visits, service provider and place of healthcare. It was measured as quality of prenatal and antenatal healthcare. 3 Indicators used to determine quality of maternal healthcare are shown in Fig. 2. --- Fertility Control Preferences: The fertility control preference of women were assessed through (1) desire for more children 3 and ( 2) ideal number of children. 3 Statistical Analysis: Analysis was done using SPSS software. Mean scores, standard deviations, ANOVA and t-test were applied to determine associations among variables with p-value less than 0.05. Moderation analysis was carried out to determine the interaction effects among the variables. --- RESULTS Findings showed that rates of independent autonomy are very low (8-11%) in this nationally representative sample of women from Pakistan. Similarly less number of women (10%) reported access to good quality maternal health care, 58% reported access to medium quality healthcare and 32% were getting low quality care. 64% of couples considered four or more children as ideal family size and 23% of women and 30% of men wanted to have another child within two years of previous childbirth. Table - I & II. --- DISCUSSION The main objectives of this in-depth analysis was to determine the nature of inter-relationship between women's demographic characteristics, autonomy, access to maternal health care and fertility control preferences. Findings revealed that 45% of women who were categorized as having "High Autonomy" also more likely to report access to good quality maternal health care as well as better fertility control preferences as compared to other women. As "High autonomy" in this analysis was determined by combining response by women who reported individual decision making and joint decision making in areas of income control, household purchase, healthcare decision and travel, it is important to understand the position of women in family system as well role of social and cultural values to understand the findings . Traditionally, women are not encouraged to take independent decisions even in household matters until their old-age. It is a rare phenomenon that women take independent decisions related to their own healthcare and fertility control. 10,11 Also in the context of post-natal healthcare it is more likely that women depend on their care-takers at the time of delivery or in conditions of ill-health. Thus women's solo-decision as a pathway to access high quality maternal health care and positive fertility control outcomes is not achievable on realistic ground. Analysis also showed that women in younger age, with less than three children and employed status were more involved in joint decision-making and reported access to better quality maternal health care. This is consistent with findings from another study 12 where in case of young couples husband involvement was found to be a significant predictor for an access to good quality reproductive healthcare at the time of delivery. Women's fertility preferences were the main outcome variable for this analysis. Consistent with other evidence 13,14 the present study findings revealed that overall women in younger age groups, with higher education, better economic conditions, urban residence, and currently having less than three children had better fertility preferences. A case-study from Punjab 1 and studies from other developing countries 5,15,16 have confirmed this pattern of relationship. The positive influence of women's education with fertility control has also been indicated by study from Bangaladesh. 17 The main purpose of this study was to determine whether women's autonomous status and access to maternal health care will independently or after interaction predict women's fertility control preferences. Findings from multivariate analysis showed that women's younger age, having less than three number of children and independent or joint decision-making (indicators of high autonomy) remained the most significant predictors for access to better quality maternal healthcare and better fertility control preferences when other variables were controlled. Findings also revealed that quality of ante-natal healthcare accessed by women significantly influence women's choice for ideal number of children independently and even after interaction with other variables. Recommendations: Findings strongly suggest that joint decision-making in couples maximize access to better quality ante-natal and post-natal healthcare which lead to positive outcomes in fertility control. To achieve success in fertility control, programs should target young, less educated women living in rural areas of Sindh, Balochistan and Giglit Baltistan. It is recommended to conduct further analysis by including other variables from PDHS 2012-13 data such as media exposure, contraceptive use patterns, and experience of domestic abuse and women's and men's attitudes towards wife beating which may explain role of other factors in determining women's fertility preferences. --- Authors' Contribution: SH: Conceived and designed manuscript. SH & AM: Did statistical analysis, AM: Did manuscript formatting. SS: Reviewed the paper and improved the manuscript. Takes responsibility for ensuring integrity of the study.

Background and Objective: Fertility control preferences and maternal healthcare have recently become a major concern for developing nations with evidence suggesting that low fertility control rates and poor maternal healthcare are among major obstructions in ensuring health and social status for women. Our objective was toanalyze the factors that influence women's autonomy, access to maternal healthcare, and fertility control preferences in Pakistan. Methods: Data consisted of 11,761 ever-married women of ages 15-49 years from PDHS, 2012-13. Variables included socio-demographics, women's autonomy, fertility control preferences and access to maternal healthcare. Results: Findings from multivariate analysis showed that women's younger age, having less than three number of children and independent or joint decision-making (indicators of high autonomy) remained the most significant predictors for access to better quality maternal healthcare and better fertility control preferences when other variables were controlled. Conclusion: Women's access to good quality maternal health care and fertility control preferences are directly and indirectly influenced by their demographic characteristics and decision-making patterns in domestic affairs.

Background: Anti-immigrant arguments often claim that immigrants burden healthcare systems due to increased health problems and healthcare utilization. This study challenges this assumption by comparing the health status of immigrants and native inhabitants using the Charlson comorbidity index, aiming to demonstrate that immigrants are healthier and will use fewer healthcare services. --- Methods: The APNA cohort study includes all inhabitants of Navarra, Spain, with a population of 661,023. A cross-sectional observational study was conducted on 503,392 adults. The Charlson Index was computed as a comorbidity measure. The Mann-Whitney U test compared the index between immigrants and native Spaniards, and quantile regression examined the relationship between immigrant status and Charlson Index, adjusting for age, sex, and socioeconomic status. --- Results: Of the population, 18.4% were born abroad. The average Charlson index was higher in Spaniards (1.55, SD = 1.89) than in immigrants (0.45, SD = 0.93; U-Mann-Whitney p < 0.001). The quantile regression showed that, after adjustment, the Charlson Index was higher in Spaniards than in immigrants by -0.071 (95%CI 0.066-0.077). --- Conclusions: This study contradicts the myth that immigrants burden healthcare systems. Immigrants in Navarra, Spain, are healthier and have lower comorbidity indexes than native inhabitants. Public health policies should consider these findings to promote evidence-based approaches and challenge misconceptions about immigrants' healthcare utilization. Immigrants in Navarra, Spain, are healthier than native inhabitants, debunking the myth that they burden healthcare systems. Public health policies should consider these findings for evidencebased approaches and challenge misconceptions about immigrants' healthcare utilization. --- Key messages: Immigrants in Navarra, Spain, are healthier than native inhabitants, debunking the myth that they burden healthcare systems. Public health policies should consider these findings for evidence-based approaches and challenge misconceptions about immigrants' healthcare utilization. Abstract citation ID: ckad160.1632 Self-reported general health/psychological status of Ukrainian female refugees in the Czech Republic 533 490 refugees from Ukraine received 'temporary protection' from the Czech government. The data for the cross-sectional study (919 females) were obtained via an online survey which recorded self-reported physical health and psychological status, specific aspects of mental health, coping strategies and demographic characteristics. The average age of participants was about 38 years old and more than 70% had children. Most respondents have a university education (71%), came from cities and towns (88.7 %), and had employment in Ukraine (73.8 %). As regards, self-reported health, 43% of females reported their general health as good, 46.8% as fair, and 10.2% as bad and very bad. In addition, 27.9% reported that their health has worsened during the last month and 4.5% that their health had worsened or that they had sustained injury due to the war. Also, 52.7% self-reported their psychological status as fair, 26% as bad, and 7.7% as having very bad status. Preliminary results showed that refugees more often used problem-focused and emotion-focused strategies and less avoidant coping strategies. Ineffective coping strategies of self-blame and behavioural disengagement were associated with poorly reported physical health/psychological status. Effective coping strategies were positively associated with better-reported psychological status. The majority of Ukrainian female refugees (75.2%) have a moderate level of perceived stress, and 20.3% have a high level. Total stress score was moderately positively correlated with the avoidant coping strategy (r = .48), so the higher the perceived stress the higher the possibility for respondents to employ avoidant coping strategy. Moreover, there were strong positive correlations between perceived stress and self-reported emotional and psychological status (r = .61) and positive correlations with self-reported physical health (r = .29). The higher level of perceived stress related to the worst self-reported physical and mental health. --- Key messages: The research outcomes could be used in the social policy of the Czech government to help Ukrainian female refugees to better adapt to the country and avoid worsening physical and mental health status. Social policies can reduce the negative physical and mental health outcomes associated with refugees' resettlement. Abstract citation ID: ckad160.1633 Impact of access to housing on mental health and coping amongst Ukrainian refugees in England Maureen Seguin M Seguin 1 , T Deinekhovska 2 , O Fokaf 2,3 , K Iemelianchuk 2 , A Poppleton 4 , B Roberts 1 , C Sanderson 5 , M --- Background: Though the link between war-related trauma and poor mental health is well-established, less is known about stressors due to prolonged displacement, and how these relate to mental health. As the numbers of forcibly displaced persons rise worldwide, the associated mental health burden represents an urgent public health need. This qualitative paper explores housing-related stressors amongst adult female Ukrainian refugees England, mental health impacts, and coping responses. --- Methods: We draw on 40 semi-structured interviews: 30 with Ukrainian refugee women, 10 with stakeholders (council staff, mental health professionals, staff/volunteers at relevant charities). Thematic analysis identified macro-and micro-level factors impacting housing access, perceived mental health and coping. --- Results: Most of the Ukrainian sample were provided with housing for an initial 6 months. Facing the pervasive shortage in council housing, many were attempting to transfer into rented accommodation at interview time. These efforts were hindered by a lack of employment history, discrimination from landlords, and the language barrier. Interviewees linked these issues to high stress levels and deteriorating well-being, adding to their anxiety over the ongoing war. Coping centred on support-seeking (reaching out to councils, charities, other Ukrainians), distraction (exercise, volunteering), problemsolving (taking a methodical approach to problems), and cognitive restructuring (focusing on the positive). --- Conclusions: Ukrainian refugees face significant barriers in accessing longterm housing in England, forcing some to choose between insecure housing and returning to a war zone. This bind has compounded mental health issues attributed to the trauma of leaving Ukraine and the ongoing war. Though refugees took an active approach to coping with housing hardships, resources to support the transition to long-term housing is necessary to better safeguard their mental health from further harm. --- Key messages: Ukrainian refugees face significant barriers in accessing housing in England, forcing some to choose between insecure housing and returning to an active war zone. Participants linked barriers to accessing housing to high stress levels and a deterioration of well-being, compounding trauma from fleeing Ukraine and anxiety over the ongoing war. Abstract citation ID: ckad160.1634 Intermarriage and health: Mortality among Finnish migrants in Sweden by spousal country of birth --- Background: Finnish migrants in Sweden experience a mortality disadvantage relative to the native population in part due to health behaviours. Interaction between migrants and natives may lead to a convergence of health behaviours and thereby mortality between the groups. Finnish migrants who are married to a native Swede may thus have mortality rates that are more similar to the Swedish population compared to those married to fellow Finns. Conversely, mortality rates of migrants married to a fellow Finn may more closely resemble those of the population in Finland. --- Methods: We use register data to identify all Finnish migrants aged 40-64 in Sweden in 1999 who were married to a native Swede or a fellow Finn. We identify reference groups in both Sweden and Finland, using a combination of inverse probability weighting and direct matching to adjust for differences in sociodemographic characteristics between the groups. We analyse mortality from all causes, CVD, alcohol and smoking related causes during 2000-2017. --- Results: Compared to Finnish migrant men married to a fellow Finn, migrant men who are married to a native Swede have lower mortality rates, closer to that of the native population of Sweden. This difference is largely explained by sociodemographic characteristics, although lower levels of all-cause and CVD mortality remain after adjustment. By contrast, migrant

and the Chi-square test for independence on the software IBM SPSS Statistics. This analysis allowed a preliminary identification of the specific drug use trends and health and social needs of non-binary people who use drugs, which will also be briefly included in this presentation. Moreover, this was the first time EMCDDA used a two-step approach method to collect data regarding sex (M/F) and gender (Man, Woman, Non-binary). In this sense, relevant methodological considerations regarding gender inclusiveness in survey data collection will also be presented, highlighting the relevance of systematically collecting gender-inclusive data to monitor gender-specific drug use patterns and trends and to inform the design of genderresponsive policies and social and health responses to drug problems.Non-binary people who use drugs present gender-based specificities in drug use patterns. It is relevant to systematically collect gender inclusive data to monitor gender-specific drug use patterns and trends.

Introduction The human immunodeficiency virus (HIV) epidemic in Indonesia has continued to grow, with a 25% increase in HIV incidence in people aged 15-49 y since 2001 and almost 700 000 people living with HIV/acquired immune deficiency syndrome (AIDS) (PLWA) as of 2011. 1 Due to the rapid increase in HIV prevalence in Indonesia, stigma has become a prominent obstacle in efforts to prevent and treat HIV/AIDS. For the purpose of this study, we adopt a widely accepted definition of stigma, wherein simultaneous labelling, stereotyping, separation, status loss and discrimination occur in the context of social, economic and political power. 2 Furthermore, PLWA experience internalized stigma, where individuals perceive themselves as less valuable than other community members and anticipate discrimination. 3 Internalized stigma leads to significant mental health consequences such as depression and social isolation. 4,5 Despite extensive research on the manifestations of stigma towards older PLWA, few studies have assessed the stigma experienced by young adults, ages 18-30 y, as they enter the workforce, obtain higher levels of education and play participatory roles in their communities. This study is the first to characterize the stigma experienced by young PLWA in Indonesia. --- Methods --- Design The study was approved by the Institutional Review Board (IRB) at the University of California, Irvine with consent from Dinas Kesehatan (the Bandung health bureau). We conducted this study in June 2016 over 4 weeks at six clinics in Bandung: Bungsu Hospital, Immanuel Hospital, Klinik Mawar, Rumah Cemara and two Dinas Kesehatan clinics. All the clinics are government-mandated community health centres that provide basic maternal and paediatric care, infectious disease treatment and basic primary care. The primary patients served by these six clinics come from the Bandung metropolitan area but are usually of lower socio-economic status, as they are unable to afford access to private clinics. We administered the validated HIV/AIDS Stigma Instrument (HASI-P) to 36 patients between 18 and 30 y of age at the participating health care clinics to collect data about HIV stigma in six core domains: verbal abuse (VA), negative self-perception (NSP), health care neglect (HCN), social isolation (SI), workplace stigma (WS) and fear of contagion (FC). 6 The survey was available in Indonesian. Patients were asked how often they experienced a series of stigmatizing events in the last 3 months, with a response of 'never' assigned a score of 0, 'once or twice' a score of 1, 'several times' a score of 2 and 'most of the time' a score of 3. Higher scores indicate higher perceptions of stigma. --- Data analysis XLSTAT 2016 for Windows (Addinsoft, New York, NY, USA) was used for all statistical analyses. Frequencies and percentages Participants were given a survey that contained the following questions and were asked to rate each state from four options: never, once or twice, several times or most of the time (n=36). S. Aggarwal et al. were reported for categorical variables and means, standard deviations and medians were reported for continuous variables. Scores for each of the six subscore types (VA, NSP, HCN, SI, FC and WS) were assessed for normality with frequency histograms and the Shapiro-Wilk test, both of which revealed heavily skewed distributions that did not support normality. Thus non-parametric tests such as the Kruskal-Wallis test were used to analyse score differences between specific groups (e.g. hospital/health centre). The differences in responses within each subscore type were compared across male vs. female patients, those diagnosed <5 vs. ≥5 y ago, patients <25 vs. ≥25 y old, employment status and married vs. unmarried. Due to the heavily skewed distribution, the NSP subscore variable was split into two roughly even categories: 'low' values less than the median and 'high' values greater than or equal to the median. Associations with participants who obtained a positive or negative NSP score against other HIV stigma subscores (age, gender, marriage status, employment status, years of diagnosis) were assessed using Pearson's χ 2 or Fisher's exact tests. A p-value <0.05 was statistically significant. --- Results A total of 43 PLWA were recruited for the study, but only 36 patients completed the entire HASI-P instrument and were included for final analysis. The mean age of participants was 24.7 y (median=25), with males comprising 77.8% (n=28) of the study sample. A total of 83.3% (n=30) of participants were employed, 19.4% (n=7) were married and the average number of years with a diagnosis of HIV was 4.4 (median=5). The percentage of participants choosing each answer option is provided in Table 1. The median scores for FC, VA, SI, WS and HCN were all 0 while the median score for NSP was 4. There were no statistically significant differences (p>0.05) between male vs. female PLWA, between PLWA diagnosed <5 vs. ≥5 y ago and between patients younger vs. older than 25 y in any of the subscore types. Although not statistically significant, 65.0% of participants who had been diagnosed with HIV for ≥5 y reported a high NSP stigma score (≥4) compared with only 27.5% of participants who were diagnosed for <5 y. While the median scores for VA, HCN, SI, FC and WS were all 0, the NSP score of 4 suggests that there is some degree, while minimal, of internalized stigma that young PLWA harbour within themselves that has resulted in mental health implications. Approximately 45% (n=16) of surveyed PLWA felt at least once in the last 3 months that they did not deserve to live and 64% (n=23) felt completely worthless, suggesting that mental health is a prevalent concern in PLWA. --- Conclusions This is the first study assessing the perceived stigma of young PLWA ages 18-30 y in Indonesia. While these results are preliminary, given the negative self-perceptions often exhibited by young PLWA, access to mental health services should be a priority in the clinics that provide antiretroviral therapies. 7,8 Access to mental health services is minimal in Indonesia, with only 0.01 psychiatrist per 100 000 people by one estimate. 9 We hope that future studies in Indonesia can be conducted to further understand the psychiatric needs of young PLWA and how private and public sectors can improve resources for those suffering from the mental health effects of HIV. Authors' contributions: SA conceived the study, designed the study and coordinated data collection and writing of the manuscript. LY and BH were involved in data collection and assisted in drafting of the manuscript. DHL conducted the statistical analysis for the study. EK, JBL, KL, CT, AA, ARY, ML, TK and CG assisted in data collection and manuscript editing. CD edited the manuscript and acted as the principal investigator for the study.

Background: Young people living with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) (PLWA) are at risk for HIV stigma.The HIV/AIDS Stigma Instrument for PLWA was administered to 36 young PLWA across six clinics in Bandung, Indonesia, to assess the fear of contagion (FC), verbal abuse (VA), social isolation (SI), workplace stigma (WS), health care neglect (HCN) and negative self-perception (NSP).The median scores for FC, VA, SI, WS and HCN were all 0 while the median score for NSP was 4. In the last 3 months approximately 45% of surveyed PLWA felt they did not deserve to live and 64% felt completely worthless. Conclusions: While these results are preliminary, access to mental health services should be a priority in the clinics that provide antiretroviral therapies.

INTRODUCTION Immigrants", Journal On The Horizon, no.9 (2001), 1-6.). Unfortunately, social media is a borderless world that contains not only positivity, but also negativity. The spaces of freedom offered are often used by parties to spread ideas through destructive content, such as violence and sexuality. One of the violent content spread on social media is the content of child delinquency (Child Wearing) brawls. At present, brawls as a form of ) . --- RESULT AND DISCUSSIONS The Impact of Juvenile Delinquency --- Brawls and Brawl Violence Content Posted on Social Media on Children. Childhood is a period when a person has not fully established self-control and tends to be driven to mischief and do negative deeds. Some of the things that characterize a child's psychology are: 1 Furthermore, article 15 of the child protection law also states that every child has the right to be protected from the influence of: 1) abuse in political activities; 2) involvement in armed disputes; 3) involvement in social unrest; 4) involvement in violent events; 5) involvement in warfare; and 6) social evil. In addition to violence, the government also seeks to provide

Protection from brawl Juvenille Deliquency violence content in social media is defined as children right and it is arranged in many Indonesia regulation law. But in fact, children can access the violent content easily from their social media. This writingis aim to examine influence of brawl Juvenille Deliquency violence content to children establishment. Method used in this research is qualitative with are data condensation, display, drawing and verifying conclusion processing technic. The result show that the violation of children right by brawl Juvenille Deliquency violence content is frequently happen in social media. Its give the negative impact because its appeling violence behavior to the children, which in long term can make them involve to criminal activity. The protection act is urgently need to take from the parent and the government.

Introduction: On average, minoritized racial and ethnic groups, including non-Hispanic Black and Hispanic adults, sleep more poorly than non-Hispanic White adults (hereafter, Black and White). Although racial and ethnic sleep disparities have been well-documented, few studies have investigated factors that may contribute to sleep disparities, such as the neighborhood environment. We hypothesized that Black and Hispanic adults demonstrate associations between more positive neighborhood conditions and higher sleep quality. Methods: In the community-based Offspring Study, we assessed cross-sectional associations between the neighborhood environment and self-reported sleep quality in Black, Hispanic, and White adults (n=993; 27-91 years; M=56 , SD=11). Participants self-reported positive (cohesion, safety) and negative (problems, disorder) aspects of their neighborhood experiences on 29 questionnaire items, which were summed on subscales for each aspect of the neighborhood. We assessed sleep quality with the Pittsburgh Sleep Quality Index. Both sleep quality and neighborhood experiences were treated as continuous variables. We performed multivariable regression analyses stratified by racial and ethnic group and adjusted for age, education, and gender identity. Results: More positive neighborhood experiences (higher neighborhood cohesion and safety; lower disorder and problems) were associated with higher sleep quality in Black, Hispanic, and White adults in unadjusted models. In adjusted models, only neighborhood cohesion was associated higher sleep quality in each racial and ethnic group (Black: 0.17, [0.03, 0.31]; Hispanic: 0.09, [0.03, 0.16]; White: B=0.129, [0.004, 0.25]). In White adults, higher neighborhood problems were associated with poorer sleep quality (B=-0.17, [-0.26 Based on a previously validated approach, frailty phenotype was identified when three or more of the following five criteria were fulfilled: self-reported weight loss, exhaustion, low physical activity, slow walking pace, and measured low grip strength. Multivariate logistic regression models were used to assess the association between shift work and frailty. Results: Among 242,126 participants,201,489 (83.2%) were day workers and 40,637 (16.8%) shift workers. Frailty was identified in 4,308 participants (1.8%), including 3,312 day workers (1.6%) and 996 shift workers (2.5%). Compared with day workers, shift workers were at higher risk for frailty after adjusting age, sex, and ethnicity, i.e., odds ratio (OR) =1.58 [95% CI, 1.47-1.70] (p < 0.0001). The effect of shift work appeared to be more pronounced in 5,659 permanent night shift workers (OR = 1.98 [95% CI, 1.68-2.32], p < 0.0001). The differences between day workers and shift workers persisted even after further adjusting for social economic status, sleep duration, and chronotype (OR = 1.38 [95% CI, 1.28-1.48] for all shift workers; OR = 1.53 [95% CI, 1.30-1.80] for permanent night shift workers, both p values < 0.0001). Conclusion: Middle-to older-aged adults who were currently performing shift work, especially those permanent night shift workers, were more likely to be frail. Longitudinal and interventional studies are warranted to elucidate the causal relationship between shift work and the risk of frailty. --- A. Basic and Translational Sleep and Circadian Science X. Sleep and Circadian Disparities

ethnic minority (vs. White) adolescents. PSQI scores were not independently associated with MetS or interacted with race in the association with MetS. Conclusion: Unhealthy sleep is associated with increased MetS risk, particularly for racial/ethnic minority adolescents. Given the greater sensitivity to sleep health, improving sleep quantity and quality may be candidate targets for MetS interventions in at-risk populations who experience health disparities. Support (if any): American Nurses Foundation (18A01422). Center of Biomedical Research Excellence (COBRE) in cardiovascular health (P20GM113125)

BACKGROUND Providing healthy food and accelerating nutrition improvement is one of Indonesia's programs implemented by the Gerakan Masyarakat Sehat (GERMAS) to prevent and eradicate stunting (Kemenkes RI, 2017). According to the results of a survey by the World Health Organization (WHO), the incidence of stunting in Indonesia is the third country with the highest prevalence of 36.4% in the Southeast Asia region (Kemenkes RI, 2018). Meanwhile, the prevalence of stunting in 2016 was 27.5% and increased to 29.6% in 2017. The current survey results show that the program issued by GERMAS needs to be adequately implemented. The family has the task of family development to facilitate the care and fulfillment of family members in a healthy family environment (Susanto, 2015). Therefore, good family environment facilities can support the fulfillment of the needs and development of children in the family. Stunting is a condition of growth and development of children who experience problems of inadequate nutritional intake from the womb to the age of five so that children have a length or height that is less when compared to their period. (Kemenkes RI, 2018). Causes of stunting include maternal nutritional deficiencies during pregnancy, exclusive breastfeeding practices, complementary feeding practices for children, frequent exposure to infections, low household socio-economic status, premature birth, short birth length, and low maternal height and education level. aging, food management, health care, water and environmental sanitation, urbanization, and natural and manufactured disasters (Tumilowicz, 2015). The home environment is the place that most influences children's health, especially for children before entering school. Life experiences, such as frequent housing movements, can hinder the development of a home environment that is conducive to a child's well-being (Krupsky, 2019). Family mobilization and healthy and adequate housing is an aspect of family functioning that impacts the physical and mental health of the family and its members and the long history of living in the environment where the family currently lives (Friedman, 2010). Family mobility is a family relationship (Krupsky, 2019). Greater instability and confusion will affect internalizing and externalizing behavior, developmental delays, and overall physical health (Beck, 2019). Families will also experience difficulties in receiving health services when they move their residence too often (Busacker,2012), so that the vaccines received by children when they Incidents in Toddlers in Indonesia. --- METHODS The research design is a literature review. This literature review was compiled --- RESULTS Based on the results of the literature review conducted, it is known that there is a relationship between family mobilization and the incidence of stunting in toddlers. --- RESULTS Based on the description of family mobilization and the incidence of stunting in children under five, children who experience stunting can be identified starting from children who are still in the womb to children aged under five, where this incident is caused by inadequate nutritional intake from in the womb to toddler age (Kemenkes RI, 2018). This is a family problem that can be experienced from the first stage of the family with a new partner to the second stage of the family with the birth of the first child and continues until the baby is 30 months old (Friedman, 2010) (including child abuse and neglect), and problems transitioning into parenting roles. (Friedman , 2010). If an area has a community with difficulty accessing and contacting health services, children are more vulnerable to malnutrition, which can affect their growth. The distance to health services makes parents' upbringing less good because families always consider the costs to be incurred, so families will tend to prioritize their income to be used for food rather than for treatment, considering all the existing limitations (Mentari, 2020). This happens more often in rural areas than in urban areas, because access and travel time for families to reach health services is easier and faster because families have better transportation and road access (Indrastuty, 2018). Factors like these tend to influence families to change their place of residence so that families get a better environment and socioeconomic progress (jobs, economic status) (Lawrence, 2015). (Indrastuty, 2018). Mobilization of residence is closely related to instability and chaos in early life (Busacker, 2012). Children from families with greater instability and disorder are more susceptible to negative health outcomes such as internalization and externalization of child behavior, delayed development, and poor overall physical health (Krupsky, 2019). So that chaotic household conditions can food for their toddler (Indrastuty, 2018). This is a trigger factor for parents to give poor parenting to their children so that children's nutrition is not fulfilled properly, and finally, children are more prone to stunting Talapessy. E.Y., et al. ( 2023) (Maywita, 2018). Therefore, families must pay more attention to the quality and quantity of nutritional intake in children's --- CONCLUSION Based on the results of a review that was carried out on the nine articles obtained, it is known that there is a link between family mobilization and the --- DATA AVAILABILITY STATEMENT The data that support the findings of this study are available from the corresponding author upon reasonable request. --- AUTHOR CONTRIBUTIONS --- Substantial --- CONFLICT OF INTEREST The authors declare no conflict of interest. Family

Stunting is the inadequacy of nutritional intake from the womb to the child at the age of five, which is indicated by the child having less length or height comparing to the age. In this study, the researcher linked family mobility as one of the factors causing the increasing case of stunting. The purpose of this literature study is to describe family mobilization with the stunting case in children under five in Indonesia. The research design used in this study was a traditional literature review. Articles are tracked using several search engines (Google Scholar, PubMed, Springer link, Sinta, and Plos One). The results of this study indicated that family mobilization in reaching health services can affect the nutritional status of children under five. The affordability of health services is caused by several factors such as road access, distance and travel time. It also relates to the family residence, the pattern of care provided, and the socio-economic status of the family which can cause children under five experiencing stunting. The conclusion in this study is that family mobilization such as a lack of family health attention in reaching health services, inadequate needs and a healthier lifestyle or low economic status, as well as a poor or lack parenting knowledge can cause children under five susceptible to infectious diseases so that the children are prone to stunting.

Introduction: Substance use disorders(SUDs) are a major health concern and current treatment interventions have proven only limited success. Despite increasing effectiveness, still about 50-60% relapse within 6-12 months after treatment [Cornelius et al., Addict Behav. 2003;28 381-386]. SUDs are defined as chronic disorders of brain reward system, motivation, and memory processes that have gone awry. Medication reducing craving and substance use is mainly available for alcohol dependence and to a lesser extent for other substances. Hallucinogens may represent a group of agents with potential anticraving properties subsequently reducing substance use in SUD patients. For instance, lysergic acid diethylamide(LSD) and psilocybin have previously been shown to effectively alleviate symptoms of alcohol and nicotine dependence. Objectives: New treatments preferably focusing on reducing craving and subsequent substance use are therefore urgently needed. The hallucinogen psilocybin may provide a new treatment option for SUD patients, given the beneficial results observed in recent studies Methods: Systematic revision of literature. Results: In the 1950s, a group of drugs with potential to alter consciousness were discovered (hallucinogens). Several studies suggested their anti-SUD potential, improving self-acceptance and interpersonal relationships, reducing craving and alcohol use. As a result of its recreational popularity during the 1960s, they were banned in 1967, greatly hampering scientific research in this field. Recently, psilocybin, an hallucinogenic substance in psilocybincontaining mushrooms has gained popularity in neuropsychological research, showing to increase trait openness, cognitive and behavioral flexibility, and ratings of positive attitude, mood, social effects, and behavior and even reported persistent positive changes in attitude and behavior. These findings might suggest a valuable compound for the treatment of psychiatric conditions with several additional studies providing supportive evidence for the therapeutic potential of psilocybin for SUD treatment and relapse prevention. Conclusions: With the reported limited amount of side effects and potential beneficial effects of psilocybin in SUD, there are valid reasons to further investigate the therapeutic efficacy and safety of psilocybin as a potential SUD treatment. On the one hand, psilocybin may exert its anti-addictive properties by beneficial effects on negative emotional states and stress. On the other hand, psilocybin may improve cognitive inflexibility and compulsivity. Research on the efficacy of psilocybin on SUD is still limited to a handful of published studies to date. As a result, many important questions related to the use of psilocybin as a complement to current treatment of SUD and its working mechanisms remain unanswered. Before psilocybin can be implemented as a treatment option for SUD, more extensive research is needed. --- Disclosure of Interest: None Declared --- EPP0293 Comparison of stress and coping mechanisms among family members of patients abusing licit and illicit substances Introduction: Addiction has long been recognized as a disease that may have a dramatic influence on the addicted individual's family members, manifesting as stress or trauma-related physical and psychological symptoms, resulting in increase in the usual family's use of health-care services. There is little research available to identify and explore problems of families associated with such patients. In this study, we will evaluate stress among family members of substance abuse patients and try to focus on how these family members are dealing with these stress factors. The study will also compare different types of coping mechanisms among family members of patients taking licit and illicit substances. Objectives: To identify stress among families of patients abusing licit and illicit drugs and assess and compare their coping mechanisms. Methods: 175 family members of patients with licit substance abuse cases and 175 family members of patients with illicit substance abuse were taken for study after informed consent. Stress among participants was evaluated using Symptom Rating Test and The Depression Anxiety and Stress Scales (DASS). Coping Questionnaire (CQ) and Breif COPE was used to assess coping among them. --- Results: The study demonstrated that the total number and severity of symptoms, including psychological and physical symptoms, are found lesser in caregivers (participants) of patients abusing licit substances than in patients abusing illicit drugs. These symptoms among family members grow as the patient's age rises. Symptoms in participants are more if their patient is female as compared to male. And also, total symptoms are more if they are living in nuclear family (Table 1). In our results, total coping and engaged coping mechanisms in family members are found to be not significant as per drug type and remains the same for both licit and illicit drugs abusing patients' families. Avoidant coping mechanisms in family members are more if their patient is female and in nuclear family. Conclusions: In our study, it was clearly noticed that the total symptoms, both physical and psychological, were found more in family members of patients abusing illicit drugs. Impact of substance abuse related problems is found more in female members compared to male members of family. --- Disclosure of Interest: None Declared --- EPP0294 The influence of problem drinking persons on the quality of life of their surroundings depending on gender and age Introduction: The social consequences of alcohol affect not only drinkers, but also the people communicate with him. They are including: mental health, quality of life, health, living conditions and needs in using health system resources. Objectives: 1,531 people were examined, who belonged to three qualitatively different comparison groups: patients with alcohol addiction (329 people); healthy relatives of patients with alcohol addiction (238 persons) and representatives of the general population (964 persons). Methods: clinical, clinical and psychopathological, methods of quantified scales and mathematical statistics. Results: The data obtained indicate that the majority of respondents who caused some harm to the respondents were men. But the level of harm of alcohol abuse of women was significantly higher. Alcohol abuse problems of microsocial environment (substance abuse, employment, financial problems, and health effects) had a more significant effect on depressive disorders in the control group than in the alcohol addiction group and their relatives. Significant correlation of depressive disorders due to the drunkenness of others was associated with fear for children, the possibility of aggression. Depressive disorders in the group relatives of patients with alcohol addiction correlated with aggression towards them with patients with alcohol addiction or persons in a state of alcohol intoxication, discomfort due to being with their relatives in public, at parties, inability to control alcohol use. It was shown that the presence of drinkers in the company of women significantly increases the specific weight of people with depressive disorders among them, while such an effect was not found among male respondents. It has been established that in the case of the presence of drinkers in the environment, the expressiveness of such manifestations of depression as insomnia increases the most in women; weight loss, sexual disorders; suicidal tendencies and feelings of guilt. The influence of presence of drinkers in the environment of children on tfrequency of manifestations of their discomfort is described. It has been confirmed that the most frequent cause of children's ill health is their drinking parents, as well as other (besides parents and siblings) drinking relatives. It was found that in healthy respondents, the unfavorable features of the behavior of relatives and close drinkers are always directly correlated with indicators of the ill health of children in their environment, while in respondents addicted to alcohol, these correlations have a complex, mosaic nature. Conclusions: The study found the prevalence of depressive disorders in the microsocial environment of drinkers. A significant decrease in the quality of life was noted primarily in children and women who had drinking relatives with a large number of drunk days.

sleep microarchitecture. This suggests that the sleep microarchitecture of the randomized subjects is similar to a broader insomnia population that has subjective insomnia but that does not meet all eligibility criteria including objective and subjective sleep duration thresholds.

I don't know how old I am. I have no recollection of a time when I did not live with the Connollys. I call Mrs. Connolly mamma. I have never had but one pair of shoes, but I can't recollect when that was. I have had but no shoes or stockings on this winter. I have never been allowed to go out of the room where the Connollys were, except in the nighttime and then only in the yard. I have never had on a particle of flannel. My bed at night has been only a piece of carpet stretched on the floor underneath a window, and I sleep in my little H. Markel under-garments, with a quilt over me. I am never allowed to play with any children, or have any company whatever. Mamma (Mrs. Connolly) has been in the habit of whipping and beating me almost every day. She used to whip me with a twisted whip-a raw-hide. The whip always left a black and blue mark on my body. I have now the black and blue marks on my head, which were made by Mamma with the whip, and also a cut on the left side of my forehead, which was made by a pair of scissors. (Scissors produced in court.) She struck me with the scissors and cut me. I have no recollection of ever having been kissed by anyone-have never been kissed by Mamma. I have never been taken on my mamma's lap and caressed or petted. I never dared to speak to anybody, because if I did I would get whipped. I have never had, to my recollection any more clothing than I have at present-a calico dress and shirt. Whenever Mamma went out I was locked up in the bedroom. I do not know for what I was whipped-Mamma never said anything to me when she whipped me. I do not want to go back to live with Mamma because she beats me so. I have no recollection of ever being in the street in my life. 2 I first came across this horrid story in 2009, while researching an essay I was writing for the New York Times. The quote above was extracted from the testimony of a 10-year-old little girl named Mary Ellen McCormick. What is most amazing about Mary Ellen's testimony is that she delivered it in a courtroom on April 9, 1874! Orphaned as a baby, Mary Ellen was first sent to the city orphanage on Blackwell's Island and, subsequently, was adopted by a Manhattan couple named Thomas and Mary McCormick. After Thomas's premature death, Mary remarried and took to beating the child. Sometime in 1873, Mary Ellen's neighbors complained about her plight to the New York City Department of Charities and Corrections. The agency sent a social worker named Etta Angell Wheeler to investigate the situation. Wheeler was shocked to find she had little recourse to help the little girl. In a culture of "spare the rod, spoil the child," there was not yet a single, formal law against child abuse in the American system of jurisprudence. Undaunted, Wheeler implored Henry Bergh, the founder of the American Association for the Prevention of Cruelty to Animals, to take on the cause. Bergh viewed Mary Ellen's plight to be similar to the horses he routinely saved from "violent stable owners." In other words, he saw Mary Ellen as "a vulnerable member of the animal kingdom needing the protection of the state." 3 Bergh promptly hired the well-connected attorney Elbridge T. Gerry to plead Mary Ellen's case before the New York Supreme Court. In a novel use of the writ of habeas corpus, Gerry asked the court to take custody of Mary Ellen and to find other accommodations for her because if she was returned to her abuser's home, she would almost certainly be killed or irreparably harmed. The tactic worked. Justice Abraham R. Lawrence found the child's adoptive mother, Mrs. Connolly, to be guilty on several counts of assault and battery. More important, the court assumed custody of Mary Ellen and she never again returned to the Connolly home. (After a short stay in an orphanage, she was adopted by Etta Wheeler and her sister.) Justice Lawrence's decision is widely regarded by legal historians to be the first adjudicated case of child abuse in the American court system. Astoundingly, it took 90 more years before a pediatrician, a radiologist, a psychiatrist, and an obstetrician-gynecologist formally classified child abuse as a medical problem. On July 7, 1964, C. Henry Kempe and his colleagues published their seminal article "The Battered-Child Syndrome" in the Journal of the American Medical Association. 4 In the decades since, a consortium of dedicated health professionals, legal advocates, teachers, parents, and social activists have made great inroads in recognizing and ameliorating this glaring problem. Nevertheless, the risks and harms for vulnerable children continue to strike at an alarming rate. In 2012, for example, the CDC reported more than 3.4 million referrals to US, state, and local child protective services. Approximately 686,000 of them (9.2 per 1,000) were victims of some form of child maltreatment. A total of 78% were victims of neglect; 18% of physical abuse; 9% of sexual abuse; and 11% were victims of other types of maltreatment, including emotional abuse, threatened abuse, parental drug and alcohol abuse, or lack of supervision. Of these children, 1,640 died as a result of abuse (2.2 per 100,000). The victims were also more likely to be young, with 27% of the victims younger than 3 years of age and 20% aged 3 to 5 years; children under the age of 1 year experienced the highest rate of victimization (21.9 per 1,000 children). The rate of victimization was 8.7 per 1,000 children for boys and 9.5 per 1,000 children for girls. Four-fifths (80.3%) of the perpetrators of various forms of maltreatment were the children's parents, while 6.1% were relatives other than parents; 4.2% were unmarried partners of parents; and, of all the perpetrators, 54% were men and 45% were women. 5 More-much more-must be done to tackle this threat to the public's health and our youngest citizens. The abuse, maltreatment, or harm to our greatest national resource and future is simply too dire a subject to neglect. The real cost of a child's health and well-being is priceless and, morally, one case of child abuse is a case too many. --- * * * This month's Op-Ed section overflows with excellent and provocative ideas. We begin with Jonathan Cohn who writes on the war on tobacco and public cynicism; Joshua Sharfstein analyzes applying public health methods to prevent violent injuries; Gail Wilensky explains why prescription drug pricing is not just an election issue; Sara Rosenbaum discusses Medicaid's EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) for children under age 21; John McDonough writes about oral health and health policy; Lawrence Gostin writes about the past decade's efforts to develop fair and practical emergency quarantine regulations; Catherine DeAngelis asks how helpful are hospital rankings and ratings; and David Rosner reviews the risks climate change poses for the public's health. For this issue's Original Contributions, we lead with a paper by John A. Graves and Pranita Mishra. They discuss the evolving dynamics of employer-sponsored health insurance and how that affects workers, employers, and the Affordable Care Act. Robert A. Nathenson, Brendan Saloner, Michael R. Richards, and Karin V. Rhodes write on Spanish-speaking immigrants' access to safety net providers and translation services across traditional and emerging US destinations. Mark Hellowell, Katherine E. Smith, and Alexandra Wright report on the myriad problems encountered after implementation of Scotland's innovative health tax on large retailers selling tobacco and alcohol. Madeleine Phipps-Taylor and Stephen M. Shortell's article looks at the ways to motivate physician behavior changes in accountable care organizations (ACOs). Our last paper for the year is a systematic review of measurement properties for integrated care by Mary Ann C. Bautista, Milawaty Nurjono, Yee Wei Lim, Ezra Dessers, and Hubertus J.M. Vrijhoef. --- As the holiday season comes upon us once again, it is our privilege to thank our authors, reviewers, and readers and to wish all a joyous season and happy new year.

hild abuse, be it physical, sexual, or emotional, is one of the saddest, needless, and longest running stories in the history of public health. Even more outrageous has been our collectively poor track record in adequately recognizing, solving, or, at least, preventing this problem. Using data collected in 2008, the US Centers for Disease Control and Prevention (CDC) estimated that the total lifetime costs associated with confirmed child abuse and neglect cases for that year (1,740 deaths and 579,000 nonfatal cases) was about $124 billion, although other methods of measurement applied suggest that the cost may be as large as $585 billion. The CDC estimated that the average lifetime cost per victim of nonfatal abuse was $210,012

Introduction The earliest case reports of dissociative disorder appeared at the end of the 18th century, and detailed descriptions of the condition first appeared in medical literature in the 19th century. In the 18th century, there was discussion on whether hysteria (somatoform symptoms) or dual consciousness (dissociation) should be used to categorize the condition. Somatoform hysteria eventually emerged as the conceptual basis for all of these illnesses [1]. A break in the normally integrated functioning of consciousness, memory, identity, or perception of the environment is known as dissociation [2]. Dissociation may be abrupt, acute, or insidious in onset. There are many types of dissociative disorder as per the International Classification of Disease (ICD) 10, namely dissociative amnesia, dissociative fugue, dissociative stupor, trance and possession disorders, dissociative motor disorders, dissociative convulsions, dissociative anesthesia, and sensory loss. The term "hysteria" has been used to describe these conditions in the past, but it currently appears preferable to avoid it as much as possible due to its many, and different connotations [3]. As per the International Classification of Disease (ICD) 10, trance and possession disorders are defined as states involving a temporary loss of the sense of personal identity and full awareness of the surroundings. The primary issue is the cross-cultural diversity of dissociative trance and possession states, like many mental conditions. Trance states exhibit variety in frequency and attribution, and they are perceived as manufactured in some cultures while pathological or socially acceptable in others. Behavior in those in possession and trance is frequently interpreted as being identical to changing that person's identity to that of another. Affected people may speak with different dialects or vocal tones or behave differently from other people [4]. The majority of people with dissociative disorders describe self-harming; up to 86% of dissociative people report having engaged in non-suicidal self-harm (NSSI) in the past, and up to 72% had attempted suicide at some point in their lives [5]. In a study, women with dissociative disorder in Magnetic Resonance Imaging (MRI) research showed considerably smaller hippocampus and amygdala sizes than healthy control subjects [6]. This case will bring out the multi-factorial reasons as to how dissociative disorder is a challenge to the psychiatrist and how it burdens the patient and their family. --- Case Presentation A 45-year-old married man from a low-income background came to the emergency room with a five-year history of limb weakness, unconsciousness, jerky movements, and memory problems after each episode. No prior psychiatric history in him or his family. He was moved to the intensive care unit (ICU) and assessed by a neurologist, with a normal electroencephalogram (EEG) result. He was then referred to psychiatry to investigate psychogenic nonepileptic seizure (PNES). Upon further evaluation, it was discovered that the family had concealed important details about his symptoms due to the stigma associated with mental disorders. The patient faced significant stressors, including strained relationships with his brother and son, as well as financial difficulties. The patient had recurring 15-minute episodes marked by jerky movements, teeth clenching, and upward eye rolling, with no memory of them. Despite seeing multiple doctors and taking anticonvulsants, the episodes didn't improve; in fact, they became more frequent and longer. That same year, the family consulted a faith healer who alleged that another faith healer named "Narayan" was responsible for these symptoms as an act of revenge. Shortly after, the patient experienced another episode, exhibiting peculiar behavior. He believed he was under "Narayan's" influence, with an altered voice and distorted facial expressions. During these episodes, he attempted to harm himself and his family, with no recollection afterward. He experienced episodes embodying an elderly neighbor and an unknown young girl, accompanied by second-degree auditory hallucinations where he heard these personas call him by his real name. This occurred while he was under a neurologist's care. Over five years, additional anticonvulsants like phenobarbitone and lacosamide were prescribed. The son noted that his mother and younger brother briefly encountered similar auditory hallucinations, with the young girl claiming to be sent by the faith healer "Narayan" for revenge, lasting only three days with no intervention. The family concealed both the stressor and these episodes from the doctor due to the stigma associated with them, resorting to multiple faith healers who reinforced their belief in possession and the voices. The patient underwent a plain computed tomography (CT) brain and MRI brain, and blood tests, including a complete blood count, kidney function, and liver function, all showed results within the normal range. Consequently, the patient received a diagnosis of trance and possession disorder. Treatment began with 20 mg of fluoxetine capsules and 1000 mg of sodium valproate, which was gradually reduced and eventually discontinued. The family and patient received psychoeducation about the disorder, how to recognize the episodes, and the importance of managing the behavior and committing to long-term treatment and follow-ups. The patient also received education on identifying triggers and learned breathing exercises and distraction techniques. Currently, after six months of follow-up, despite ongoing stressors regarding his strained relationship with his brothers and son, there have been no further episodes of trance and possession. --- Discussion Dissociation/dissociative disorder diagnosis and treatment are a significant public health concern. Patients with dissociative disorder make up a sizable underserved community whose lack of acknowledgment results in high costs to individuals and society. Particularly males with dissociative disorder may go unnoticed because they are more likely to deny symptoms and traumatic history. In order to reduce the risk of suicide in both general and clinical populations, it is important to consider the strong link between dissociation, dissociative disorder, and suicidal and self-destructive behavior. The cultural and professional ignorance about the scope and gravity of the sort of trauma that causes dissociative disorder, as well as the prevalence of dissociative disorder patients, constitute the socio-cognitive issue. The human cost of improper diagnosis and treatment is quite substantial [7]. Disorders of dissociative trance and possession pose a challenge to psychiatry [8]. It is understood that culture influences the belief in the bounded individual self and depends on other cultural presumptions, which in turn affect these states [9]. Through the study of discrete behavioral states (DBS), dissociation research may also significantly advance our knowledge of the links between the mind, the brain, and the body. Many mind/brain/body mysteries in neuroscience, psychology, and psychiatry may be clarified through DBS models [10]. The clinician's job is to provide an alternate explanation for psychological conflicts and unmet needs, not to dismiss spiritual causes for reported symptoms [11]. Dissociative disorders may be triggered by co-occurring psychosis, affective illness, conflicts, or personality traits that reduce the person's capacity for adaptation, or more directly, they may cause the conscious or inadvertent use of dissociation to vent discontent and misery. Dissociation can be understood as a trauma response, as a way to convey emphatically how one feels out of control, confused, and overpowered., and as a tool to investigate and articulate one's position on more significant social, moral, and spiritual concerns [12]. The cornerstone of consultation liaison with psychiatry (CLP) is the integration of all information from all sources to deliver the best possible medical care. The care given should be sensible financially, sensitive to the needs of patients and other specialists, and attentive to prevention [13]. In the above case, delayed seeking of treatment secondary to stigma led to the worsening of the patient's symptoms. The culture and beliefs of the family also played a role in it as well. We see that dissociative disorder not only impacts the patient but also the family's mental health as in this case where his wife and son also had a brief period of secondary auditory hallucinations which resolved without any intervention. Many a time the physician may also dismiss patients' beliefs affecting access to care leading to more increase in the illness burden on the patient and family. It also shows the importance of CLP for better patient management. --- Conclusions Diagnosing and treating dissociative disorder is still a major challenge faced by the majority of psychiatrists. Even after that, educating the patient and relatives and how they perceive this illness also plays a role in the management while keeping in mind not to go against their belief. Adding to this challenge, the social and cultural barriers that come with it also add to its burden. There is a common belief even now that it is more predominant in females. Men with dissociative disorder and their families are more hesitant to visit doctors due to them playing the dominant masculine gender roles, making it more difficult to treat them. Delay in treatment also may have led to shared psychosis for a brief period which couldn't be assessed in detail here. Consultation liaison with psychiatry also plays a very important role in diagnosing and managing many psychiatric illnesses including dissociative disorder as seen in this case. --- Additional Information Author Contributions All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the work. --- Concept and design:

Dissociative disorders have been present in our society since time immemorial, with culture, society, and spiritual beliefs playing a major part. It went through many changes from its name and what it constituted. Diagnosis can be made based on the International Classification of Diseases (ICD) 10, Diagnostic and Statistical Manual of Mental Disorders (DSM) 5, and now the current International Classification of Diseases (ICD) 11 criteria. One of its constituents is trance and possession disorder which is one of the main obstacles faced by psychiatrists in Indian society. Through this case, we can assume that there are many factors involved that lead to delays in diagnosing and managing a case of dissociative disorder, most importantly the social and cultural factors. Even now cultural-socio-spiritual beliefs add to the challenge of dissociative disorders. This case reveals that individuals first consult a general physician before visiting a psychiatrist; so, the need for consultation liaison psychiatry (CLP) and its role today in diagnosis and further management is emphasized. There still exists a need for awareness to be made regarding the mind-body relationship and psychosocial support to both patients and their relatives keeping in mind their beliefs.

Book Review  Spend enough time online and you will inevitably come across a political debate. Within these debates, you can count on accusations that some participants are actually bots. Though the profiles appear to belong to ordinary people, the accusation is they may actually be fake profiles created to spread propaganda and mislead people. The accusation is difficult to prove, but the suspicion is based on real events. Back in 2016, acting on behalf of the Russian government, the Russia-based Internet Research Agency (IRA) attempted to interfere in the U.S. Presidential election. Actors at the IRA managed fake social media accounts which, backed up by an army of autonomous bots, posed as Americans espousing pro-Trump and anti-Clinton views. This was not the only online interference in that election cycle. The English firm Cambridge Analytica used deceptive means to gather Facebook data on 87 million Americans without their knowledge and then used this data to create psychological "profiles." Working with the Trump campaign, Cambridge Analytica pillars-trashing, pretexting, bullshitting, and penetration-and how they apply specifically to mass and interpersonal social engineering. Gehl and Lawson argue that "masspersonal" social engineers use the same techniques as these earlier social engineers to great effect on individual and societal levels, all made possible by "the unique affordances of the internet and social media platforms." Masspersonal social engineering, they claim, not only describes the strategies of the IRA and Cambridge Analytica, but also presents a new, unique cause for societal concern. Unfortunately, what the book fails to capture is perhaps more important: what allows for rampant online manipulation, and how we can release its hold over us. --- Reviewed by Nathaniel Knopf Let us start with what the book gets right. As far as tools to describe online manipulation, this book is a decent place to start. The provided framework for masspersonal social engineering highlights the steps necessary to create what is essentially immersive online propaganda. In doing so, it gives one the tools to compare instances of online manipulation and to distill what the bad actors are trying to do. The book takes a roundabout path to deliver the framework-it is not until page 165 of the 225-page book that the authors turn from the earlier social engineers, leaving time to discuss only two examples of masspersonal social engineering. But the lengthy history does fulfill the authors' promise to connect masspersonal social engineering to its ancestors, and various digressions on the toxic, hypersexualized language used by computer hackers and garbage as an overlooked byproduct of knowledge production may be of interest to some. In the last chapters, to showcase masspersonal social engineering, the authors apply it to the IRA and Cambridge Analytica. The framing for the IRA's actions is cohesive enough, but the application to Cambridge Analytica raises some potential issues with the four pillars of their framework. The authors treat these four pillars-trashing, pretexting, bullshitting, and penetrating-as essential ingredients of masspersonal social engineering. For Cambridge Analytica, however, they manipulate the functions of these pillars to better fit the framework to the event. The authors recap how Cambridge Analytica captured the data of 87 million Facebook users (i.e., "trashing") using innocuous appearing games and web applications-strategies which the authors describe as "pretexting." This use of pretexting to facilitate trashing is different from the function of pretexting elsewhere in the book, which is typically to gain credibility with the target during active manipulation. This malleability of the four pillars suggests that the framework as a whole might not be so precise. That said, one can imagine applying it to examples not discussed in the book, such as guerrilla marketing campaigns, so the concept probably has broader use. The book presents a reasonable framework for discussing online manipulation, but the authors go one step further than presenting a new framework. Gehl and Lawson claim that masspersonal social engineering presents a unique threat to society. The events highlighted by the book are certainly representative of a great disinformation crisis facing our nation. But masspersonal social engineering fails to fully capture and address the core, systemic problems contributing to disinformation, instead focusing on individual behaviors. Specifically, the authors fail to address the unique, critical role that social media companies like Facebook play in making disinformation schemes possible. The authors mention that Facebook is incentivized to sell advertising space to anyone with the cash, and they correctly call for stronger data protection laws in the United States to match those in Europe. But the real reason behind events like these is not that bad actors can advertise on Facebook or that Facebook makes personal data more accessible; addressing these problems alone would be too superficial to prevent manipulation. To explain why, it is necessary to illustrate how social media companies have intentionally created platforms that actively spread disinformation, and why they will continue to do so without major outside regulation. Social media websites such as Facebook make use of machine-learning models to decide what content should be served to users. In order to maximize user engagement, and therefore profits, Facebook's models are specifically configured to spread polarizing, inflammatory, and often misleading content like wildfire. In an expose on Facebook's machine-learning models, Karen Hao of the MIT Technology Review confirmed exactly this: "A former Facebook AI researcher who joined in 2018 says he and his team conducted 'study after study' confirming the same basic idea: models that maximize engagement increase polarization. They could easily track how strongly users agreed or disagreed on different issues, what content they liked to engage with, and how their stances changed as a result. Regardless of the issue, the March 2023 models learned to feed users increasingly extreme viewpoints. 'Over time they measurably become more polarized,' he says" [1]. Hao also describes internal researchers making shocking discoveries, such as Facebook's own recommendation tools being responsible for 64% of all extremist group joins on the platform. Attempts to limit this were dismissed internally as being "antigrowth." Task forces meant to assess the relationship between political polarization and engagement were disbanded. To this end, Facebook has chosen to assume a crucial, symbiotic role in disinformation campaigns. Bad actors publish lies and manipulative content, which Facebook preferentially spreads, generating profits along the way. We saw the consequences of this symbiosis on 6 January 2021. Facebook's own algorithms contributed to the creation of an army of conspiracists who believed that deep-state child predators had thrown the election to force Trump out of office [2]. They were willing to commit treason for their cause. To Meta, Facebook's parent company, this is just an externality of a wildly profitable strategy. There is always the chance that with enough negative attention, companies might begin self-regulating to protect their image. However, given Facebook's pitiful attempts at self-regulation, which saw the deactivation of a model that filtered antivaccine misinformation in the name of "fairness" to conservatives [1], I think it is unlikely that self-regulation would do much good. It certainly has the potential to leave us open to masspersonal social engineering and other harm. So what can we do to protect our society against disinformation? A good place to start would be limiting how large and powerful these social media platforms can get. The sort of profit-seeking behavior that leaves the door open for disinformation and masspersonal social engineering is not unique to Facebook. If Facebook is correct in its hypothesis, that feeding users polarizing content is the best way to increase engagement, then the problem generalizes to any social media company that makes more money with increased engagement-basically all of them. In the book's conclusion, Gehl and Lawson give this phenomenon a nod, labeling it "the political economy of bullshit." However, the solution they propose falls short. Their antidote is improved media literacy-to ask people to think critically and parse out bullshit they see online. I do not wish to bash critical thinking, and our country's lack of skill certainly bears some of the blame for how easily conspiracy theories can spread. However, the political economy of bullshit is a systemic problem, and systemic problems require systemic solutions. Whether the problem is disinformation, climate change, or a pandemic, relying on individual responsibility as a solution all but guarantees failure. So, the big issue that Gehl and Lawson fail to address is this: Anything relying on mass manipulation, be it election interference, antivaccination conspiracies, or future insurrections, is more possible in a world where social media companies are allowed to exist in their present form. if maSSperSonal Social engineering is really the societal threat that Gehl and Lawson say it is, then we need to think harder about the systemic causes that make it possible. Fortunately, there are steps that our society can take to limit the power and scope of platforms like Facebook, thereby reducing the opportunity for disinformation campaigns and masspersonal social engineering. We do not have to allow corporations like Meta to grow so unfathomably large. Contrary to what Meta and other social media companies would like us to believe, we have the power and the means to regulate their behavior. We can interrupt this trend of radicalizing people for profit, and, with any luck, protect our society from mass delusion and subsequent destruction.   References

then created "psychologically targeted" ads meant to sway potential voters. It is hard to say how effective either operation was in influencing public opinion. The events themselves, however, are well established. In Social Engineering, authors Gehl and Lawson frame these operations as examples of "masspersonal social engineering," their framework for manipulative online communication with roots in social engineering. Masspersonal social engineering has four essential ingredients: 1) "trashing," which amounts to snooping on one's target to gather data; 2) "pretexting," taking on a new identity to gain credibility; 3) "bullshitting," a mix of appearing informed, disregarding the truth, and being friendly in order to get on the target's good side; and 4) "penetration," ultimately getting the target to do or think something they otherwise would not. To define this framework, the authors draw from two schools of social engineering. First, the mass social engineers of the 20th century who made use of newspapers, radio, and television to create what is now public relations. Second, the interpersonal social engineers of phone and computer hacking who exploit human weaknesses to break into computer systems and buildings. The authors then tackle each of the four

The self-care challenges of the COVID-19 pandemic are layered upon the pre-COVID challenges of burnout [1]. According to the Centers for Disease Control and Prevention (CDC), as of January 16, 2021, 365,072 healthcare workers have been infected with COVID-19, and 1254 have died in the USA [2]. Amnesty International reports widespread healthcare worker deaths worldwide [3]. In Italy, for example, the Italian National Institute of Health documented COVID-19-related deaths of 160 doctors, 40 nurses, and 2 suicides [4]. Early studies in the UK indicated that BAME (Black, Asian, or minority ethnic) healthcare workers appear to be significantly over-represented in the total number of COVID-19 deaths [5]. Before the pandemic, up to 50% of US physicians were experiencing professional burnout [6][7][8]. The Agency for Healthcare Research and Quality (AHRQ) defines burnout as a "long-term stress reaction marked by emotional exhaustion, depersonalization, and lack of a sense of personal accomplishment" [9]. Recently the WHO included burnout in the ICD-11 [10]. Within this pre-existing context of high burnout, the COVID-19 pandemic hit. Healthcare professionals at all levels rose above burnout to provide an extraordinary medical response, stepping forward to save lives at great cost to their own health and wellbeing. Healthcare workers in Scotland and their households, for example, accounted for 17.2% of all COVID-19-related hospital admissions, even though they represented only 11.2% of the working age population [11]. The profound toll of the COVID-19 pandemic on the physical and emotional state of healthcare staff necessitates that a new scientific self-care approach be urgently implemented that responds to the unique challenges of the COVID-19 pandemic affecting the health of clinicians. --- The Impact of COVID-19 on Family While healthcare workers constantly struggle with work-life balance, the issue of dual loyalty in caring for their families and patients has materialized in an unprecedented way during this pandemic. Enormous stress has been placed on healthcare workers' families [12]. This quote has been removed because it was inaccurate. When both parents are frontline healthcare workers, they have had to implement measures should their children be orphaned [13]. Household members of healthcare workers are directly at risk for contracting the virus, with deleterious or even fatal outcomes, especially among elderly parents/grandparents. Not even in the military are family members put at such risk. Some healthcare workers have chosen to protect their families by living apart from them, despite the emotional toll of this separation. Dr. Christian Rose provides an illuminating description of his dilemma after his exposure to a COVID-19 patient: I'm looking for a room where I can stay…. a no man's land where a colleague's spare bed may be the closest approximation to home we can find. [14] Recent reports have revealed that household members of healthcare workers who cared for COVID-19 patients were nearly twice as likely to be admitted to hospital with COVID-19 than other working age adults [11]. Unfortunately, there has been little research on the impact of burnout on medical families prior to COVID-19 to build upon [15,16]. --- Moral Injury Dean and Talbot have redefined burnout as moral injury [17,18]. They posit that burnout is a symptom of a broken healthcare system. In contrast, the concept of moral injury, taken from military experience, means an injury caused by being involved in actions that transgress our deeply held moral beliefs. Dean and Talbot cite the journalist Diane Silver, who calls moral injury a "deep soul wound" that pierces a person's identity, sense of morality, and relationship to society [17]. Discovering an ethical and moral pathway for doctors and nurses during the COVID-19 crisis has been difficult, as they face terrible conflicts related to working without adequate personal protective equipment, deciding who receives a ventilator, being unable to protect patients from witnessing the resuscitation and passing of patients beside them, needing to limit family at the bedside of dying patients, and the constraints imposed on using culturally defined practices surrounding death and burial [19]. The "Enormity Problem" As Bill Blakemore, noted ABC news correspondent has stated, the world is facing an "enormity problem," that is, a problem so big it is almost impossible to think about any solutions [20]. Lack of national leadership at every level during a time when we need it most is especially demoralizing [21]. This "enormity" analogy is applicable to the COVID-19 pandemic for several reasons. --- a) Suffering of the Innocent This pandemic is unlike any other disaster we have encountered in that we are in a "slow-moving mass casualty" [22]. The sheer magnitude of the suffering and death of innocent persons, without an end in sight, coupled with an as-yet inadequate understanding of the disease course and dearth of evidence-based treatment options, have left healthcare providers feeling overwhelmed and helpless. It is akin to the emotional despair well known to humanitarian workers serving mass populations impacted by war and ethnic conflict [23,24]. When one of us first visited the refugee camp "site 2" on the Thai-Cambodian border in 1988, he experienced for the first time the horrible suffering of tens of thousands of innocent Cambodian men, women, and children. Images from the trauma stories I had heard that day flooded my mind…There was no way I could help them… There were too many people with too many traumatic life experiences living in too terrible poverty and confinement. [23] b) Destruction of the Natural World The ecocide of our natural world has added to the complexity of curbing this pandemic. The medical concept of One Health brings hope that the root causes of such pandemics can be prevented. One Health is a multisectoral and transdisciplinary medical approach working at all policy levels, with the goal of achieving optimal health outcomes by fostering positive health linkages between people, plants, animals, and their shared environments [25]. --- Racial Trauma The challenges of the COVID-19 pandemic have been exacerbated by racial trauma [26••]. The severe social inequities and health disparities among communities of color have been brought to the forefront by the disproportionate impact of COVID-19 on Black, Latino, and Indigenous American populations. Without national systemic efforts to address the social determinants of health, healthcare workers are left without the tools to effectively care for their minority patients and vulnerable populations. An example is having to discharge a patient with instructions to quarantine when the patient lives in an overcrowded situation without the ability to isolate. Studies in the USA [27], Sweden [28], and Britain have revealed that migrants, Black persons, ethnic minorities, and Asians, respectively, have been disproportionately infected by the COVID-19 pandemic [29•]. Racial trauma has emerged as a major chief complaint among healthcare staff of color [26••]. Despite hours caring for critically ill COVID-19 patients, Asian American healthcare workers have been accused of causing the pandemic, called racial epithets and even physically assaulted. The physical and mental exhaustion associated with these challenges cannot be meaningfully captured by the term "burnout." With the entire medical profession experiencing collective trauma, medicine is at a selfcare turning point. The medical system's anemic prepandemic response to burnout, such as dinners for doctors and relaxation classes, while helpful, were not sufficient to aid health practitioners in dealing with the intense exhaustion and pain caused by the large-scale human suffering of the COVID-19 pandemic [30•]. New self-care instruments and practices necessary to meet these challenges are offered by the authors (www.HPRTselfcare.org). These instruments have been translated into Italian and widely disseminated in Italy during the recent crisis (www.intraumacenter.com). Healthcare systems need to move beyond burnout through sustainable change targeting the root causes of pandemic distress [31]. Only by doing so can we heal the damage done by COVID-19 to healthcare workers and revitalize the ideals and spirit of medical practice. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Purpose of Review This paper is a review of the self-care challenges of the COVID-19 pandemic on the physical and emotional health and well-being of healthcare providers. New self-care practices are presented. Recent Findings Globally, thousands of health care practitioners and staff have been infected; many have died. Research studies reveal that this pandemic has threatened the health of healthcare staff, their families, and communities in many unique ways, such as fear of infecting family (lack of safety at home), moral injury, witnessing the suffering of the "innocent," coping with a problem too big to solve (the enormity problem), and racial trauma. Summary The COVID-19 pandemic has impacted the global population in ways not seen in a century. The unique self-care challenges of COVID-19 while enhancing the symptoms of burnout, i.e., physical, and mental exhaustion, despair, helplessness, and suicidal thinking, need to be addressed directly. This paper offers a new COVID-19 self-care model and approach.

INTRODUCTION Surabaya is one of the big cities in Indonesia, which is in East Java Province. Surabaya is also the most significant metropolitan city in East Java. Its development also influences the population growth process in Surabaya, which is increasing every year. This population growth affects the increasing demand for land in the city of Surabaya for facilities and infrastructure. So its development reduced space for the needs of public open space. (Murniatun, M., Zainal, S. & Idham, M. 2019). Even though it is only a supporting facility, public open space is essential and needs to be considered in development in a big city like Surabaya. The Mayor of Surabaya is committed to developing typical Surabaya tourism, such as village and garden tourism. Surabaya does not have tourist destinations with natural scenery or beaches with beautiful stretches of white sand. Surabaya, East Java, was named the best city in the tourism sector according to the 2018 Wonderful Indonesia Tourism Awards. The city of Surabaya is considered to have commitment, performance, innovation, creation, and leadership in developing regional tourism. This is also not spared from the efforts of the Surabaya city government in managing, utilizing, and preserving every potential that exists, where this potential is strung together to become a tourist attraction. Based on Law number 26 of 2007 concerning spatial planning and Regulation of the Minister of Public Works number 05/PRT/M/2008 concerning guidelines for the provision and use of green open spaces in urban areas, it is stated that it mandates explicitly the need for the provision and utilization of green open spaces whose proportions are determined to be at least 30 (thirty) percent of the total area of the city. Green Open Space (RTH) is part of the open spaces of an area filled with plants, plants, and vegetation to support direct or indirect benefits generated by green open space in the area, namely security, comfort, welfare and beauty of the area. City parks are part of the city's green open spaces. Its existence has the meaning of securing natural ecosystems that significantly influence the existence and survival of cities. (Suyono, R. Hamdani Harahap, & T. Alief Aththorick. 2017). City parks are also widely used by the community to carry out various passive activities. Therefore the function of city parks includes the function of green open spaces in general, the existence of city parks is essential in an urban area, mainly because of its functions and benefits in improving and enhancing the quality of the urban environment. (Exacty Pradana, A., & Maulidy Navastara, Ardy. --- 2018). Bratang Flora Park is part of the Surabaya City Green Open Space and can be said to be a means of public space. Green Open Space aims to maintain the harmony and balance of urban environmental ecosystems, create urban balance, and improve the quality of a healthy, beautiful, clean, and comfortable urban environment. Not only that, but Green Open Space also functions as a safeguard for the existence of urban protected areas, controlling pollution and damage to soil, water, and air, as a place to protect biodiversity and control water management, and as a city aesthetic. This study aims to analyze the public's perception of the social and economic benefits of Flora Bratang Park. --- LITERATUR REVIEW Perception Perception is a process owned by someone in assessing and interpreting an object, event, or relationship -the relationship obtained and the final result is in the form of conclusions about the existence of information and interpreting the message as a whole. (Muniarti, S., Salam, R., & Nuri Amelia, R. 2021). --- Green Open Space Green Open Space is an essential part of the city-forming structure because it has the primary function of ecological support. Green Open Space aims to improve the quality of the urban living environment that is comfortable, fresh, and clean to protect the environment, creating harmony between the natural environment and the built environment that is useful for the benefit of society. (Lestari, Siti., Umar S., & Sahri Alam, Andi. 2016). The benefits of providing Green Open Space are growing freshness, comfort, and beauty of the environment, reducing pollution, and creating environmental harmony. The functions of the existence of Green Open Space are: 1) Become a space where residents can gather 2) Has an aesthetic function 3) Has a planning function 4) Has an educational function 5) Has an Economic function --- Ecotourism Ecotourism is a form of tourism that emphasizes preserving nature, providing economic and cultural benefits for the surrounding community. Ecotourism is responsible travel to natural areas that conserves the environment, supports the well-being of local people, and involves environmental interpretation and education. (Setiawan, H., Purwanti, R., & Garsetiasih.R. 2017). --- RESEARCH METHOD This research was conducted in one of the green open spaces in Surabaya, located in Flora Bratang Park, Jl. Menur, Gubeng subdistrict, Surabaya city, was brought under the management of the Sanitation and Green Open Space Service in Surabaya. The time of research was carried out in May -July 2022. This research is descriptive research with a qualitative approach. Data collection was carried out through observation, interviews, and visits to relevant agencies and using literature studies. Respondents were determined using a purposive sampling method. Purposive sampling was carried out by determining the criteria for the selected respondents, namely visitors to the Flora Bratang Surabaya Park and at least 15 years old. The number of respondents was 50 visitors to the Flora Bratang Surabaya Park. The data analysis technique used is qualitative data. Primary and secondary data were processed using three stages of method analysis and carried out simultaneously, namely reduction, data presentation, and concluding. The measurement scale used in this study is the Likert scale. --- RESULT AND DISCUSSION Community Perceptions of the Social Benefits of Surabaya Bratang Flora Park Bratang Flora Park is one of the parks in Surabaya which has the potential to fulfill community rights arising from the presence of public spaces. This can be seen from its strategic location and the diversity of facilities in Bratang Flora Park. Bratang Flora Park's many facilities and strategic location play a role in meeting the community's needs for recreation, economics, social, education, and sports. Many community social activities are carried out in the flora garden, including family, birthday, reunion, and other social events. These activities were carried out in the flora garden by utilizing the pavilion, gazebo, and open land in the flora garden area. From the analysis of Table 1, it can be seen that the average value of the community's perception of the social benefits of the Surabaya Bratang Flora Park is 4.46 or is categorized as very good. This is because the flora park has sufficient facilities for community recreational activities. Besides the location is spacious and comfortable, it is also shady, pretty strategic, and easily accessible to the community. Facilities at the Bratang Flora Park include a pavilion, gazebo, flora/fauna, gardens, reading garden, a prayer room, toilets, and a fountain. With the existing facilities, the community can directly use the pavilion, and gazebo for community social activities, which are free of charge (free). With the facilities that are well cared for and the cleanliness of the park, the community feels comfortable doing activities in the flora garden. With proper planning of activities according to the program, maximum results related to the management of Bratang Flora Park will be obtained. --- Community Perceptions of the Economic Benefits of Surabaya's Bratang Flora Park Public open space itself is a space that can provide recreational opportunities, a natural environment, a place to hold special events, and the lungs of the city (Pebriyandi Suherlan, E., Salampessy, Messalina., & Rusli, Abdul Rahman. 2021). Apart from being a meeting space, interact and a place for other social activities. Even though the benefits can provide benefits that can advance the quality of life of the people or communities living around these public spaces, one of which is that if a public space is utilized, maintained, and managed creatively, it can become a profitable business. Public open space, as one of the elements of a city, can give its character to an area and generally has a function, social interaction for the community, community economic activity, and a place for cultural appreciation. The role of public space in urban planning is as a place for street vendors (PKL) who sell food and drinks. Providing souvenirs and entertainment services also serves as the city's lungs that can refresh. From the analysis of Table 2, it can be seen that the average value of the public's perception of the economic benefits of the Surabaya Bratang Flora Park is 4.31, or very good categorized. This is because the management of the flora garden as a public open space in the city of Surabaya is in great demand by residents as a means of family recreation because of its strategic location and easy access by the community. A good public space is where celebrations are held, social and economic activities are carried out by people meeting each other, and various cultures are mixed. Public open spaces can function as trading areas for traders because of the hectic activities in public open spaces that can accommodate the activities of traders around them. In the Bratang Flora Park, there are also street vendors (PKL) assisted by the Surabaya City Cooperative Service, totaling 40 street vendors who are very helpful for visitors to the Flora Park when they want to buy food and drink, and there are also plant traders in the Flora Park area (Bratang Market). Prices for food and drinks are very affordable for visitors to Flora Park. In addition to the street vendor booths, which are neat and clean, the service is also excellent. With the maximum management of the flora garden, it will become a dance for the community to visit the Bratang Flora Park so that the existence of street vendors (PKL) will be more crowded with buyers so that the economic value for the street vendors will increase and develop more advanced. --- CONCLUSION The level of public perception of the community's social and economic benefits is respectively 4.46 and 4.31, or very good. This is because Batang Flora Park can be a public space for reading, discussing, and entertainment events. Meanwhile, from an economic standpoint, the existence of Flora Park can improve the surrounding community's economy with facilities for traders, most of whom come from the surrounding community. Community perceptions of social and economic values at the Bratang Flora Park Surabaya can be categorized into an excellent understanding. Thus it can be interpreted that the community is aware of the existence and function of green open spaces in Flora Park, which are essential to support the carrying capacity of the surrounding community's social and economic survival.

This study aims to analyze public perceptions of the social and economic benefits of the Bratang Flora Park in Surabaya. This research was conducted in May -June 2022 at the Bratang Flora Park, Surabaya. Data obtained through field observations, interviews, questionnaires, and literature studies were then analyzed descriptively and qualitatively with the help of a Likert scale. The results showed that the public perception of the community's social and economic benefits was respectively 4.46 and 4.31, or very good. This is because Bratang flora park can be a public space for activities such as reading, discussing, and entertainment events. Meanwhile, from an economic standpoint, the existence of Flora Park can improve the surrounding community's economy with facilities for traders, most of whom come from the surrounding community. In addition, the surrounding community shows a good understanding by realizing the existence and function of green open spaces in Flora Park. These are essential to support the carrying capacity of the surrounding community's social and economic survival.

Introduction As of writing this report, the United States Centers for Disease Control and Prevention (CDC) has recommended the use of three Coronavirus disease 2019 (COVID-19) vaccines, with more in development [1]. Vaccination campaigns for COVID-19 will be key in curbing this global pandemic, but must be purposeful to ensure they do not propagate existing disparities of COVID-19 s impact on communities of color. COVID-19 has been particularly devastating to Black and Latino/Hispanic (henceforth: Latinx) communities in the U.S. [2,3]. Long-standing social inequities in social determinants of health place communities of color at elevated risk of COVID-19 infection, severe illness, and death compared to non-Hispanic whites [4]. Therefore, it is imperative to document and strategize how COVID-19 vaccines can be successfully disseminated throughout these communities. Previous research shows that Latinx adults are less likely than non-Hispanic whites to be vaccinated [5,6]. Low perceived risk of influenza and healthcare providers' failure to recommend vaccination may contribute to lower vaccination rates [7]. Compared to non-Hispanic whites, U.S. Latinxs reported more vaccine-related side effects and were more likely to be misinformed about the availability of vaccines [8]. In addition to individuallevel barriers, systemic barriers have been well documented. Latinxs in the U.S. are less likely to have access to health care and more likely to suffer the effects of discriminatory policies, higher healthcare costs, lack of insurance, and language barriers; all of these factors constitute significant challenges to equitable public health efforts [3]. Data on the acceptability of the COVID-19 vaccines among minority populations are limited. However, a cross-sectional survey of a representative sample of U.S. adults found that both Black and Latinx respondents reported lower intent to be vaccinated for COVID-19 compared to non-Hispanic whites [9]. Another nationally representative longitudinal study found that intent to receive vaccination declined between April and December of 2020, with the highest decline observed among U.S. Hispanics [10]. This is consistent with previous findings from the 2009 H1N1 pandemic, which observed that intent to receive vaccination may be highest early in a pandemic before a vaccine is available [11]. With respect to the impact of COVID-19 in Puerto Rico (PR), it is important to highlight the unique socio-political status of PR as a U.S. territory, the economic crisis in 2016, and the devastating force of Hurricanes Irma and Maria in 2017 [12]. Because of these variables, and their ongoing impact in PR, it has been difficult to measure the impact of COVID-19 in PR as well as the overall effectiveness of current vaccination efforts. Current analyses suggest that the number of COVID-19 associated deaths in PR during the pandemic is higher than expected, with the number of COVID-19-associated deaths rising to more than double the numbers originally reported [13]. With the introduction of the SARS-CoV vaccines, it is important to determine variables associated with intent to receive vaccination. Unfortunately, there are no studies to date that have documented intent to receive vaccination in PR against COVID-19. In this Short Communication, we report the factors associated with the intent to receive vaccination against COVID-19 among adults living in Puerto Rico. --- Materials and Methods We conducted an online survey among adults 21 years of age and older living in Puerto Rico to identify social and behavioral factors impacted by the COVID-19 pandemic (21 is the age of majority in Puerto Rico). The data collection instrument was available in Spanish (Puerto Rico's official language) in a secured online platform. The data collection instrument included several measures to assess socio-demographics, respondents' experiences with COVID-19 information sources, perceived impact of COVID-19, and perceived governmental response, and were culturally adapted following a process previously used by the research team [14,15] and integrated previously validated measures [16]. The final survey instrument contained 70 items in total, and skip patterns were included to reduce burden among participants. Intention to get vaccinated against COVID-19 was assessed asking, "If there existed an approved vaccine to prevent the coronavirus infection, how likely is it that you would get vaccinated?" followed by a 4-point scale (not at all likely to very likely). Respondents were recruited using social media platforms and with the support of several community-based organizations that sent blast emails and posted study information on their websites and social media from 7 July 2020 to 13 July 2020. After screening and providing consent to participate, a total of n = 1031 respondents completed the survey. All research procedures were approved by the Human Research Subjects Protection Office of HIDDEN FOR PEER REVIEW. Of the 1031 participants who completed the survey, two participants were excluded for incomplete data, leaving 1029 survey responses in the dataset. A total of 1016 responses were available for analysis from respondents who reported their intention to get vaccinated for COVID-19. The intent to receive vaccination was then dichotomized to maximize the number of participants in each category. Risk factor count was calculated as the number of the following factors: diagnosed with heart disease, respiratory illness, cerebral illness, diabetes, kidney disease, cancer, or age ≥ 65 years old. Health regions were derived from self-reported postcodes. All measured variables were selected a priori to be analyzed independently for association with intent to receive vaccination using Chisquare tests for categorical variables and t-tests for continuous variables. Variables with significant association and variables selected a priori (perception of government response and overall impact of COVID-19) were included in the multivariate logistic regression analysis. Adjusted odds ratios and their p-values for the independent variables were reported. The significance level of all analyses was at α = 0.05. All analysis was conducted with SAS 9.4 software. --- Results Respondents had a broad distribution of demographic and socioeconomic characteristics (Table 1), with a mean age of 46 years old and 73% identifying as women. In the bivariate analysis, younger age, higher education, pre-COVID-19 employment, male sex, gay/bisexual identity, and single marital status were all associated with increased intention to be vaccinated. Increasing numbers of risk factors for poorer outcomes from COVID-19 (i.e., aged 65 and older, comorbidities) were not associated with vaccine intention. No significant relationship was observed between pre-COVID-19 employment, sexual orientation, and marital status and intent to receive vaccination after adjustment (Table 1). However, younger, male respondents, and those with higher educational attainment, reported higher intent to receive vaccination. Respondents who had a yearly income of $50,000 or more had significantly higher intent to receive vaccination (POR = 2.4, p = 0.0096) than those who earned less than $10,000. Respondents living outside of the San Juan metro region had significantly lower intent to receive vaccination when compared to respondents who lived in the metro region (POR = 0.647, p = 0.0082). Respondents who were less likely to get vaccinated expressed less worry about the impact of COVID-19 and perceived the Puerto Rican government's response to be deficient. Respondents who reported a high degree of confidence in one's ability to evaluate the credibility of information about COVID-19 reported higher intent to receive vaccination (Table 2). National and international health organizations (World Health Organization, Centers for Disease Control and Prevention) were identified as the most reliable sources for COVID-19-related information for respondents with a high likelihood of getting vaccinated (75%), followed by healthcare professionals (70%) and news programs (51%). While these sources were also selected as the most reliable among respondents with a low likelihood of vaccination, healthcare professionals and national/international health organizations were trusted at significantly lower rates than those intending to vaccinate (59% and 56%, respectively). --- Discussion These results, which are part of a larger survey created to evaluate the impact of COVID-19 on people living in Puerto Rico, provide insight into vaccine acceptability and intent to receive vaccination amongst the respondents and may be useful to current vaccination efforts in Puerto Rico and the U.S. Although the total number of risk factors for poor COVID-19 outcomes was not associated with intent to receive vaccination, decreased intention observed among older respondents is troubling. Several limitations should be considered when interpreting the findings of this study. As mentioned previously, vaccine acceptability tends to decrease over time following the onset of a pandemic, and responses from July of 2020 may overestimate intent to receive vaccination. Moreover, the item assessing intent to receive vaccination was posed in a hypothetical manner as no vaccine was yet available. As such, perceptions and intentions may have changed since that time, in particular with regards to media coverage of different vaccine manufacturers and vaccines currently approved or in development. Further, the study used a convenient online sample of adults. This may have led to self-selected participants who had access to the internet and were interested in the topic. Despite these limitations, this was the best approach to capture information during the stay-at-home orders that were in place at the time of data collection. Lastly, it is possible that confounding factors not collected by the survey instrument such as religion or health literacy may have additional effects on intent to receive vaccination. --- Conclusions These findings highlight the importance of considering sociodemographic characteristics identified with low intent to receive vaccination when designing public messaging related to increasing COVID-19 vaccinations. In particular, older individuals earning less than $50,000 a year and those living in rural areas may be at particular risk of not being vaccinated. Furthermore, in light of reported perceptions of the government's response to the COVID-19 crisis, communication initiatives should consider efforts to promote vaccinations via trusted sources of information, particularly among those who are less likely to get vaccinated. Communication campaigns may benefit from using established guidance from the CDC and WHO, and by being delivered by local healthcare professionals and through news outlets to ensure success. --- Data Availability Statement: Data are available upon completion of a data sharing agreement with the principal investigator, Carlos E. Rodriguez-Diaz. --- Funding: The work of Juan Pablo Zapata was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through grant numbers UL1TR001436 and 1TL1TR001437. The research presented in this paper is that of the authors and does not reflect the official policy of the NIH. --- Institutional Review Board Statement: The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board of the University of Puerto Rico Medical Sciences Campus (Protocol #: A9650220; approved 7 July 2020). Informed Consent Statement: Written informed consent was waived due by the Institutional Review Board under Exemption 2: Research involving the use of survey procedures recorded in a manner in which human subjects are unable to be identified and in which any disclosure of the human subjects' responses outside the research context could not reasonably place the subject at risk of criminal or civil liability or be damaging to the subjects' financial standing, employability, or reputation.

We conducted an online survey among adults in Puerto Rico to identify factors associated with the intention to receive vaccination against COVID-19. Sociodemographic variables were analyzed independently for association with intent to receive vaccination. Significant associations were included in the multivariate logistic regression analysis. A total of 1016 responses were available for analysis. In the bivariate analysis, younger age, higher education, pre-COVID-19 employment, male sex, gay/bisexual identity, and single marital status were associated with increased intent to receive the vaccination. In the multivariate logistic regression, younger, male respondents, and those with higher educational attainment reported higher intent to receive the vaccination. Lowerincome and living outside the San Juan metro region were associated with lower intent to receive the vaccination. National and international health organizations were identified as the most reliable sources of information, followed by healthcare professionals. These findings highlight the importance of considering sociodemographic characteristics and using trusted sources of information when designing COVID-19 vaccination public messaging.

FULL ARTICLE: --- Context Australia and Scotland (where the authors of this commentary live and work) have rural populations of 29% and 17%, respectively . Rural communities in these countries will be the most impacted by climate change, as well as the cities of Brisbane and Edinburgh, whose built environments will also be unduly affected by sea level rise . In Australia, the regional areas of the Central Coast in New South Wales, the Sunshine Coast in Queensland, and Greater Shepparton in Victoria are set to experience the highest degrees of hardship due to predicted increases in forest fires, coastal inundation and riverine flooding . In Scotland, warmer and wetter conditions are predicted to bring major inland and coastal flooding, increased coastal erosion, but also alternating drought conditions for rural farming communities. More generally, disruptions to natural habitats and ecologies alongside rising temperatures and unliveable heat are anticipated to bring new and related challenges to both human and non-human communities . Surprisingly little research has been conducted on the influence of climate change on mental health . One notable exception is the work of Helen Berry and colleagues who, for more than a decade, have been drawing attention to the need for an overarching framework that incorporates multidisciplinary perspectives. As Berry and colleagues argue, the relationship between climate change and mental health is not a straightforward, linear one , but rather a complex web of interactions that require a systems approach to research and intervention -from large-scale epidemiological studies to groupbased community interventions. For these researchers , the starting point for future research on climate change and mental health is an appreciation that relationships between people and their environments operate at different scales, from individual to collective and from local to global. Ironically, this purview also defines the academic discipline of human geography, of which social geography is a part . In this commentary, we (re-)introduce social geography to rural and remote health researchers and practitioners as we did in a commentary in this journal in 2008 . While the past decade has seen the uptake of social geographic perspectives by rural mental health researchers, particularly in Australia , this understandably takes time. In the context of a global climate change emergency, however, we would like to prompt a re-visiting of what social geography has to offer rural mental health at a time when thinking and doing things differently could not be more important. --- What is social geography? The origins of social geography as a subdiscipline of human geography have been traced back to the late 19th century. According to the International Encyclopedia of Geography, social geography 'focusses on the relationship between society and space, with particular emphasis on issues related to social identity, nature, relevance, and justice' . Throughout most of the 20th century, social geography was concerned with cultures of inclusion and exclusion; that is, how societies were spatially distributed in ways that meant that some groups were advantaged while others were marginalised. Of special interest were issues of gender and sexuality, class, race and racialisation, the geographical displacement of migrants and refugees, and disability (including mental illness) . In terms of rural mental health, social geographers have argued that characteristics of rural communities -such as a culture of self-reliance, a lack of anonymity, rural gossip, and social proximity in general -create barriers to helpseeking and care for people with mental health problems living in these areas . Social geography has developed over time to take up new perspectives and explore new challenges. One of these is identity. As a concept, social geographers now regard identity not as predetermined or fixed but instead something that continually evolves over time through interactions with the environment . This has developed into an area within the discipline known as 'more-than-human' or 'hybrid' geography in which the term 'social' is understood to comprise not just human but also nonhuman entities. As such, the natural world is not 'out there' to meet human needs. As humans, we affect the world at the same time that the world affects us in mutually dependent but also mutually constitutive ways. We are 'of the world' and so our thoughts, feelings, and behaviour simultaneously affect and are affected by what happens in the world. This concept is of particular relevance to climate change as a consequence of the Anthropocene but is also useful in understanding the relationship between climate change and mental health. --- Issues --- Earth emotions and ecocultural identity Over the past decade, a new literature of human emotion has emerged from interdisciplinary engagements across the sciences and the humanities , including collaborations between human geographers and neuroscientists . These collaborations challenge two enduring misconceptions: first, that emotions are primarily internal, private experiences and, second, that neuroscience is a study of the brain in isolation from the rest of the body . In both cases, there has been an increasing appreciation across several academic disciplines that as 'feeling bodies' we are responsive to the social, cultural, political and ecological circumstances within which we live and operate. In other words, our mental health -in fact, our health in general -is co-dependent on the health of the natural environment . As such, chronic impacts on the environment due to climate change are thought to give rise to specific earth-related emotions . What they ascertained through a formal impact assessment process is that people living in this area were suffering from a kind of trauma related to the chronic deterioration of their natural environment. Experienced as desolation or melancholia, Albrecht refers to this syndrome as solastalgia and argues that it is a similar feeling to nostalgia (or homesickness) but is instead emplaced -an experience of the loss of a place while still living in that place. This is different from, but related to, the concept of ecoanxiety -a sense of impending disaster or doom in relation to the natural world. Both solastalgia and ecoanxiety have been recently recognised and adopted by the American Psychological Association . Just as collaborations between academic disciplines have helped develop a vocabulary of earth-related emotions, so too have they worked towards a better understanding of psychological wellbeing in relation to climate change. One concept that has proved useful in this regard is ecocultural identity. Scholars in this area created the concept to challenge the Western idea of identity as something that is possessed by a person. Ecocultural identity is not an object but an overarching relation that considers the human 'self' to be always connected to the 'more-than-human' world . As with all identities, ecocultural identity can be positive or --- Lessons learned The hallmark of geographical thinking is that, as humans, we are not separate from the world but embedded relationally within it. Understandings of 'the social' that limit this to a category of solely human interaction perpetuate the false dichotomy between humans and nature that underpins the climate crisis. We would like to suggest that in order to fully apprehend and address the impact of climate change on the mental health of rural communities, we need to extend what 'social' means. Society is a collective coexistence not just between humans but also between humans and the rest of the natural world. While climate change can and will affect the mental health of rural communities, positive ecocultural identity may well prove to be an important protective factor. As social geographers, we urge rural mental health researchers and practitioners to recognise how both human mental health and climate change are relational states. We suggest that a climate change agenda in rural mental health scholarship might seek to interrogate our geographically differentiated psychoterratic futures, particularly with a view to identifying and cultivating empowering connections between people, nature and place. REFERENCES:

The objective of this commentary is to suggest ways in which current and future research on climate change and rural mental health can be enhanced by social geographic perspectives. As the effects of climate change escalate, the mental health of rural and remote communities will be placed at increasing risk. As such, it is imperative that academics and practitioners recognise the value of multidisciplinary approaches to tackling this issue. Issues: As social geographers, the authors of this commentary outline concepts from their field that they find helpful in understanding the relationship between people and places, and how these relations give rise to emotions that are responsive to environmental conditions. Lessons learned: Ultimately, the authors would like to prompt a re-thinking of 'social' as a category, which is usually confined to interpersonal interactions between humans and suggest a broadening of the concept to include both human and non-human worlds. Rural and Remote Health rrh.org.au

To the editor: Since the outbreak of the SARS CoV-2-virus in China, a vast number of unprecedented political initiatives have been undertaken internationally to keep the pandemic under control. 1 People all over the world have been exposed to increasingly unsettling news, and lately also unparalleled incursions into their lives. In Germany after a period of restraint, federal governments announced the shutdown of educational institutions on Friday, 13 March 2020. This was the first direct encroachment onto the lives of a large part of the population. German borders were partially closed on 15 March. The following day, German Chancellor Angela Merkel, among other leaders, appealed for solidarity and compliance with medical recommendations by a long awaited public speech (unprecedented television address), whereas other international leaders repeatedly also used Twitter. 2 Finally, on 22 March, the government announced a prohibition of contact, which largely bans gatherings of more than two people in public spaces. The political effects of the COVID-19-pandemic are unprecedented, as are the psychological. However, how do people cope with these changes and implementations, as well as the spread of the virus as such? We launched a survey to ask respondents about the level of threat they perceived, their trust in governmental interventions, their level of general anxiety and depression, their safety-related behavior (i.e. buying groceries), and how they evaluate virus-specific hazards. Running the survey over that acutely critical period of 2 weeks allowed us to investigate developments over time from 10 to 24 March (Fig. 1). From the first day onwards, COVID-19-related fear, as well as safety behavior, show a clear upswing with a peak 1 day after the announcement of governmental restrictions and curtailment of individual freedoms. COVID-19-related fear peaks a second time 1 day after the Chancellor's speech. Trust in governmental interventions to reduce the spread of COVID-19 increases from the day of their implementation onwards. A rising tendency is also shown for anxiety and depression. This suggests that concern about COVID-19 could cause more disconcertion alongside psychopathological manifestations. Slight upward trends can be seen for respondents' evaluation of the risk of catching the virus, of suffering complications and of dying from it (if diseased). In addition, the reported risk of suffering complications and the risk of dying from COVID-19 peak on the day after safety policies were announced, possibly demonstrating a top-down regulation of risk evaluation under stress. 3 Besides illustrating the indubitably increasing concern regarding the spread of COVID-19, insights are three-fold: people are profoundly disconcerted by the COVID-19 outbreak, and this might even reach a critical threshold. In this case, establishing emergency infrastructure for people suffering from withdrawal and psychological disconcertion is crucial. 4,5 Second, the level of trust in governmental policies is gaining ground, not only via social media but all along with public speeches. Third, the subjective perceived risk is overestimated compared to existing incidence rates, 6 which might be a result of the feeling of threat. The public concern about COVID-19 needs to be acknowledged by an explicit information policy. 7 --- Conflict of interest We have no competing interests.

At a time of growing governmental restrictions and 'physical distancing' in order to decelerate the spread of COVID-19, psychological challenges are increasing. Social media plays an important role in maintaining social contact as well as exerting political influence. World leaders use it not only to keep citizens informed but also to boost morale and manage people's fears. However, some leaders do not follow this approach; an example is the German Chancellor. In a large online survey, we aimed to determine levels of COVID-19 fear, generalized anxiety, depression, safety behaviour, trust in government and risk perception in Germany. A total of 12 244 respondents participated during the period of restraint and the public shutdown in March 2020. Concurrent with the German Chancellor's speech, a reduction of anxiety and depression was noticeable in the German population. It appears that, in addition to using social media platforms like Twitter, different-and sometimes more conservative-channels for providing information can also be effective.

Introduction This article aims to explore the issue of objective position and the influence of people's stereotypes on things. To understand these problems, it is necessary to find examples from the following cases to explain. Not long ago, there was a late-night attack at a barbecue restaurant in Tangshan. After the incident, it was once hot search, and the evaluation and public opinion were shocked. There are two points raised in these questions. First of all, the problem of stereotyping which is the underlying social context [1]. Whether or not should women go out in the midnight and wear naked clothes and fight back but without any strength [2]. And the freedom to dress and travel, within reasonable and legal limits. Stereotypes are ideas that have been held for a long time, that many people agree with, but that don't have a definite answer. In today's environment, stereotypes play a role, and they appear in many comments. It shows that stereotypes have an impact on the discussion of things, there is a negative impact, and the stereotype makes people have different positions, so that there is a phenomenon of public outcry. In today's fledgling society, stereotypes are hard to change. In general, this paper hopes that stereotypes will gradually become rational and effectively controlled, and eventually people will have a more comprehensive understanding of things. --- Theoretical Foundation Gender positions are widespread, but gender equality is not. It is not common in the home and workplace, from ancient times to now. In family scenes from ancient times to the present, women have been stereotyped that they should not leave their families to start work, but stay at home for cleaning, sorting, cooking, child care and other housework to "serve" their husbands and children returning from work without growing up. Such cognition solidifies women into family nannies, cooks, maternity sister-in-law and unemployed people in the practical sense, losing their economic status and social ability as normal people. Women pay great physical and mental work, but are often crowned with some negative labels and titles. For example, when given words that describe poor personality, teenagers tend to associate them with women [3]. Similarly, men are convinced that they should work hard outside and even lose personal space, time and even health to support their family. Until today, some stereotypes still exist, such as "a girl to read so many books useless, or early married life a fat boy the most satisfactory", "girls should wear conservative behavior restraint", "if something bad happens to a girl, then must be because the girl's fault", "the man should earn money, should be strong, should like and pursue the car house rather than pink", "even if the ability is not outstanding, but have more career promotion opportunities than women as men deserve" [4]. But in fact, this old patriarchal idea and its remaining stereotypes about gender are unfair to either gender, depriving the social roles of women and the male family roles [5]. Take gender-related ideas such as gender social theory as an example, different groups have different positions and different interests under the backward ideas. When the society demands progress and requires them to rise and die out at the same time, conflicts will inevitably appear [6]. When one tipping point appears, and the emotions of a certain group are aroused in an instant, there is a war with another group and the deep-rooted stereotypes behind it [7]. Such wars are especially easy to expand and intensify, when contemporary mass communication is highly developed and everyone can gain a voice through social platforms [8]. Interests, stereotypes, hate speech, dehumanization and other factors are highly likely to evolve into extreme unrest in political and economic life. --- 3. Case Study --- Case Description At 2:00 a.m. on June 10, 2022, a man was refused to accost a girl in white in a barbecue shop and became angry. To eliminate embarrassment, he angrily slapped the girl's face. Consequently, another girl at the same table stood up to speak for the girl when she saw that the situation was getting worse. However, as a result, the man became more and more angry. With the increasing noise, the man's partner rushed to join the fight and beat up the three girls who ate barbecue with the initial girl. During the fight, the man dragged the girl in white out of the shop with her hair, kicked her face with his foot several times, and even smashed her head with a bottle of wine. The man still swears until he is forcibly pulled away and the girl who was beaten was seriously injured and sent to the hospital. Two days later, the success of 10.183 million made the whole event known to all, and the following hate speech, attacks or diminishes which incites violence or hate against The International Conference on Interdisciplinary Humanities and Communication Studies DOI: 10.54254/2753-7048/5/20220728 groups, based on specific characteristics such as physical appearance, religion, descent, national or ethnic origin, sexual orientation, gender identity or other, was indeed mixed with the speech of concern. --- Case Analysis In the Tangshan beating incident selected in this paper, the female voice is always ignored. During the occurrence of the event and the subsequent fermentation process, it can be found that the sadness, despair, fear, anger and other emotions of the female group are greatly caused, while the male group is slightly weaker. In a state dominated by extreme emotions, most women are excited to speak online about fear, gender inequality, and other properties. This increases the anger of the men over indiscriminate attacks, and also gives a small group a seemingly reasonable excuse to stop and erase the discussion of gender issues. As the vested interests, the group do not allow and recognize the existence of gender problems. There is a phenomenon t9hat all women discuss gender, but this discussion cannot be involved and allowed by all men. Some men were even pleased that it was "a wake-up call to feminists". In the statistics, the positive mood even accounted for 9% see (Figure1). Figure 1: "Tangshan Barbecue Shop Heat People incident" Sensitive Information [9]. In fact, the incident triggered the unique sense of fear and powerlessness brought to women due to the inherent factors such as different physical quality, psychological activities and life experience between men and women. So behind this incident is a social issue that is closely related to gender, group stance, stereotypes, hate speech, and even mass communication, and that cannot be ignored. In fact, it is not fair to classify all men as potential perpetrators, which is undoubtedly a gender-opposed hate speech, but the condition that being dominated by extreme emotions should also be taken into account [7]. After excluding the emotional factors, the rest is a small number of people who do not recognize the discussion of gender. These group want to erase all the discussion with the belief that men have more social value than women, that women should naturally be subordinate to men, that the suppression from men to women is reasonable, and that men should be more angry than the fear that women are beaten and abused. Not only being a modern manifestation of backward patriarchal thought, the value is also a counterexample of social gender theory [5][6]. And subconsciously, the group believe that women should be weak and should not resist. The scene was used by some people to ridicule the group of women as "female boxers" -a word that insults feminists (Hubertine Auclert of La Cito yenne who first proposed that it means women's struggle for equal rights) because the pronunciation of the two words is very similar in Chinese. However, Feminism is closely related to gender and gender is closely related to politics. As a political force as it cannot be ignored on the social stage, the trend to redefine the lives of women will sweep by them, thus shaping a sense of political activism [10]. --- Discussion Attack in the northern city of Tangshan, most people would be in the news for this case obvious female voice in the group, and sometimes focuses on the feminist views shake and some men's social status to be threatened, break the balance of a speech is always damage to the interests of a group. Some men are annoyed that they are attacked by the perpetrators in the news, and some men who have always retained traditional ideas are attacking the balance of feminism and male power through this event, because it threatens their social status and survival level. In this case, women complained about unequal gender discrimination and unequal treatment for the sake of the "girls help girls" doctrine. Women view the news event for equality, while men tend to distort the news by touching their own interests. This unhealthy value is a performance of enjoying arrogant privilege about gender. Most men vent grievances by holding up the banner of "women's rights as women's fist". As an unevolved legacy of the past, some men agree that they are higher ideological than women, and thus cannot tolerate humiliation, criticism and censorship from women. --- Conclusion The gender position is universal, yet, the gender equality position is not common. The existence of stereotyped influence makes women lose their economic status and social ability as normal people. Similarly, men in this kind of cognition are also solidified to think that they should work hard outside, and even it is reasonable to lose personal space, time and even health to support the family. Subsequently, this ancient patriarchal ideology and its remaining gender stereotypes are unfair to any gender. It deprives women of their social roles and men of their family roles. In this new media era, the characteristics of the mobile Internet, such as real-time transmission, fragmented scenes and multi-directional interaction, have technically given citizens the right to express themselves publicly, but at the same time, the Internet has also become a noisy public opinion field. Interests, stereotypes, hate speech, dehumanization and other factors are likely to evolve into extremely restless factors in political and economic life and expand and intensify on the Internet. At the same time, many news media were criticized for weakening the bad behavior of the perpetrators because of the use of such "neutral" words in their reports, which caused doubts and dissatisfaction.

Some stereotypes about gender still exist in today's society. Backward ideas lead to different positions and benefits of different groups. When society requires people to progress and at the same time requires them to improve or vanish, conflicts will inevitably arise. In addition to disturbing the normal order of public opinion, it will divert people's attention from the event itself and bring about secondary disasters. However, many people do not allow or acknowledge the existence of gender issues because they are vested interests in this ideology. This article uses the method of case study to analyze the gender inequality caused by this stereotype. Additionally，the factors caused by stereotyped influence are very likely to evolve into extremely restless factors in political and economic life and expand and intensify on the Internet. Consequently，this has formed an extreme social mentality, led to excessive venting of social emotions, and brought negative effects to social harmony.

Introduction Sex education is a controversial topic in the whole world. Do teenagers need sex education? In Asia countries, most parents won't discuss sex with their children because it is too sensitive for adolescents. For instance, the sexual values and behaviors of young Chinese people have changed significantly since the country's opening up and reform: the youth's sexual behavior and their comparatively limited sexual knowledge cause a great deal of trouble. For instance, among young people, the low rate of contraceptive use (32.3% among unmarried women) has contributed to a high rate of induced abortions (28.13%) and unmarried pregnancies [1]. In the last few years, the problem of Child sexual abuse (CSA) has received growing attention in China. Also, if there is no good sex education for teenagers or parents don't keep up to date with what their children know about sex, they may face more severe problems such as CSA. According to a meta-analysis of 27 studies, Chinese females reported lower. Still, total CSA rates (15.3%) are not significantly lower than are estimated to occur internationally, and males reported substantially higher real CSA (13.8%) than in the international composites [2]. But in other nations, such as the United States or several European countries, schools provide pupils with a variety of sex-related activities or tiny counseling clinics. Allow students to freely ask questions about their bodies or safe sex out of curiosity. This healthy education benefits students' health in a variety of ways. Such as postponing sexual intercourse initiation, increasing their usage of protection, specifically condoms, and having fewer instances of unprotected sex [3]. This paper compares sex education in Chinese adolescents and U.S. adolescents in three different fields: schools, parents, and governments. --- 2. Analysis of the importance of adolescent sexuality education --- Importance of school sex education for adolescents Adolescents go through increasingly intense experiences with sexual development as they go through the phases of puberty, establish closeness, and exchange sexual thoughts. Sexual development is understood to be a multifaceted process [4] Schools should connect students to sexual health and other health services at school or in the community and foster positive relationships between adolescents and essential adults [5]. Take this study as an example: there is no significant difference in the attitude of male and female teachers toward teaching sex education in Federal government colleges. Teachers have observed that students experience many changes during adolescence and thus manifest behaviors that are anti-social and damaging to their general well-being. So they will do some work for students to avoid those bad habits. Some of the teachers have worked at the school for a long time and have grown familiar with the behavioral patterns of teenagers, as well as their concerns about how they look and their desire to try new things. As a result, they recognize the need of providing them with useful information for a healthy development [6]. Experienced teachers from international schools can devise effective programs to safeguard pupils against sexual cognition deficiencies. What do Chinese teenagers look like in school when they are exposed to sex education? According to the Medical Ethical Committee of Peking University Health Science Center, the data came from a cross-sectional study of Chinese junior high school pupils [7]. A convenience sample strategy was used to conduct a sex education survey within a school environment due to the potential for controversy and a high rejection rate. With the support of school administrators or by reaching out to individuals linked with the local education or health sectors, the survey invited all kids inside the school to participate. The most popular sex education topic was "mental health during puberty", with "reproduction and contraception" coming in last, presumably due to parental guilt. However, evidence suggests that sex education, including knowledge of reproduction and contraception, might positively influence behaviors that prevent undesired pregnancy. As a result, China should adopt a comprehensive schoolbased sex education curriculum that covers reproduction and contraception information to raise gender equality awareness and reduce school bullying. --- The importance of parents for their children to learn about sex education When people discuss sex education with teenagers, the first thing that comes to mind is the parents, who are the people closest to their children. And parents play an essential role in delivering sex education to their children. However, due to the sensitive nature of the subject and their ignorance of sexual topics, the majority of Asian parents are hesitant to have frank conversations with their kids about sexual concerns. Take the example of adolescents in Iran; there are two scenarios, which are nothing more than the cooperation between parents and the school or the encouragement of parents to actively participate in the discussion of sex education because the home environment will influence the children's thinking about sex education. They dare to explore or ask questions. There were six main themes in how Iranian parents taught their boys about sexuality: • Strict control and restriction. • Trying to build peace and tolerance. • Criticizing cultural taboos. • Doubt and confusion. The idea of "transition from tradition to modernity" came from these groups. Also, thorough monitoring, limiting access to sexual information, and not knowing what will happen are the two worst examples of this. Using quotes from parents, "I know that he watches some things on his phone sometimes". His mother has also seen him a few times and scolded him severely. "We haven't talked about sexuality because he doesn't like talking about small things!" I also didn't think he had to talk about sexual things with him. When kids asked their parents about sexual things, most parents kept quiet. Most parents felt unprepared or unsure about how to have healthy conversations with their children about sexuality, but they were open to learning more. "What a strange muddle! I have moments of desperation! Do I need to argue with him? Or have her confiscate his mobile device. Maybe disconnect the home network? That girl, should I find her? In my perspective, these are not the solution. No idea what to do here!" These are the words of a father. There is a conflict between religious tenets and the demands of modern life for Iranian parents. They explained that they didn't know how to balance tradition and progress and that spiritual teachings didn't apply to everyday life. Parents' perspectives on sex education for their children reveal an optimistic current of change from tradition to modernity. Parental concerns have been found to include doubts about sexual education's value and a lack of clarity between traditional religious teachings and contemporary sexual mores. They hoped that keeping the peace with their kids would encourage them to follow the family's morals and principles. And the evidence for culturally responsive educational interventions for parents to improve their skills and knowledge regarding sexuality education. Parents transitioning from tradition to modernity will be more equipped to handle these issues [8]. --- The government should make teenagers learn sex education correctly Preventing young people from coming into contact with sexual content is nearly impossible. A father from Iran expressed his concern that his children were exposed to explicit sexual information on their smartphones. Teenagers now devote considerable time and energy to their technological devices and social media sites. They run the risk of being exposed to adult content, fraud, and unwanted sexual messages from strangers at any time and in any place. A teen's developing sense of sexuality and susceptibility to harm might be affected by events like these. As a result, the government must take the necessary steps to improve the internet ecosystem. It will be three years since Relationships, Sex, and Health Education (RSHE) lessons became required in all English schools. In 2023, the government will look over its advice on RSHE. But a study released yesterday by the Sex Education Forum shows troubling holes in RSHE. Many young people are still not getting the promised high-quality curriculum, and there is a gap between the promised investment and the help teachers are getting on the ground. The review gives us a chance to fix this terrible mistake. The risks our teens and young adults face now have never seen before. Worries about how young people can find harmful material online have grown. A recent study from the Children's Commissioner found that 79% of 11-year-olds had seen violent pornography, and 27% had seen pornography. A higher frequency of pornography use is linked to a higher likelihood of sexual violence, and teens' unrealistic standards are being skewed by their easy access to violent and explicit sexual content online. Even worse, it's linked to long-lasting physical and mental harm for a lot of young people [9]. Although not explicitly dedicated to sex education, these particular sections of the school policy and advisory guide do encompass information about sex-related health interventions, prevention, and care for students. As an illustration, they delineate protocols about sexual assault, homophobic harassment, and the involvement of pregnant and parenting pupils within the school community. As an illustration, they trace protocols concerning sexual assault, homophobic abuse, and the participation of pregnant and parenting pupils in school activities [10]. The government conducts real-time oversight of school sex education policies. The organization develops policies in response to various concerns, monitors multiple social media platforms, and implements legislation to safeguard minors to promote order in the digital space. --- Conclusion Sex education is critical for teenagers, and it works best when everyone gets involved-schools, parents, and the government. It is not only about what causes a baby to be born in schools; it is also about helping kids understand their bodies' feelings and how to have good relationships. Furthermore, schools provide a sex program to ensure that youngsters are appropriately sensitized to the value of sex to decrease adolescent pregnancies or prevent adverse effects. Parents play an essential role in sex education. Parents speak with their children, maintain communication with the school, and monitor their children. Parents must also enhance the family atmosphere by allowing their children to discuss sex freely and providing suitable counsel, particularly in extraordinarily religious or feudalistic families. For the sake of their children, they must take this action. The government is in charge of providing correct information to the general public. Establishing rules by appropriate authorities allows for the specification of educational content to be presented in schools, ensuring its accuracy and utility. Teachers must trained to address these issues effectively in the classroom. When adults worked together, they were able to support teenagers in making educated decisions about their health and relationships. And to avoid a high risk of pregnancies and a lower incidence of infections. The goal is to create a cultural framework that values the overall well-being of all persons. Sex education requires a coordinated strategy combining schools, parents, and governmental bodies to guarantee that adolescents obtain the necessary knowledge.

For the rapid development of today's society, schools spend much time on students' education, parents spend much energy on students' academic lives, and the government builds or refurbishes many libraries for students. What we don't realize is that there is a lack of sex education in China and abroad, especially among high school students. Through questionnaires, this paper examines the importance of sex education in Asian countries, like China and other Western countries, from the perspective of parents, schools, and the government. This paper concludes that strengthening sex education in schools, parents' communication, or other ways to improve students' knowledge of sex, and the government policies and measures to enhance the awareness of sex education for teenagers. The goal of this paper is to make the sex education environment in China better and to increase the awareness of sexuality among the youth. They were growing their knowledge about their bodies and relationships, decreasing their risk-taking, and reducing the frequency of unprotected sex.

GERONTOLOGY INTERNSHIPS, PRACTICUM, AND FIELD WORK FROM A FACULTY PERSPECTIVE Rona Karasik, Saint Cloud State University, Saint Cloud, Minnesota, United States While internships, practicum, and field work tend to be viewed primarily as student and site focused, academic faculty are also important to an internship's success. Faculty roles may include assisting students in selecting and applying for site placements, ensuring that students are a "good fit" and properly prepared for a particular setting, overseeing quality control and assessment, guiding students to reflect on and harvest their learning throughout their internship, and at times, serving as advocate, trouble-shooter and/or mediator (Karasik, Donorfio, & Greenberg, 2023). In addition to student-facing responsibilities, faculty are also often involved in curricular aspects of internships and similar experiences (e.g., setting program parameters, expectations, and student learning goals and objectives), as well employing internship outcomes to academic program assessment (Karasik, 2009). Internship faculty also serve as a liaison between the academic program and community partners. Developing and maintaining community partnerships requires a broad skill-set, including but not limited to knowledge of the local aging network, collegiality, diplomacy, cultural and self-awareness, flexibility, and effective communication. Honing and consistently applying these traits is also essential, as recent studies suggest that at least some community partners perceive faculty involvement in community-based learning to be uneven and/or deficient (e.g., Karasik, 2020;Karasik & Hafner, 2021). Given the many roles faculty play in regard to internships and similar experiences, this presentation explores gerontology-based internships from a faculty perspective and shares the reflections and insight of one faculty member who has served as a gerontology internship coordinator for close to 30 years. As has been discussed, the population of older adults is growing at a rapid pace and the need for staff in residential environments has grown to a crisis situation. Agencies are in dire need of staff at all levels from CNAs to nurses, social workers and administrators. There is an opportunity for agencies to help train the new generation of age savvy staff by working with universities to provide hands-on experience such as internships, practicum, and field work. This presentation examines the preceptor and community agency perspective of working with students interested in aging. We explore how to achieve a win/win/win/ win experience (student, preceptor-agency/university/older adult). The presenters represent a agency preceptor and a preceptor-faculty member. Key areas for consideration include: 1) Experience/education of students; 2) Time commitment for preceptors/ agencies; 3) Agency and university support for preceptors; 4) Support for students from preceptors, agencies and the university; 5) Flexibility in responsibilities and scheduling between agencies, preceptors, and students; and 6) Ensuring that the experience is valuable to both students and agencies. Presenters will discuss strategies for meeting the needs of students and agencies while at the same time meeting the requirements of the university. These strategies include student involvement in day-to-day activities, as well as projects, teaching moments, providing support to preceptors as well as on-going communication and feedback. The goal is to provide an environment (both agency and university) that fosters growing an age savvy workforce. Abstract citation ID: igad104.0490 --- TRADITIONAL AND NONTRADITIONAL INTERNSHIPS: A GERONTOLOGY STUDENT'S PERSPECTIVE Jessica VanderWerf, University of South Florida, Tampa, Florida, United States Today's gerontology students are more diverse than ever. Some come to the classroom with little to no experience working with older adults, while others are looking for further education and/or credentials to add to their employment

As the 65+ population continues to grow, so too does the need for an age-savvy workforce. There is not a field or profession that will not intersect in some way with older adults (Karasik, Donorfio, & Greenberg, 2023). Current work shortages and forecasts, however, raise considerable concern for a sustainable and adequately prepared workforce. With regard to preparation, gerontological field placements, internships, and practicums are becoming increasingly instrumental to workforce development. Both the Gerontology Competencies for Undergraduate and Graduate Education (2020) and AGHE's Gerontology and Geriatric Curricular Standards and Guidelines (2021) strongly recommend internship, practicum, and/or field work experiences for students at all levels. Fostering a successful intergenerational experience, however, can be challenging. In this presentation, key components, core elements, necessary steps, best practices and logistical considerations will be discussed. For example, who are the key players and what are their roles in such experiences? What needs to happen at the programmatic and curricular levels? In addition to exploring the various facets of gerontological field placements, attention will be given to utilizing AGHE's Standards and Guidelines and Gerontology Competencies to help identify several "interactional competencies" that relate to internships, practicums, and field experiences. This session also serves as an introduction to the range of perspectives (student, faculty, community agency) that follow.

Abstract Aim: The purpose of the current research was to develop a model of the functions of social networks in the control of the psychological security crisis of the family (the postcrisis phase of the Khuzestan flood case study). This research was done in two parts, qualitative and quantitative. Method: in the qualitative part, by interview and grounded theory method, the components of the model of social network functions effective on the control of the psychological security crisis of the family in the post-crisis phase were categorized into 6 data networks of the foundation, including: The central phenomenon, causal conditions, contextual conditions, intervening conditions, strategies and consequences were categorized. The statistical population in the qualitative part includes academic professors specializing in crisis management and the functions of social networks, as well as experienced experts in the field of flood crisis management in Khuzestan province who are active in this field (such as managers of the crisis management organization). Sampling method in the qualitative part was obtained from saturated and targeted level equal to 20 people. In the quantitative part, the qualitative model presented in the previous part was tested by questionnaire and structural equation method. The statistical population in the quantitative part was the experts and employees of the crisis management organization in Iran. Findings: Sampling in quantitative part was obtained by simple random sampling equal to 384 people. Based on the results of the qualitative section, the identified codes were categorized into 6 main networks, 16 main components and 87 sub-components. Based on the results of the quantitative part, causal conditions with a factor load of 0.588 have an effect on the central phenomenon. The central phenomenon, contextual conditions, and intervening conditions are effective on strategies with factor loadings of 0.515, 0.309, and 0.419, respectively, and strategies are effective on outcomes with factor loadings of 0.558. Conclusion: Based on the obtained results, it is suggested that in the post-crisis phase such as Khuzestan flood, the internet should be provided to the people of the society so that they can receive news and information quickly through social networks. Society must be ready to accept social networks; Therefore, for this purpose, the government should create the necessary culture for using social networks among the people. Keywords: Functions of social networks, crisis control, psychological security of the family

Fear of missing out (FoMO) and rumination mediate relations between social anxiety and problematic Facebook use, Addictive Behaviors Reports, 9. DeWolfe, Deborah J. (Author) and Nordboe, Diana (Editor). (2000). Field Manual for mental health and human service workers in major disasters.

Introduction Interpersonal violence is a contemporary adolescent health problem, and novel research is required to examine its determinants. Antisocial behaviors can be established as early as pre-adolescence or even preschool, and may manifest in various forms of bullying. Bullying is a common problem in the Canadian school system; of particular concern are physical and relational forms of bullying due to their high prevalence among males and females [1]. The physical appearance of children is one of many possible determinants of bullying experiences [1]. An individual's appearance affects how others react and respond to them in social contexts. Internalization of these behaviors could then lead to perpetration of bullying [2]. Analogously, the 'Obesity Stigma Approach' suggests that weight-based stigma places overweight and obese youths at risk of anti-social health outcomes; these findings have been supported by past cross-sectional analyses [1]. We explored the temporal sequence between adiposity status and reports of bullying in a sample of high school students. Based upon prior cross-sectional research [1], we hypothesized that males who are obese at baseline would be more likely to become victims and perpetrators of physical bullying and that obese females would be more likely to be relationally victimized. In theory, increased adiposity would make obese youths targets for physical bullying; however, increased adiposity would also help those involved in physical bullying dominate their peers at key developmental stages of life, possibly leading to increased bullying perpetration. For relational bullying, increased adiposity status poses no advantage, but youths could still be victimized for not meeting physical ideals [2]. --- Material and Methods --- Survey and Study Population Health Behaviour in School-Aged Children (HBSC) is an international survey conducted in affiliation with the World Health Organization [3]. The 2006 Canadian HBSC involved 186 schools and 9,672 students [3]. The Queen's University Research Ethics Board approved the study. Consent was also sought from the school board and each individual school. The study used an active consent procedure for acquiring parental consent, in which parents or guardians were sent letters asking for consent. Finally, the child's consent to participate in the study was acquired. Approximately 74% of students in the sample participated, and only 10% of students declined to participate or spoiled the questionnaire. Other nonparticipants were students who failed to return the parental consent form, who did not receive parental consent, or who were absent on the day the survey was administered. 17 schools in Ontario agreed to a special follow-up study in 2007. Of these, 16 schools were surveyed again in 2007 (one withdrew due to a student death), making 2,031 students available for longitudinal analyses. The present study focused on these 2,031 students: 291 were further excluded based on missing height and weight data (n = 271), no date of birth information (n = 15), or implausible changes in heights or weights (n = 5), leaving a final sample of 1,738 students (85.6%). --- Survey Methods --- BMI and Obesity Classification In order to calculate BMI (kg/m 2 ), heights and weights were provided by self-report. Participating children were classified as normal weight, overweight or obese based on international cut-offs developed by Cole et al. [4]. --- Bullying The HBSC bullying questions were developed originally by Solberg and Olweus [5] and have been shown to provide accurate estimates of prevalence. Children were asked questions about both perpetration and victimization of bullying behavior, with response categories ranging from: 'never' to 'greater than once a week'. As per existing precedents [5], bullying involvement was dichotomized (at least 2 or 3 times per month or not). Two specific forms of bullying were investigated. Physical bullying perpetration was assessed through a single question: 'I hit, kicked, pushed, shoved around, or locked another student(s) indoors.' Two questions were asked about relational bullying perpetration: i) 'I have kept another student(s) out of things on purpose, excluded him or her from my group of friends, or completely ignored him or her,' and ii) 'I spread false rumours about another student(s) and tried to make others dislike him or her.' Affirmation of either or both of these relational bullying questions indicated relational bullying perpetration. Analogous questions were also used to assess victimization by the two forms of bullying for a total of four measures of bullying involvement. --- Statistical Analyses A repeated measures multi-level logistic regression model was employed to quantify associations between adiposity and bullying involvement. This was performed using SAS version 9.1.3 and the PROC GLIMMIX procedure (SAS Institute Inc., Cary, NC, USA). The multi-level model consisted of three levels: i) within students, ii) between students and iii) between schools, and simultaneously accounted for clustering at the school level. Potential confounders included screen time, age, a measure of self-esteem, and socioeconomic status (measured via family affluence score) which were selected based upon prior literature and backwards elimination processes. A descriptive subanalysis was conducted among children who were free of the bullying outcome of interest at baseline. Incident cases of each type of bullying in 2007 were identified and compared with baseline adiposity levels; Fisher's Exact Test was used in these comparisons. --- Results Among males, approximately 2-fold increases in the odds of bullying involvement were observed among obese participants for both physical victimization and perpetration, though neither of these represented significant increases (p > 0.10). A similar effect was observed for the odds of relational victimization among males (p = 0.07). Overweight and obese females reported 1.29 (0.58-2.86) (p = 0.53) and 2.98 (1.03-8.61) (p = 0.04) times the relative odds of relational bullying perpetration respectively, and this trend approached significance (p = 0.06). No other statistically significant trends were identified among females (table 1). Among males who did not engage in bullying at baseline (2006), no statistically significant increases in the incidence of perpetration or victimization (any type) were observed by BMI class. Among females, significant differences were found for relational perpetration, with higher levels reported for obese (14.8%) versus overweight (2.0%) and normal-weight (3.8%) respondents (p = 0.02). --- Discussion This study confirmed that obese males and females experience increases in odds of victimization due to two major forms of bullying. In addition, obese females reported increases in relational perpetration. Our findings are congruent with previous cross-sectional studies [1,6] and confirm that obese children are at risk for social consequences attributable to their standers, and providing support for victims [11]. Targeting those at particularly high risk for bullying involvement may increase the effectiveness of interventions as well as decreasing negative psychosocial consequences of bullying involvement. Particular focus should be paid to school level interventions, using techniques similar to those combating racism and gender discrimination, in order to reduce the prevalence of weight-based teasing. Stigmatizing behaviors directed towards the obese need to be decreased. The promotion of environments where all body types are accepted is one avenue by which this psychologically damaging behavior can be reduced and potentially eliminated. --- Conclusion Interpersonal violence can affect the healthy development of children as they transition to adulthood. Our study demonstrates the importance of physical appearance as a determinant of bullying experiences among Canadian youths. This research adds to the growing body of literature that shows that excess adiposity has consequences beyond direct physical health. --- Human Subjects Approval Statement The Queen's University General Research Ethics Board approved the Canadian HBSC survey protocol. Consent to participate was sought at the school board, school, parental and student levels. --- Disclosure Statement No conflicts of interest declared. appearance, consistent with Lerner's Theory of Planned Behavior, and the Weight Stigma Approach [2,7]. These views about obese children may translate into negative attitudes and behaviors towards them. Our study findings are important as increased involvement in bullying is associated with other forms of interpersonal violence as children grow and develop. Victimization due to bullying can lead to engaging in and being injured from physical fights and weapon carrying for self-defense [8]. Those who do not retaliate directly may still manifest other adverse consequences, including social anxiety or depression [9]. These relationships may have long-term health and social consequences, especially during critical periods of the life course. Important gender differences were observed in our findings. Boys are much more likely to be bullied physically while girls are more typically involved in relational bullying. This may be attributable to perpetrators targeting that which is important to their peer group, with boys valuing physical dominance over their peers and girls valuing close, intimate relationships. Interventions aimed at such differences have shown mixed receptiveness to anti-bullying interventions by gender, with some studies showing no differences following interventions [10] and others favoring either girls [11] or boys [12]. However, clear differences exist in bullying experiences by gender. This study has several strengths. First, the study was longitudinal, in contrast to most existing studies which are crosssectional [1,6]. Second, past longitudinal research has only been conducted in younger children (ages 7.5-8.5 years) [13] and also older adolescents (ages 15-20 years) [14]. Results from all of these research contexts are consistent. Hence, obese youths may face bullying experiences throughout key developmental periods. Limitations of this study warrant comment. The sample size available was small, with few incident cases of bullying occurring. This limited our ability to conduct a conventional cohort analysis. The time period under observation was only 1 year and perhaps had insufficient latency to observe effects. The assessment was based on self-report, and while extensive validation work has been performed self-report bias is still an issue. Our findings may therefore underestimate the true association between BMI status and bullying behavior. These limitations may collectively affect the generalizability of the study to other youth populations. School-based anti-bullying interventions have been shown to be effective overall [10,15], despite gender differences in receptiveness. These interventions have focused on increasing awareness surrounding bullying behaviors, empowering by-

Objective: Obesity can have negative effects in terms of stigma and discriminatory behavior. Past cross-sectional analyses have shown that overweight and obese youths are more likely to be involved in bullying. Here, we examine such relationships in a longitudinal analysis. Study outcomes were self-reports of: i) physical bullying victimization and perpetration and ii) relational bullying victimization and perpetration. Methods: Participants were administered the Health Behaviour in School-Age Children Survey in 2006 and then again in 2007, and included 1,738 youths from 17 Ontario high schools. Relationships between adiposity and each of the four forms of bullying were evaluated using multi-level analyses. Results: Excess adiposity was shown to precede bullying involvement in this study. Obese and overweight males reported 2-fold increases in both physical and relational victimization, while obese females reported 3-fold increases in perpetration of relational bullying. Among those free of bullying at baseline ( 2006), significant increases in perpetration of relational bullying were reported by obese females in 2007 relative to normalweight females (14.8 vs. 3.8% among normal-weight girls; p = 0.02). Conclusions: Findings are congruent with previous cross-sectional studies and confirm that obese youths are at increased risk of social consequences attributable to their appearance.

Introduction: In psychology, the term "adjustment" refers to the behavioral process through which people and other animals maintain balance among their many requirements. Humans have the capacity to adapt to the physical, social, and psychological demands that come with being dependent on other people. The process of adjustment describes and explains how a person adapts to themselves and their surroundings without making any distinctions on the success or failure of the adjustment. It supports achieving desired goals, believing in one's own skills, and controlling basic impulses to manageable levels. Therefore, adjustment promotes self-initiated intellectual, emotional, social, and physical growth and development. Darwin introduced the idea of adjustment for the first time and used it as a strategy for surviving in the physical world. As social beings we live in a society, we form opinions about others and others have opinion about us. Everybody wants acceptance and recognition from and within the society. We try to behave according to the norms of the society so that we can adjust with others. Nowadays, every student adjusts mainly in these three aspects. Every family faces financial problems and other problems. So, there is a necessity to adjust to these situations. Every student should adjust with the school environment, and also follow the rules and regulations of the school and what the teacher taught. There must be need of adjustment with the peer group. A man cannot live in the society without adjustment. Everyone should follow the customs and traditions of our society. At the adolescence stage, the students are facing emotional problems. So, there is a necessity to research how the students are facing emotional problems and how to make them to adjust with the society and school. The issue of students' adjustment has gotten worse quickly, leading to unrest and indiscipline among them and having a detrimental effect on both their academic performance and personal growth. Teenagers who fail to make the necessary adjustments become frustrated and lose their sense of self-worth and confidence throughout their academic careers, as opposed to someone who has made the necessary adjustments and is more determined to face life's challenges head-on and find more inner peace and happiness. The goal of the current study is to assess how well college students are adjusting to their academic lives and to offer decisionmakers and higher education managers with the data they need to improve students' adjustment levels and spur them on to achieve better results. Success is nothing more than the outcome of one's adjustment. Academic success is the result of education and measures how far a student has progressed in reaching his academic objectives. Exams and ongoing evaluation are standard ways to gauge academic success. Academic success can be characterized as excellence in all academic subjects both in and outside of the classroom. Academic achievement is the knowledge or competence acquired in academic disciplines, which is typically determined by test results or instructor evaluations. High academic achievement is influenced by a variety of factors, one of which is adjustment. --- Review of related literature: Velmurugan and Balakrishnan (2011) examined the relationship between the social adjustment and self concept of the higher secondary school students with respect to gender and locality and they found that social adjustment is independent upon gender and locality. The correlation coefficient between social adjustment and self concept is found to be negligible. Winga Maureen Adhiambo, Agak John Odwar and Ayere A. Mildred (2011) investigated the levels of school adjustment and its relationship with academic achievement. The results showed that there were no significant differences between girls and boys in school adjustment, there were significant differences between high achievers and low achievers in dedication, absorption, engagement and school adjustment. Roy and Mitra (2012) examined the pattern of adjustment among early and late adolescent school students. The study revealed that early and late adolescents group differed significantly from each other in the home, health and social areas of adjustment. Girls showed better adjustment than boys. Yellaiah ( 2012) conducted a study of adjustment on academic achievement of high school students. Sample of the study consists of 300 students studying in class IX from various government and private schools, rural and urban areas of Mahabubnagar district in Andhra Pradesh. He concluded that adjustment and Academic Achievement cause significant difference between male and female students, Government and Private Schools students. Joymalya Paramanik, Birbal Saha, Bhim Chandra Mondal (2014), studied the adjustment ability among secondary school students in relation to gender and residence. The study revealed that there is no significant difference between adjustments of students residing either at urban or rural area. Dr.Subhash Sarkar , Sangita Banik (2017), to investigate the adjustment of the student of adolescence period in West Tripura in relation to their academic achievement, age, gender etc. in a sample of 120 adolescents (60 boys & 60 girls). Data was analyzed by using Standard Deviation, Mean, Percentile, t-test, Pearson Product Moment Correlation. The result of the study indicated that there were no significant differences between boys and girls in adjustment and academic achievement in adolescence period. The result also revealed that there was a significant difference among emotional adjustment, social adjustment, educational adjustment and academic achievement in adolescent period. The researcher also found that there exist positive relationship between adjustment & academic achievement of boys& girls in adolescence period of West Tripura District. The study has implications for students of adolescence period, teacher, parents and policy makers as well. G. Pugazhenthi ( 2019), studies the social adjustment and academic achievement of high school students. The population for the present study is consists of 640) ninth standard students are studying in the secondary classes in Thanjavur district of Tamil Nadu. Using simple random procedure from the list of schools the researcher identified 27 schools and 640 high school students from Thanjavur district. The present study found out there is a significant difference in the mean scores of social adjustment between the groups of high school students with regard to gender, medium of instruction, residence of the student, locality of the school and type of family. The present study found out there is a significant difference in the mean scores of social adjustment among the groups of high school students with regard to type of school and fathers educational qualification. Yousef Jahannejadi, Davood Taghvaei, Zabih Pirani (2020), found that there was a significant mediating role of self-efficacy in the relationship between social adjustment and hope with academic well-being in students. --- Title of the study: "Social Adjustment and Academic Achievement of Secondary School Students" Operational Definitions: Social Adjustment: Adaptation of the person to the social environment. Adjustment may take place by adapting the self to the environment or by changing the environment. Secondary School Students: secondary school refers to the schools in Guntur that ranges its classes from 8 th to 10 th . For the present study the research had taken 8 th class students. --- Academic Achievement: "Knowledge attained or skills developed in school subjects, usually designed by test scores or by marks assigned by teachers." At present the definition of academic achievement is attainment of marks in total subjects of the students. Objectives: 1. To find out the social adjustment of secondary school students with respect to the Gender. 2. To find out the social adjustment of secondary school students with respect to the Locality. 3. To find out the social adjustment of secondary school students with respect to the Type of Management. 4. To find out the relationship between social adjustment and academic achievement of secondary school students. Hypotheses: 1. There is no significant difference in social adjustment of male and female secondary school students. 2. There is no significant difference in social adjustment of rural and urban secondary school students. 3. There is no significant difference in social adjustment of Government and Private secondary school students. 4. There is no significant relationship between social adjustment and academic achievement of secondary school students. --- Delimitations: 1. The study is confined to Guntur District only. --- 2. The study is limited to 100 secondary school students only. 3. The study is limited to 8 th class students only. --- Plan and procedure of investigation: The present investigation falls under normative survey method. It deals with clearly defined problems and has definite objectives. The researcher had taken up a random sample of 100 students studying 8 th class in rural and urban areas belonging to the Guntur District. The researcher used the tool questionnaire for colleting the data and the tool consists of 40 questions. --- Analysis and Interpretation of the Data: Hypothesis: There is no significant difference in social adjustment of secondary school students with respect t o Gender, Locality and Type of Management. The mean of the urban students is 77.8 and S.D. is 5.77 and the mean of rural students is 81.0 and S.D. is 5.41 and t-value is 4.05 was significant at 0.05 level. It was concluded that there is a significant difference between the rural and urban students. Hence, the variable Locality has influence on the social adjustment of secondary school studetns. --- S.No The mean of the Government students is 80.60 and S.D. is 5.83 and the mean of Private students is 78.25 and S.D. is 5.62 and t-value is 2.93 was significant at 0.05 level. It was concluded that there is a significant difference between the government and private students. Hence, the variable Type of management has influence on the social adjustment of secondary school studetns. --- Hypothesis: There is no significant relationship between social adjustment and Academic achievement of secondary school students.

Adjustment is a popular expression used by the people in day to day life. It gives peace and harmony in home, school and society. Every human being has adjustment at every stage in his life. That is why the adjustment is natural and also every human being adjust with the environment prevailed in the society. In the same way we have to know that how the students are having adjustment. The main purpose of this study was to find out the social adjustment of Secondary school students. The study was conducted on a sample of 100 students studying 8 th class in Government and Private Schools of Guntur District. For data collection, the investigator had used questionnaire consists of 40 questions, constructed and standardized by the researcher. The collected data was analyzed by using Mean, S.D. and "t" values. Results revealed that there is no significant difference in the social adjustment of students.

Introduction This project was designed to collect and to share information in order to better prepare teachers of Native students. The project gave Native elders an opportunity to record their education experiences in their own words. This study involved five in-depth, in-person interviews with Dakota and Lakota elders between 40 and 70 years old. Elders provided reflections on experiences of past generations, on their own educational experiences, on the preferred learning methods of Native students, and on their visions for teachers" practices and influences on Native children. Data analysis was conducted to identify themes. Stories and comments from elders were organized around those themes. --- Project Goals --- Goals of the project included: To learn more about Native American culture. To prepare better teachers of Native students. To give Native elders an opportunity to record their education experiences in their own words. --- Research Questions This study involved two research questions: a. Why do Native students and families find it difficult to communicate with and to trust public school administrators and teachers? b. What do teachers need to know about past events related to Native students and their continuing impact in order to improve the experience of Native students and families in public schools? --- Significance of the Project Various researchers and reporters have documented the array of experiences that native students had in educational settings between 1879 and the 1930s (Child, 2000;Coleman, 1993;Reyhner, 1992;Spack, 2002;and Wallace-Adams, 1995). Many boarding schools, including the Carlisle Indian Industrial School (in Pennsylvania), were established and youngsters were forced off the reservations. In the 1930s, most boarding schools were closed. Boarding schools were an important part of the American Indian experience. They still are a critical factor in why some American Indian parents find it difficult to communicate with public school system administrators and teachersand even more difficult to trust them… In order to undo the boarding school legacy, it is important for every teacher with American Indian students in the classroom to have an awareness of past events and their continuing impact (American Indian contributions to the world, Retrieved November 3, 2009 from http://www.kporterfield.com/aicttw/articles/boardingschool.html). Although a great deal of writing exists about the history of education of Native students, no recent study incorporated personal experiences of Dakota people in southern Minnesota. David Larsen, Director of American Indian Affairs at Minnesota State University, Mankato, and former chairman of the Lower Sioux Community, reported that movies and textbooks have not accurately presented the Dakota traditional beliefs and experiences with educational organizations (Larsen, 2010). This project was intended to help correct the lack of knowledge among future classroom teachers so that they are prepared to be better teachers of Native students. The project gave Native elders an opportunity to record their education experiences in their own words. This study used grounded theory that allows researchers to review qualitative data and to use inductive reasoning to support conclusions from that data (Corbin and Strauss, 2008;Charmaz, 2000). These ideas were then used to draw conclusions and to form the findings section in this paper. --- Research Design and Methodology This study involved five in-depth, in-person interviews with Dakota and Lakota participants between 40 and 70 years old. The principle and student investigators located available respondents for this project based on convenience samples. Participants in this research included Native elders identified by professors and staff members at MSU, Mankato. Respondents were of Dakota or Lakota membership. --- educational experiences, on the preferred learning methods of Native students, and on their visions for teachers" practices and influences on Native children. First, each interview was transcribed. Then it went through a special process of categorizing the data. This process is called "coding," whereby "[r]esearchers create a conceptual interpretation of the data, impose an order on it, explicate the relationships between categories, and organize those relationships to communicate their ideas to audiences" (Charmaz, 1990). After coding a document one or more times, it was then analyzed further through the use of memos. Memos were used for "…clarifying basic codes and revisiting and fine-tuning methodological issues and procedures" in this research", as well as to layout specific ideas using evidence from the interviews to draw conclusions about what was being said (Loftland and others, 2006). By looking at and committing these "ideas, hunches, questions, and elaborated categories [I] define [d] what is implicit and what is explicit in the data," so that important aspects could be cut out from the less important (Charmaz, 1990). Elders provided reflections on experiences of past generations, on their own educational experiences, on the preferred learning methods of Native students, and on their visions for teachers" practices and influences on Native children. Data analysis was conducted to identify themes: racism, teaching values, incomplete histories, and language recovery. Stories and comments from elders were organized around those themes. --- Past Generations Personal Educational Experiences All five of the interviewees provided examples of negative educational experiences that they attributed to being Dakota. For example, Gwen told about her childhood experiences when teachers would not correct or reprimand students who called her bad names and denigrated her skin color and hair color. --- Preferred Learning Methods --- Visions for Practice One of the elders presented a set of seven principles for living true to the Dakota culture. These seven principles summarize the themes that were identified in the project interviews. They also provide some ideas about behaviors and values that teachers might incorporate into their classroom values. 1. Woinina (silence)

This project was designed to collect and to share information in order to better prepare teachers of Native students. This study involved five in-depth, in-person interviews with Dakota and Lakota elders between 40 and 70 years old. Elders provided reflections on experiences of past generations, on their own educational experiences, on the preferred learning methods of Native students, and on their visions for teachers" practices and influences on Native children. Through grounded theory, data analysis was conducted to identify themes. Stories and comments from elders were organized around those themes. Future studies might include use of the videotaped interviews in MSU courses for future teachers and evaluating attitude shifts among the viewers.

INTRODUCTION Waterpipe smoking (also called hookah, shisha, narghile, hubble bubble) is popular among young adults across the globe. Over half of university students in Jordan 1 and adolescents in Saudi Arabia 2 smoke waterpipes. One in five American college students reported smoking waterpipes and believed that waterpipe smoking is less harmful than cigarettes 3 . A survey of UK university students found that 14% smoked waterpipes in the previous month 4 . Relative to cigarette smoking, waterpipe use is associated with greater carbon monoxide, similar nicotine, and dramatically more smoke exposure 5 . Daily use of waterpipes produces a urinary cotinine level equivalent to smoking 10 cigarettes per day, and a single session of waterpipe use produces a urinary cotinine level equivalent to smoking two cigarettes in one day 6 . In towns and cities across the UK, the number of shisha bars has increased dramatically in the past decade. In 2007 there were 179 shisha bars compared to 566 in 2012 7 . The packets of favoured tobacco sold in shisha bars often carry no health warnings, in direct defiance of the UK Trading Standards regulations and the WHO advice that waterpipe tobacco should be subjected to the same regulation as cigarette and other tobacco products 8 . Most of the reported data on waterpipe use in young adults has examined its use in cities and among university students. This report assessed waterpipe use in young adults in a semi-rural suburban town that contained no known shisha bars, although a large number of local shops and market stalls sell shisha paraphernalia and tobacco. This survey aimed to measure the prevalence of waterpipe use, awareness of the tobacco content and associated health risks of waterpipes among young adults in Tameside in order to design an appropriate social marketing campaign targeted at this group. --- METHODS A self-completion questionnaire was piloted with young adults before distribution to secondary schools and higher education colleges across Tameside. This resulted in the survey being shortened to the questions shown in Table 1 in an attempt to maximize uptake and completion. Tameside is a semi-rural suburban area; poverty and unemployment levels are higher than average for England and the prevalence of cigarette smoking among adults is higher than the national average 9 . The targeted participants were people aged 16-25 years attending school or college. This included sixth form within school, sixth form college and higher education community college. The participating schools and colleges took the responsibility of conducting questionnaires with samples of young adults in their establishments. The paper questionnaire was distributed to students over the age of 16 years and completed independently and anonymously by the students. The significance of the differences in responses between those that reported smoking waterpipes and those that did not was calculated using the z-test for the difference between two independent proportions. --- RESULTS --- Demographics The total number of eligible full-time students enrolled at the six participating schools and colleges was 2624. A total of 210 questionnaires were completed with a response rate of 8%. Males (106) and females (104) were equally represented among the respondents. The vast majority of respondents were aged 16-18 (133), with just 23 people over the age of 19 years participating (Table 1). --- Survey responses Survey responses are summarized in Table 1, and 20% of respondents identified themselves as smokers. Of the 43 self-reported smokers, 16 (37%) were female and 27 (63%) were male, while 30 were aged 16-18 years, 11 aged 19-24 years, and 2 were aged over 25 years. In all, 25 people (12%) reported that they smoked cigarettes and 33 (16%) reported smoking shisha waterpipes. Of those that smoked waterpipes, 15 (45%) smoked at home and 29 (88%) smoked in shisha bars. Of the total respondents, 62% did not know that shisha waterpipes contained tobacco. Of those that smoked waterpipes, 18 (55%) knew that they were smoking tobacco, 10 (30%) reported that waterpipes did not contain tobacco and 5 (15%) did not know. A total of 177 of the respondents did not smoke waterpipes and of these, 62 (35%) stated that it contains tobacco (z-score=2.17, two-tailed p=0.03), 44 (25%) stated it did not contain tobacco (z-score=-0.58, two-tailed p=0.56) and 71 (40%) did not know (z-score=-2.75, two-tailed p=0.006). The young people who smoked waterpipes were significantly more likely to report that waterpipes contain tobacco, and significantly less likely to report that they did not know whether waterpipes contained tobacco, than those that did not smoke waterpipes. When asked if smoking waterpipes was less harmful than smoking cigarettes, 18% of respondents reported that waterpipes are less harmful than smoking cigarettes, and 56% answered that they did not know. Of those who smoked waterpipes, 7 (21%) thought that waterpipes were less harmful than cigarettes, 12 (36%) thought they were not less harmful and 14 (42%) did not know. Of those who did not smoke waterpipes, 31 (18%) thought waterpipes were less harmful than cigarettes (z-score=0.51, two-tailed p=0.61), 42 (24%) thought they were not less harmful (z-score=1.52, two-tailed p=0.13) and 104 (59%) did not know (z-score=-1.74, twotailed p=0.08). There was no statistically significant difference between those that smoked waterpipes and those that did not in their beliefs about whether or not waterpipes are less harmful than cigarettes. The vast majority of respondents (81%) stated that if they wanted to know more about how shisha tobacco could affect their health they would access information via the internet. Social networking websites was by far the most popular route for communication for messages about the health risks associated with smoking shisha waterpipes, with 35% of respondents preferring this route, compared to 25% preferring the next most popular route of leaflets. --- DISCUSSION This survey has demonstrated that the use of shisha waterpipes amongst young adults in a semi-rural, underprivileged area in North West England is similar to that in university students in large cities 7 . The proportion of young adults who reported using waterpipes (16%) was higher than the proportion who reported smoking cigarettes (12%), reflecting the trends found in other young adult populations, and suggesting that there is no difference in the popularity of waterpipes in the young adult university population compared with the non-university population. It has previously been reported that smoking waterpipes has become more common than smoking cigarettes among UK medical students 10 , and US university students 11 . This survey suggests that waterpipes may be replacing cigarettes as the method of choice for smoking tobacco among the young adult population in the UK. Despite there being no known shisha bars in the study area, 88% of waterpipe users reported smoking in shisha bars. This suggests that either young people are travelling into neighbouring cities in order to visit shisha bars, or that illicit venues exist in the local town. These results suggest that the increased use of waterpipes by young adults cannot solely be attributed to the increased number of shisha bars in cities and large towns. Most young people in this survey were unaware that shisha waterpipes contain tobacco; however those that smoked waterpipes had much greater awareness of the tobacco content than those that did not. There was no difference in this sample between those that smoked waterpipes and those that did not in their beliefs about whether or not waterpipes are less harmful than cigarettes. Previous work has identified widespread misconceptions about the tobacco content and health risks of smoking waterpipes, however we did not find, as Grekin and Ayna did among American students, that waterpipe smoking is more common among those that believe waterpipe smoking is less harmful than cigarette smoking 3 . The preferred route for the communication of information about waterpipes and health in this sample was via internet social marketing. This has important implications for those working in public health who wish to raise awareness of the health risks associated with waterpipe use among young adults. It has been noted that local government and public health in the UK has been slow to respond to the increasing popularity of waterpipes as a means of tobacco use 12 . Traditional routes of communication, such as local newspaper articles, may not reach this group. --- Limitations The number of both cigarette and waterpipe users identified might be underestimated by this survey due to respondents being unwilling to identify themselves as tobacco users in the school or college setting. This survey only included young adults engaged in education. A large proportion of young adults in Tameside are not engaged in education, and these results may therefore not be representative of the wider young adult population of Tameside. --- CONCLUSIONS This survey shows the low awareness of the tobacco content and of the associated health risks of waterpipes among young adults in an underprivileged area of England. Awareness needs to be raised about the tobacco content and associated health risks of waterpipe smoking through traditional and social media, so that young people can make fully informed decisions related to their health. --- FUNDING There was no source of funding for this research. --- PROVENANCE AND PEER REVIEW Not commissioned; externally peer reviewed.

Waterpipe smoking has become increasingly popular among young adults across the globe. Evidence suggests waterpipes have overtaken cigarettes in popularity among university students in the UK. This survey aimed to measure the prevalence of use, awareness of the tobacco content and associated health risks of waterpipes among young adults in a non-university semi-rural underprivileged community in England. METHODS A self-completed questionnaire was distributed by six schools and colleges to young adults aged 16-25 in Tameside, North West England. RESULTS A total of 210 young adults completed the survey, of these 12% smoked cigarettes and 16% smoked waterpipes. Of those that smoked waterpipes, 45% smoked at home and 88% smoked in shisha bars. Of the respondents, 62% did not know that shisha waterpipes contained tobacco and 18% believed that waterpipes were less harmful than smoking cigarettes. There was no difference in knowledge of tobacco content, or of the associated health risks, between those who smoked waterpipes and those that did not. The majority of respondents (81%) stated that if they wanted to know more about how shisha tobacco could affect their health they would access information via the internet. Social networking websites was by far the most popular route for communication for messages about the health risks associated with smoking shisha waterpipes. CONCLUSIONS These results suggest that waterpipes may have overtaken cigarettes as the method of choice for smoking tobacco among the young adult population in the UK.

INTRODUCTION Social processes appear in all societies as a regulated form of social influence. The main sign of social processes is the presence of universal relations in the interactions of the subjects who create the processes and participate in them. No event in society occurs without social processes. So, social processes act as the core of relations in all relationships, catalysts in creation, and drivers in action, and are characterized by all objective and subjective connections between people. The performance of the members of the society and the development of the society takes place in social processes of various forms. As noted by T. Parsons, philosophy, unlike other social sciences, "studies systems and processes related to the whole society, the integration of social systems". Philosophy studies the activity of a person in society, his adopted status in close connection with the processes of the social system. Social processes are classified by the following indicators: By object -humanity, society, organization, large social groups, small social groups; According to the level of regulation -spontaneous, concrete-historical and management: By direction -progressive and regressive (developing and diminishing) By recognition -open and closed; By duration -short and long duration; By flow level -macro, meso and micro processes; On objective and subjective relations -natural and social. The types of social processes were proposed by the US philosopher Robert Park of the Chicago School as follows: Cooperation -cooperation, interdependence in the process of activity, the form of labor organizations in which a certain number of workers participate in one or more interrelated labor processes, the basis of cooperation is joint action and achievement of common goals. Thus, an integral part of cooperation is the mutual interest of its members; Competition is the struggle between individuals or groups for limited and unevenly distributed benefits and values to achieve positive results, such as progress in science and art; Adoption -a person's ability and desire to participate in what others are doing and imitate their behavior; Conflict -the highest stage of the development of conflicting opinions is manifested in direct conflicts of relations and interests. The opposition of the participants of this social process is usually accompanied by negative feelings; Assimilation is a social process in which a certain part of society is deprived of its distinctive features, and replaces them with another part, that is, assimilation is always a two-way process of intercultural transition. It can be voluntary or mandatory; Amalgamation -union -the process of achieving mutual cultural achievements with all participants in the process of transformation of individuals and groups into a common culture. In contrast to assimilation, the completion of the process of assimilation completely eliminates the boundaries between groups, for example, the emergence of one person as a result of the mixing of two or more nationalities; Exogamy is marriage of a certain social group or class with another social group. This process was carried out by voluntary necessity or forced means. Compulsory or preferential exogamy is one of the most distinctive features of a primitive tribe. It also includes the types that arise on the basis of "Competition", "Appropriation" and "Conflict" in this classification. In everyday life, all the indicated forms of social processes can change in parallel, exchange places or create flows. Social processes may require, oppose, or replace each other. At the same time, in general, social processes are the basis of any social changes and events, which can help to restore, maintain and replace the system. Social processes include common views of people's unanimous and mass participation in social life, with concepts such as justice, honesty, loyalty. In order to maintain the stability of the state system and the society, it is necessary to inform and warn people about the political, moral and economic moral dangers that may arise in relation to the existing social system. Only then will they become responsible for the stability of the state and society and will begin to care for the development of the state and society. Social processes mean changes in the processes taking place in society. Social processes are manifested in directed, non-directed non-standard, reversible and irreversible, growing and fading, linear, stepwise, periodic and spiral types. Directed processes are processes that have their own specific directions, goals of action, and importance. Their results can be accepted with maximum accuracy. Example: marriage process, production reform process. There are many external factors that can somehow affect the outcome of such a process. Such a social process creates vertical social mobility through marriage. Undirected non-standard processes are unpredictable processes, the outcome of which is difficult to determine. For example, conflicts in the family, mobilization in social movements. Such processes occur more or less emotionally and, as a result of stimulation, have an effect on logical and conscious action, and are often manifested in the form of social elevators in social mobility. Reversible process -this is a system that shows changes when it goes from one state to another due to some factors and then returns to its previous state. But this does not mean that the system will return to its original state. Naturally, some structures of the system remain unchanged, but the fundamentals of the system change. In reversible processes, it is a situation characteristic of social mobility, which occurs when people who entered the channels of social mobility through labor migration return to their countries or as a result of the release of persons deprived of their freedom. Irreversible processes are processes that cannot be stopped or reversed. For example, stopping youth or returning from old age to youth. This process often occurs during the post-employment period, the last stage of socialization, during which people go through a period of adaptation in society. The representatives of the society who strive to continue the work process even after working for many years and then retiring are considered participants of such processes. Such processes take place in our society at the last stage of socialization, that is, at the post-labor stage. It is during this period that the manifestations of social mobility mites are rarely observed in society. A growing process is a process in the process of development and progress, that is, rising above the zero level. Of course, such a process is the process of increasing the position and social status of women through the labor career in social mobility. A fading process is a process that leads from development to backwardness by losing all possibilities. These processes are mainly the formation of socially dangerous behavior as a result of deviation from the norms accepted by the society. Or is the opposite of horizontal mobility. For example, after the end of the former union empire, as a result of the transformation of society in our country, the prestige and importance of party leaders decreased, and instead of them, the prestige and importance of private property owners and businessmen increased. In this case, vertical social mobility will decrease. Linear processes mean striving towards progress and backwardness at the same time. For example, a process introduced into society serves to forget national traditions, identity, values and national culture. An example of this is the penetration of globalization and mass culture into the minds of women and the formation of deviant behavior in them. A gradual process is a process in which a gradual change occurs in the system, but then, under the influence of various factors, qualitative changes occur. The action described as a step in these processes is the reforms carried out in the society. The reforms that are being implemented, if they are implemented in a hurry without thinking about the consequences, can bring the society from a dynamic state to a static state. A periodic process is a process in which some parts of the system change when some steps of the system are repeated regularly. During the seasonal research of the processes in the society, some processes in the society change and the processes that do not repeat the previous ones occur. For example, officials elected to state administration or local government bodies or deputies elected to representative bodies as a result of elections rarely repeat the activities of their predecessors. A spiral process is a non-repeating process where a system returns from a higher quality level to its initial state or vice versa. For example: if a higher education institution loses its reputation (reputation), which it once had, and then it is reorganized into another without being able to restore this reputation. An example of this is the reorganization or renaming of several higher education institutions in our country. The specific interaction of people in the sphere of material or spiritual production of society determines the components of the social process. The structural and organizational regulation of the process is its mechanism, with the help of which it is ensured that the process moves from one stage to another and is carried out as a certain integrity, and the speed of transition from one stage to another is characterized by a vector indicating a line of development directed upwards or downwards. In conclusion, it can be said that the reform of social relations requires paying special attention to the factors of social processes, their flows and directions, and timely identification of stagnant events that stop development processes. Large-scale social research of all spheres of society's life is an effective means of determining the state of social structures in society, which determine the nature, characteristics and optimal conditions of social processes. According to the predictions of demographers, the rapid growth of the population of our country will continue for the next quarter of a century. By 2025, the population of Uzbekistan is expected to increase to 40 million people. The rapid globalization of the current era, the speed of events and the quality changes of the time we live in, undoubtedly, directly affect the life of women. The success of the current large-scale reforms, the tasks of building a civil society in the country will depend on the extent to which women participate in social processes and the positive or negative impact of the channels of social mobility chosen by our women on social processes.

This article provides information about the sources of social mobility, the motivation to achieve, the law of increasing needs, and the hierarchical system of distribution of social results. The presence of channels of social mobility in society, including various social institutionsthe military, religion, education, political organizations, trade unions, family, marriage, art, sports, inheritance, elections, mass media, social networks, social networks of individuals and their groups. creates conditions for movement.

INTRODUCTION Maternal employment is closely linked to various beliefs, differing worldwide, regarding the child's health, both physical as well as mental [1]. On the one hand literature quote that women working as full-timers have troubled families [2] and affect children's cognitive achievements in junior school [3]. On the contrary, studies showed the positive impact of maternal employment on child nurturing and development at various stages of life [4] and these children had higher achievements in their life as compared to non-working mothers [5]. It is often the material goals and the necessities of daily living that require both parents to work. A woman in the majority of cases, works to maintain an effective career and also to be financially independent [6]. Because of the varying results of studies conducted on maternal employment status and adolescent health outcomes, continued interest in the subject has given way to a recent upsurge in research exploring links to adult outcomes and maternal employment status. Most working women are found to live with the guilt of not being able to give their children the quantity and quality of time [7][8][9]. This increases the worry of working mothers and it may affect their family life [10]. Stress and anxiety are the mind's complex way of tackling or failing to tackle events [11]. According to research conducted in Maharashtra, India, of the 1,224 respondents, 299 (24.4%) experienced stress [12]. In a study published in Karachi, Pakistan, 27.4% of the general population aged 30 years and above reported having anxiety and depressive symptoms [13]. Stress and anxiety, especially among adolescent students, is a major public health issues since these students are the most productive group of the population. Anxiety at this age has serious mental health consequences in the adult life of these children [14]. A mother's participation is extremely important in the life of college-going teenage boys and girls. It provides him/her with reassurance and a strong base for effective coping with various situations in life [15,16]. The mothers were attentive listening to their everyday activities and challenges can help in reducing stress. Through this research, we aimed to assess an association between the mental health of adolescents, including stress and anxiety, and the working status of mothers. --- METHODOLOGY It was a cross-sectional survey. The data were collected from three private-sector and three government-sector intermediate colleges in Karachi. A simple random sampling technique was employed for the recruitment of the students through their roll number lists provided by the college administration. Participants included male and female college students doing their intermediate in government and private sector colleges in Karachi, Pakistan. Students who were not willing to answer the questionnaire and those who were on medications for psychiatric issues were excluded from the study. The sample size was calculated by using the software OpenEpi software version 3.01. The prevalence of stress was taken as 50%, with a 95% level of significance, the sample size calculated was n=246. The study was approved by the Ethical Review Board (ERB) of Liaquat National Medical College (LNMC), Karachi, Pakistan (Ref: App # 0620-2021 LNH -ERC). --- Interviews A semi-structured questionnaire was developed and administered by trained interviewers. The questionnaire was used to collect information from the students regarding their socio-demographics and the information regarding the working status of their mothers. To maintain their confidentiality, a relatively private and quiet place was chosen for administering the questionnaires. The questionnaires were translated into the local language (Urdu). Data collection continued from February to December. The study questionnaire included socio-demographic characteristics of the study participants: age, gender, education, and, the working status of their mothers. The study assessed the stress and anxiety level of the students, through validated questionnaires for stress (Perceived Stress Scale, PSS) and anxiety (Hamilton Anxiety Rating Scale, HAM-A). --- Stress To measure stress, the "Perceived Stress Scale (PSS)" was used. Individual scores on the PSS can range from 0 to 40 with higher scores indicating higher perceived stress. Scores ranging from 0-13 were considered low stress. Scores ranging from 14-26 were considered moderate stress. Scores ranging from 27-40 were considered high perceived stress [17]. --- Anxiety To measure anxiety, the "Hamilton Anxiety Rating Scale (HAM-A)" was applied. Each item is scored on a scale of 0 (not present) to 4 (severe), with a total score range of 0-56, where <17 indicates mild severity, 18-24 mild to moderate severity, and 25-30 moderate to severe [18]. --- Statistical Analysis Descriptive statistics of socio-demographic variableswere calculated as means (with standard deviations) for continuous variables and frequency (with percentages) for categorical variables. Univariate and multivariate analysis was done using logistic regression to determine the unadjusted and adjusted relationship between the predictor (age, gender, and working status of the mother) and outcome variables (stress and anxiety among college students). Odds ratios with their 95% confidence intervals were determined for each independent variable. Predictor variables with a p-value of less than 0.25 in univariate analysis were retained in the multivariable model. A p-value of <0.05 was considered statistically significant. The data were analyzed using IBM SPSS Statistics version 22. --- RESULTS The mean age of the participants was 17.24 years (SD: 0.506), with 59.3% males and 40.7% females. The majority of the students had moderate stress (80.5%) and mild anxiety (64.6%) (Table 1). About 83% of the students responded that their mothers stay at home, doing household chores. --- * SD = Standard Deviation, ** Others = Administration and Management Table 2 shows the Multivariate logistic regression analysis for the association of anxiety levels among students with the working status of mothers. The study showed no significant association between anxiety levels among students with the working status of mothers. The female students were 2.72 times more anxious compared to the male students, which was found to be statistically significant (p-value: <0.001). The anxious students were more likely to have moderate and high levels of stress. among the students was generally high it was found to be not significantly associated with the working status of their mothers. Female students were more likely to be stressed (OR: 4.71 (CI: 1.98-11.15), p-value: < 0.001), compared to male students. The age of the students, although insignificant, was likely to be protective of both anxiety and stress among students. --- DISCUSSION The etiology and pathogenesis of stress as well as anxiety are complex and multi-factorial and may differ in varied settings [19]. The results of this study showed no significant associations between stress and anxiety among college students and the working status of their mothers. [23] reveal that children who had working mothers showed a better mental health status, compared to the children of non-working mothers. The reasons suggested by them were the mother's education leading to better communication with their children. Similarly unemployed mothers having less education were associated with the lowest levels of parenting quality [24]. Several studies have shown similar results regarding stress being greater among females compared to males [25,26]. The reasons may be various and multi-faceted. Females may report their symptoms more compared to males. Psychological and social differences also might aid in explaining these gender differences [27]. The study had some limitations. The working hours of the mothers were not taken into account, which could have explained some associations in greater detail. Respondent bias may exist, whereby females are known to report their symptoms more as compared to males. --- CONCLUSION The working status of the mothers is not associated with stress and anxiety among college students. Further, longitudinal studies are required to access the effect of maternal working and non-working status on the mental health of students. --- AVAILABILITY OF DATA Data sets generated or analyzed during the current study shall be provided at the personal request of the reader. --- ETHICAL APPROVAL Ethical approval was obtained from the Ethical Review Board (ERB) of Liaquat National Medical College (LNMC), Karachi, Pakistan (Ref: App # 0620-2021 LNH -ERC). All procedures performed in studies involving human participants were following the ethical standards of the institutional and/or national research committee and with the Helsinki Declaration. --- CONSENT FOR PUBLICATION Written informed consent was taken from the participants. --- CONFLICT OF INTEREST The authors have no conflicts of interest to declare for this study. --- AUTHOR'S CONTRIBUTION

Background: Mother Child relationship is significant in the development of human beings. She is a vital factor in the physical, social, and cognitive growth and independence of a child. This study is aimed to assess the stress and anxiety levels among adolescent students and their relationship with their mother's employment status. Objective: To assess an association between stress and anxiety of adolescents and the working status of mothers. Methods: It was a cross-sectional survey. The data were collected from three private sectors and three government sector intermediate colleges, including male and female students. Analysis was conducted on the software SPSS, version 22. Results: Total 246 students enrolled. Overall 59% of participants were male and 41% were female students. Females had a higher frequency of stress and anxiety as compared to male students using the Perceived Stress Scale and Hamilton Anxiety Rating Scale (HAM-A) respectively. Around 83% of the students had staying-at-home mothers. There was no statistically significant difference identified between the stress and anxiety levels among the children of working mothers and non-working mothers.Mothers' working status is not associated with stress and anxiety among college students. It is required to conduct further studies to gain more detailed insight into the associations between the mental health of students and their mothers' working statuses.

Introduction Cooperative Extension personnel have long been known to meet clients where they are. From the beginning days of Extension, agents went to families to help them meet their needs (Allen, Dunn, & Zaslow, 2011). For those working with youth, the increased use of technology creates both a challenge and an opportunity to meet youth where they are: online. Although there can be challenges and barriers to using social media in Extension, educators can benefit from using online networking tools (Kinsey, 2010). This article describes a teen parenting program's use of social media technologies to engage vulnerable youth. --- Social Media in Education Technology use constitutes an integral part of the average American teen's life. The majority of American teens now have access to a smartphone (73%) and/or a computer (87%), and 92% of American teens report going online on a daily basis (Lenhart, 2015). With increased access to the Internet and the upward trend of smart mobile devices, today's youth are continually engaged on social media platforms, especially Facebook, Instagram, and Snapchat. Also, they are frequently using mobile text messaging and text messaging applications (e.g., WhatsApp) to communicate, with the average teen sending and receiving 30 texts per day (Lenhart, 2015). These communication tools, while commonly used for leisure and social networking, also provide a means for seeking and sharing information and can be used to promote learning. The pervasiveness of social media and technology provides an opportunity to engage youth in learning and educational experiences in a way that is both readily accessible and relevant. Social media platforms are now being used to establish learning communities that "empower students with a sense of personal agency in the learning process" (Dabbagh & Kitsantas, 2012, p. 5). Learning is promoted though constant communication and connectivity, peer/instructor collaboration, and opportunities for students to create and contribute personalized content (Gikas & Grant, 2013). --- Kim Allen --- Case Study There is an increasing requirement to help our vulnerable youth receive much-needed education to help with parenting and life and relationship skills. The North Carolina State University (NCSU) Very Important Parents (VIP) program uses a variety of social media technologies to support and deliver such programming. Meeting teens where they are creates an opportunity to help them learn in real time, using in-real-life, or IRL, situations. The VIP program has used a variety of social media platforms in a number of approaches to reach and teach teen parents. --- Facebook To share parenting tips and education, the VIP program created a public Facebook page, which can be found at https://www.facebook.com/ncsuveryimportantparents. For each group of VIP program participants, however, a closed Facebook group is created. The relevant pages allow for more privacy for participants as they share stories about themselves and their children, and they are used to disseminate a weekly instructional video, daily questions, and weekly parenting activities. These pages also are used for dialogue between participants and parent coaches regarding various topics related to the curriculum and participant life experiences. --- Instagram The VIP program created an Instagram account (@veryimportantparents) to stay connected with parents regardless of whether they are enrolled in the program. Figure 1 shows the image of an Instagram post from @veryimportantparents. Followers receive weekly parent/child activity suggestions that focus on building developmental skills in children and creating strong family connections. --- Figure 1. --- Instagram Post from NCSU VIP Program --- YouTube YouTube is becoming a site where many parents go to learn about new activities and ideas for their families. The VIP program team, which includes content specialists, parent coaches, and undergraduate work-study students, has produced 14 educational videos, in English and Spanish, for the Very Important Parents Program channel. The channel provides a resource for families to learn about parenting topics that are relevant to their daily experiences, presented using innovative technology, and rooted in parenting research. education. VIP uses NCSU Moodle services (Figure 3) to implement programming for participants who are unable to access social media resources. Moodle requires only Internet access, and participants are able to view all materials and complete activities in one location. As participants complete the VIP program, they are encouraged to download the VIP app, from appsme.com. This app allows young parents to stay connected to program resources and to have quick access to social media newsfeeds and staff contact information for ongoing questions. --- Conclusion To remain vital, Extension educators must be innovative in their programming (Meyer, Boyce, & Meyer, 2015). Youth engage in technology to help improve their lives; therefore, it is critical for youth family professionals to understand and use technology to help educate young parents where they are. As showcased here, asynchronous learning tools that are available at any time provide new opportunities to positively impact youth. --- WhatsApp Many of the young parents who are participating in the VIP program use a cell phone as a primary Internet source. WhatsApp is a free download from the app store for all phones that allows participants to receive text and video messages from the VIP program at no cost (i.e., without drawing from mobile data/text plans). This service is used to send weekly instructional videos and parenting information, as well as for regular communication between participants and their parent coaches. Figure 2 shows a @veryimportantparents WhatsApp post. --- Canva Finding new ways to present information can be challenging. Using web-based design tools, such as Canva (www.canva.com), to create engaging infographics has increased participation in program activities and has provided an exciting way to deliver educational materials and messages to participants. These colorful designs make learning more fun and accessible for all participants. --- Additional Web-Based Tools Program staff developed a central website, www.beVIP.org, to allow participants access to information before, during, and after completion of their participation in the program. This site provides free printable resources for parents and providers as well as video resources on parenting

Employing social media to engage youth in real-time learning is a growing trend. Although the use of social media by youth is increasing, barriers exist for Extension educators wanting to capitalize on youth interest in social media, including a lack of information on how best to employ social media in programming. This article highlights a teen parenting program's use of asynchronous learning through a variety of social media platforms.

Introduction Prejudice has numerous definitions, and its modern roots may be traced back to Enlightenment liberalism in the 18th century, where Gordon Allport defined prejudice as a feeling of advantage or disadvantage towards someone or something, either before or not dependent on experience (Eagly & Diekman, 2005). Many psychologists believe that prejudice is a natural response because the race was considered inferior due to early research on white supremacy in the 1920s. However, after the 1930s and 1940s, this view starts to change due to the increasing focus on anti-Semitism by Nazi ideology. There has been a fundamental shift in the understanding of prejudice, recognising that 'feelings' are not necessarily conscious (Banaji et al., 2004;Fazio, Jackson et al.,1995;Williams, 1995). When prejudice escalates, it often has destructive results on the harmony and coherence of social life. It is therefore of great interest to discuss whether prejudice is inevitable. This discussion aims to analyze whether prejudice is avoidable in terms of three causes of prejudice: the pressure of social normative rules, social identity theory, realistic conflict theory, and implicit prejudice. The existence of social norms causes people to behave in a normative way that corresponds to their social group or system in order to meet the expectations of the group. Social identity is the nature of an individual's self-image derived from the social category (Tajfel & Turner, 1986). According to realistic conflict theory, disputes arising from rivalry for resources, political rights, or social position can lead to bias (Jackson, 1993). --- The Pressure to Conform to Social Norms The pressure to conform to social norms can lead to prejudice. This attitude arises because living with stereotypical information and discriminatory behavior can produce prejudice. It is also a manifestation of normative conformity, the tendency to follow the crowd to meet the group's expectations, which conforms to the norms of its social group or system. In the 1930s and 1940s, there was a growing concern about anti-Semitism due to Nazi ideology. Authoritarians are "stereotypical thinkers who obey authority, perceive the world in black and white, and enforce tight orders," according to "Theodor Adorno". In an era of widespread racism, profoundly racist behavior and conduct from top to bottom can emerge from the inside out. Social norms of racial discrimination play a significant role in this. Because it is not easy to be a different person under a social norm, people may be under pressure from many sources, such as unappreciative friends and unsupportive family members. Equally, of course, if social norms are anti-racist, then for the masses, this counteracts the expression of prejudicial intergroup behavior in the public arena (Werner, 2021). Since the late 1950s, for example, changes in the expression of prejudice against minority groups have become increasingly evident under the auspices of egalitarian social norms. New forms of prejudice theory have addressed these changes (Gaertner & Dovidio, 1986) that is, social norms, whether positive or negative, impact us as a broad social context, and this impact is difficult to avoid. Although prejudice may seem unavoidable under social norms, we can reduce prejudice if we use such social norms wisely. For example, in racial prejudice, if the dominant norm in society is an egalitarian norm, then the general public's expression of prejudice and bigotry against minority groups will change (Katz & Hass, 1988). --- Social Identity Theory Each of us creates a distinct identity that is unique to ourselves. We do, however, form social identities based on the organizations to which we belong, such as our national, religious, political, and occupational groupings (Dovidio & Gaertner, 2010;Tajfel, 1982). One of the causes of prejudice is said to be social identity theory. The link of prejudice with categorical thinking is one of the reasons behind this. In his landmark 1954 book The Nature of Prejudice, Gordon Allport claims that humans think and categorize using categories. Once established, categories serve as the foundation for typical predictions. It is the foundation of life's order. In social identity theory, we classify everything into us: our country and other countries, our group, and their group. Moreover, outcomes include ethnocentric in-group bias, outgroup homogeneity, blaming the victim, justifying rights and superiority. For example, we prefer to think that our group is better, as Marilyn Brewer argues that prejudice "may not be due to hatred of the outgroup, but because positive feelings of appreciation, sympathy, and trust reserve for the in-group." So is it possible to avoid prejudice under social identity theory? It is not easy because humans are social creatures, and we will always put ourselves into a particular group. Even when there are good sources of information, the prejudice against outgroups may be reduced, but as long as people are in a society and operate as a particular group, the prejudice will always be there, even if people are not aware that people are prejudiced. (Gawronski & Payne, 2010) Nevertheless, again, not all biases formed by this theory of social identity are negative; there is a limit to the amount of information we can grasp based on the limits of our cognitive range, and it is also essential from an evolutionary perspective to quickly grasp the key points of a piece of information in a limited amount of time. There are just some ways in which we can still reduce this bias. --- Realistic Conflict Theory According to realistic conflict theory, competition for limited resources can result in negative prejudice and discrimination, even when the resources are not essential. For example, in the Robber's Cave experiment conducted by Muzafer Sherif in 1961, two summer camps developed negative prejudice and animosity after a sporting competition for small prizes. For example, North & Fiske (2012) argue that some young people feel resentment towards older people, most likely because of a sense of injustice that older people are receiving more significant social benefits and opportunities. So can prejudice be avoided in the face of the reality of conflict theory? Firstly, can we as individuals avoid conflict. In the case of students, we are constantly competing for everything from exam rankings to scholarship qualifications, and according to real-life conflict theory, competition and conflict increase prejudice. Secondly, at the level of larger groups and countries, there are numerous conflicts over scarce resources and social status, such as the war in Iraq. However, even if there is competition, we can adopt a win-win strategy. If a win-win is achieved in competition, as Muzafer Sherif argues, prejudice is reduced when we have a common goal (Sherif et al., 1961). For example, the recent joint agreement between the US, UK, and Australia to share advanced defense technology is a win-win situation for the US, UK, and Australia as an in-group with a common goal. Nevertheless, on the contrary, for other countries, such as France, the pressure of competition is felt as an out-group. So prejudice due to realistic conflict theory is also not easy to avoid altogether, but it is not absolute. For example, when all humanity as a whole shares the same goal in the face of climate change, prejudice will be significantly reduced. --- Implicit Prejudice There are two forms of expression of prejudice, implicit prejudice, and explicit prejudice. As the name suggests, implicit bias is a bias against someone or something that does not manifest itself, even without one being aware of it. The existence of implicit prejudice makes it more challenging to reduce and avoid prejudice. For example, under the pressure of current social norms, people can conform to the pressure of institutional discrimination (outwardly) without actually believing it themselves (inwardly). As in the case of racial discrimination, the social system advocates against it, so some of the outwardly visible racial behavior decreases but does not disappear, and some people may turn it inward (Lepore & Brown, 1997). So prejudice against this implicit is both difficult to detect and difficult to avoid and eliminate. Devine (1989) distinguished between stereotypical knowledge and identity (Ashmore & Delboca, 1981). Through a series of experiments, stereotypical knowledge is automatically activated because it has been activated for a more extended period than personal beliefs (Higgins & Wang, 1981). Thus, low-bias individuals respond to stimuli from a stereotyped group without bias only when suppressed automatic bias responses. Even still, this data shows that prejudice is unavoidable, at least on an unconscious level. As a result, prejudice appears to be unavoidable as a result of regular cognitive processes. "As long as individuals continue to think, they will be prejudiced," Billg (1985) concludes. --- Conclusion In summary, this essay argues that prejudice seems to be unavoidable because it is influenced by many factors, such as the pressure of social norms, social identity, and theories of actual conflict. With the influence of the political economy of each country and the progress of the times, some prominent acts of outward prejudice have been gradually reduced, but implicit prejudice still exists. Although prejudice is challenging to eliminate and avoid, there are still ways we can reduce it, such as social support and shared group goals. We are all part of the planet, and every person and race are equal, so hopefully, we will all be able to recognize prejudice and deal with it rationally.

Prejudice research swept through social psychology and surrounding social sciences in the 1950s like a flood. Because prejudice is a problem that affects everyone, no one is immune to it. When prejudice turns into a severe type of bigotry, it can made acts of violence, murder and even genocide. As a result, there has been increasing debate and research into whether prejudice can be avoided. Through course material, related literature, and theories, this paper examines whether prejudice may be avoided. The paper will look at the causes of prejudice, external and implicit prejudice, to see if prejudice is inevitable and suggest possible ways to reduce it.

We live in a world that is exceptionally diverse and tremendously unequal. In recent years the field of global health has grown through the recognition of these realities, but with a variety of perspectives on how they should be considered. 1 Global health has also grown in physiotherapy, with increasing numbers of Canadian physiotherapists and students engaging in initiatives abroad. In one sense, this is also a manifestation of global inequality: people with certain national and professional statuses-and the economic resources to travel-are able to intervene elsewhere, and to do so primarily on their own terms. As physiotherapists invested in global health, we see the potential for physiotherapy to have a positive impact on important unmet needs around the world. 2 Concurrently, we are concerned about the potential for such initiatives to be unknowingly ineffectual, or even to create more problems than solutions. 3 We consider this risk particularly high where global health involvement is shrouded in a veil of naı ¨ve altruism or domineering heroism, 4 perpetuating colonial dynamics whereby Western knowledge and viewpoints subjugate alternatives. 5,6 To maximize the potential for positive global health involvement while heightening awareness of the potential for ineffectiveness or even harm, we propose that physiotherapists and students engage in reflective practice premised on the concept of cultural humility. 7 Cultural humility is an ongoing process of critiquing one's own culture while striving to respectfully understand others, of recognizing and redressing power imbalances, and of contributing to partnerships that are mutually beneficial and non-paternalistic. We have found that reflecting on experiences through the lens of cultural humility can lead to useful insights to inform our actions. Here is an example: A Canadian physiotherapist volunteering at a hospital in a low-income country notices a local colleague, on staff at the hospital, conducting a treatment that the Canadian considers ineffectual at a critical time in the patient's recovery. Seeing the importance of effective treatment, he interrupts to present an alternative intervention. We respect the visiting physiotherapist's intention to contribute to what he understands to be better patient care, but we also believe that this interruption would not occur if the visitor embodied the principles of cultural humility. To begin with, the Canadian's views of what constitutes ''best practice'' might be broader if he saw the interventions currently dominant in highincome countries as products of a specific, culturally embedded world view, as opposed to universal principles to be applied regardless of context. Furthermore, reflection with cultural humility requires considering power imbalances. We hope the Canadian could see that his ability to visit a facility in a foreign country and critique its staff is one that his local colleague is unlikely to have, and that the reasons for this should not be taken as natural. In the scenario described above, the Canadian physiotherapist did not pause to consider his local colleague's rationale for conducting the treatment, which might have been consistent with the realities of the situation and the culturally grounded world view. By not seeking this information, the visiting physiotherapist not only behaved disrespectfully but also missed an opportunity to learn about the local context and culture. In this example, we show how cultural humility reveals considerations and opportunities that are not otherwise readily apparent. Although the example is hypothetical, it is similar to actual interactions we have experiencedinteractions that raised concerns because the Canadians involved saw them not as problematic but as inherent to improving physiotherapy for the underserved. Despite these concerns, we are optimistic that by using a cultural humility lens, we can create alternative courses of action that are mutually beneficial and non-paternalistic. In discussing the example above, we have focused on the act of reflection and not on precise courses of action. This strategy is intentional: because applying cultural humility is an ongoing process, it would be incongruent to present a scenario as resolved and definitive. Moreover, determining optimal courses of action would require considering more contextual detail than is presented above. Although we see evidence of cultural humility being practised with zeal in the global health communities of other professions, 8 there are few references in the physiotherapy literature, and this omission likely reflects a lack of uptake. With respect to global health involvement, we believe it is imperative that Canadian physiotherapists and students incorporate reflective practice premised on cultural humility for immediate impact. We have grounded this editorial in the field of global health both because it is what we know best and because we see the immediate advantages of adopting cultural humility in this domain. But this grounding carries the risk of perpetuating the notion of global health as something that happens over there, as somehow distinct from normal practice in Canada. In fact, however, we see cultural humility as a concept that is useful to guide respectful and effective practice not only abroad but also in contemporary Canada, with its exceptional diversity and its areas of tremendous inequality. We believe that exposure to this way of thinking should begin as early as entry-level education and that it should be increasingly incorporated into our professional ways of being and doing. Nous vivons dans un monde qui pre ´sente une diversite ´exceptionnelle, mais qui est aux prises avec d'e ´normes ine ´galite ´s. Au cours des dernie `res anne ´es, le domaine de la sante ´mondiale a e ´volue ´gra ˆce a `la reconnaissance de ces re ´alite ´s, une reconnaissance riche en perspectives sur la fac ¸on de prendre en compte ces re ´alite ´s1 . Le domaine de la sante ´mondiale a e ´galement progresse ´du co ˆte ´de la physiothe ´rapie, ou `un plus grand nombre de physiothe ´rapeutes et d'e ´tudiants canadiens participent a `des initiatives a `l'e ´tranger. En un sens, il s'agit la `aussi d'un signe d'ine ´galite ´sur le plan mondial : des personnes d'une certaine nationalite ´ou d'une certaine profession, qui ont les ressources financie `res pour voyager, sont en mesure d'intervenir ailleurs et peuvent le faire essentiellement comme bon leur semble. A `titre de physiothe ´rapeutes voue ´s a `la sante ´mondiale, nous croyons aux re ´percussions positives que la physiothe ´rapie peut engendrer afin de combler d'importants besoins aux quatre coins du monde 2 . En me ˆme temps, nous redoutons le risque que de telles initiatives s'ave `rent inefficaces sans qu'on le sache et cre ´ent me ˆme plus de proble `mes que de solutions 3 . A `nos yeux, ce risque est particulie `rement e ´leve ´la `ou `la contribution au domaine de la sante ´mondiale est recouverte d'un voile d'altruisme naı ¨f ou d'he ´roı ¨sme dominateur 4 , et perpe ´tue des dynamiques coloniales dans le cadre desquelles les connaissances et les points de vue occidentaux prennent le pas sur les autres solutions 5,6 . Afin de maximiser le potentiel d'une contribution positive au domaine de la sante ´mondiale tout en faisant

and Rehabilitation (Centre international pour l'incapacite ´et la re ´adaptation), Universite ´de Toronto; ‡Division sante ´mondiale de l'Association canadienne de physiothe ´rapie. Remerciements : Les auteurs remercient Barbara Norton et Judy King d'avoir formule ´de pre ´cieux commentaires sur une pre ´ce ´dente version du pre ´sent article.

Introduction The global health agenda has been dominating the current global health policy debate. It has compelled countries to embrace strategies for tackling health inequalities in a wide range of public health issues, such as communicable and non-communicable diseases, essential medicines shortfalls, access to healthcare delivery services, and health systems strengthening (1). Currently, achieving global health governance is depicted as a quest to undertake these challenges. Since weaknesses in shared global decision-making were identified, the second report on the post-2015 development agenda encompass global community to engage into a renewed global partnership, which could allow to strengthen it (2). Nevertheless, it seems that political global landscape is far from achieving a shared global decision-making framework. Meanwhile, the global political and economic paradigms still hinder moving toward a novel and comprehensive global development agenda for a fair policy diffusion of ideas that is as the countries' willingness to generate or adopt policy ideas independently from the economic environment where ideas have been conceived. The article of Robert and colleagues highlighted two key remarks on why Low-and Middle-Income Countries (LMICs) should (not) embrace the mainstream ideas in global health (3). One of them is related to the issue that although globalization has increased opportunities to share and spread ideas elsewhere, there is still great asymmetry of power according to countries' economic and political development. The second thought emphasizes how policy diffusion from High Income Countries (HICs) to LMICs have had flaws at understanding their political, economic, and cultural backgrounds, even when LMICs have been broadly targeted for being part of the hegemonic policy options designed and disseminated by the developed world. Accordingly, attaining a new global scenario for policy diffusion is a political challenge. Nonetheless, the global health agenda has been concentrating its efforts on policy diffusion as a result of solidarity and policy development. Both of them as outcomes of knowledge translation from HICs to LMICs lack the politics to gather a global community for engaging with global health challenges. The aim of this paper is to address two major political constraints for global health policy diffusion defined as the political process through which global health mainstream ideas are posed worldwide. The first section discusses the lack of political foundations at pursuing the global health policy diffusion. Secondly, global health will be argued as an opportunity for power redistribution among -and within-societies rather than a new wave of economic and social harnessing of thinking. Finally, a call for action on a fair political process worldwide will be stated as a path to strengthen global health policy diffusion. --- Why global health lacks politics? Along recent decades, politics of global health has been narrowly debated. On the contrary, global health governance has been the milestone for politics and political processes to influence the shaping of population health goals worldwide. Despite that several authors have developed theoretical frameworks for global health governance (4-6), politics have been conceived as one driver rather than the core for a shared governance covenant worldwide. Nevertheless, and notwithstanding that current theoretical efforts have focused on seeking for renewal in global health as a conceptual framework (7,8), politics still remain hindered by financing and policy initiatives. Thus, identifying an ideology behind global health is also a global quest by itself. Global politics has posed the social determinants of health as a cross cutting paradigm to understand population health. Nevertheless, as a social determinant of health, politics has led a misguided debate on what are global health's ideological roots. Also, it has contributed to a misleading global health advocacy debate that can be driven based on the perceptions of two conflicting policy trends: one philanthropic-based and the other state-based. The philanthropic-based trend conceives global health as a path for enhancing population health throughout specific initiatives mainly financed by private donors and international agencies, where there is no political commitment behind their goals. On the other hand, the state-based trend foresees global health problems as possible domestic threats. Therefore, political involvement is strong while countries are encountering health problems out of their control. Both conflicting policy trends are further described in Table 1. These two trends have been disseminated broadly since global health strikes capitalism as the core of the current human development arrangements. Global health issues raise reasonable concerns of capitalism as an economic model, and about their consequences on population health and well-being. Examples include the effects from global trade, migration policies, social conflicts, and economic crisis. Consequently, there has not been political will for a thorough and comprehensive political debate from different world's stakeholders for addressing gaps in the economic model. Global health will remain lacking in politics while its challenges and principles undermine the economic model as the political driver worldwide. Moreover, moving toward politics-based global health would nudge HICs to embrace a different path for development where LMICs would not be part of their enrichment policies. For policy diffusion of ideas, a lack of global health politics implies the capture of the global policy agenda by HICs while LMICs development continues tied to the global extracted economic model. Therefore, sharing global solutions shaped from LMICs' backgrounds would still be seen as a threat by HICs. What should be the political ideology behind global health endeavors? It is clear that there is not an easy pathway to answer the question without tackling the global economic and political shortfalls. --- Global health means power redistribution The main global health challenges for improving population health and well-being in LMICs are related to overcoming the high concentration of political and economic power from HICs. For those LMICs, which are striving with social, cultural, and political clashes, chances for being involved in knowledge translation for global health solutions are politically banned. Moreover, the global transit of expert knowledge leads to establish different relations of power between policy-makers and those who are thinking as a policy target (9). The power relationships for global health policy diffusion have been discussed as a governance challenge. For some authors, the lack of global health governance will not allow the design of programs to achieve international health objectives (10). Further discussion has centered on seeking a comprehensive analysis of power (11). Although a global health fair policy diffusion of ideas will be achieved only if countries worldwide are willing to share power on global health decision-making; it seems neither multilateral agencies nor advocacy agencies would be capable to move the boundaries from the current global political edge. Undoubtedly, enhancing and strengthening political fairness should be considered as a global health tenet. Nonetheless, coping a fair global health policy diffusion should be based on a new global governance without military and economic development as coercion measures for ideas adoption elsewhere. Hence, overcoming the post-Cold War paradigm on global allocation of power would demand not only moving toward a broader and new health governance global understanding, but also to new drivers for a fair distribution of power. Also, it would imply that countries should be able to choose between cooperation and isolation as a foreign policy to face global health challenges (Table 2). For HICs, adopting an isolation-based foreign policy approach would mean accepting their own fragility and vulnerability since they have achieved greater levels of population health than LMICs. Therefore, health issues from LMICs are posed as threats. On the other hand, encompassing global health cooperation should not be understood as current international aid endeavors. Achieving cooperation means to surpass the political threshold on power redistribution at global health decision-making among countries, independently of their economic development. Moving toward Universal Health Coverage (UHC) fits as an example of possible isolation-based approach for foreign policy. For some developed countries, moving forward into better health and social welfare schemes could be seen as an economic and political threat since they are attracting migrants looking for a better quality of life (12). In a cooperation-based counterfactual scenario, developed countries would see UHC as an opportunity for strengthening their own healthcare delivery organization since they are attracting people from different settings that carry their own social construction of health with them. In the European Union, tobacco control agreement is a good example of cooperation. The states moved towards a shared sovereignty for tobacco control from population health integration instead of terms for economic arrangements only (13). Although it seems the European Union case on tobacco control was able to avoid incentives for isolation of a particular global health issue, moving forward a cooperationbased scenario cannot be attempted without changes in the economic model, and politics as its custodian. Hence, global health policy diffusion would be worthless while their foundations remain based on capitalism as a political driver to reach their goals. --- Toward a fairer political process A fair policy diffusion process needs to fulfill the lack of a shared political ideology behind global health challenges. Solidarity and policy diffusion are not enough if countries are not able to see global health challenges as their own. Fairness in a global political process should be shaped not for the economic model, but for social and cultural backgrounds. Therefore, economic growth and wealth are not enough for isolating HICs once global health issues are not only circumscribed to LMICs, but also in their own social and cultural changes. Globalization itself has blurred boundaries on the spread and control of disease. Fostering countries to move from isolation to cooperation on policy diffusion of ideas will require a global understanding regarding health problems as a shared challenge for global development. There is also compromised shifting of political and economic pathways for wealth generation. Enhancing and strengthening political fairness should be considered a global health tenet for better governance. Once global community is able to understand that global health threats are beyond economic growth and political instability, a fair policy diffusion of ideas should be a shared goal to achieve high levels of health and well-being. Finally, a fair global health policy diffusion of ideas would imply a call for a renewal on both academic and political leaders worldwide on undertaken novel paradigms. Accordingly, moving towards fairness on dissemination of global health ideas should be driven from politics not only as one of the social determinants of health, but the main path for fair policy diffusion of global health ideas which are seeking better health and well-being among-and within-societies. --- Ethical issues Not applicable. --- Competing interests Author declares that he has no competing interests. --- Author's contribution CAM is the single author of the manuscript.

The global health agenda has been dominating the current global health policy debate. Furthermore, it has compelled countries to embrace strategies for tackling health inequalities in a wide range of public health areas. The article by Robert and colleagues highlights that although globalization has increased opportunities to share and spread ideas, there is still great asymmetry of power according to the countries' economic and political development. It also emphasizes how policy diffusion from High Income Countries (HICs) to Lowand Middle-Income Countries (LMICs) have had flaws at understanding their political, economic, and cultural backgrounds while they are pursuing knowledge translation. Achieving a fair global health policy diffusion of ideas would imply a call for a renewal on political elites worldwide at coping global health politics. Accordingly, moving towards fairness in disseminating global health ideas should be driven by politics not only as one of the social determinants of health, but the main determinant of health and well-being amongand within-societies.

Introduction: The foundation of society is dependent on the female gender. She is just as important to the nation's economic growth as their male colleagues and makes a significant contribution to the overall development of the nation. The nation's progress will stagnate if women do not actively participate in a variety of national, social, economic, and political activities. Indian women have historically chosen to stay at home and raise their families, but in the twenty-first century, as awareness has grown and education levels have increased, women are also choosing to pursue employment. While working women in India have begun to work outside the home, there are still several problems and difficulties that they encounter in this day and age. At work, they don't always receive equal treatment. The advantages that are offered to male employees are also not extended to them. One of the biggest problems and obstacles that working women today confront is gender bias. Other problems include uneven pay, security, mental and physical harassment, inadequate family support, stress and anxiety, and insufficient maternity leave. Women are frequently ignored, talked over, interrupted, and passed over for jobs, discredited, dismissed, stigmatized, and undermined. They are also frequently excluded from significant meetings and projects and given ambiguous or unhelpful feedback or explanations. However, the daily obstacles that women face that prevent them from advancing in their careers, drain their energy, and undermine their confidence are not as well discussed. For working women, stress, sleep deprivation, sedentary lifestyles, heavy workloads, and unhealthy eating habits are major causes of sickness. Anxiety, depression, heart disease, obesity, insomnia, asthma, arthritis, psychological problems, high blood pressure, thyroid, body aches, and exhaustion are among the health disorders that they are more likely to experience. According to a Harvard study on working women, women who experience job stress are 40% more likely to develop cardiovascular disease. Many also claimed that their child, who was their main responsibility, was being ignored, which caused them to experience irritation, remorse, and melancholy. --- Health Issues of Scheduled Tribe Employed Women: • Stress and Anxiety: The majority of working women experience constant fatigue and are overwhelmed because they work nonstop more or less than 8 hours of sleep a day is the norm for employed women, which increases their risk of developing diabetes, high blood pressure, heart disease, and stroke. Mental health is one of the most important health problems for women. Workplace pressure to achieve and other work-related pressures can lead to common disorders including stress, anxiety, and depression. Inadequate sleep and unhealthful eating practices can also be factors in depression. --- • Chronic Backache: The fact that working women are shattering the glass ceiling in the workplace cannot be disputed. But they also end up breaking their backs in the process. Body movement is restricted and multiple issues arise when people sit still in front of a screen for extended periods. They also don't have time to relax at home. • Thyroid: Because of the hormonal changes that occur in the body both before and after pregnancy, hypothyroidism is twice as common in women. It causes irregular menstruation, weight gain, and slowed metabolism. Both dehydration and irritable bowel syndrome (IBS), or chronic constipation, are rather frequent issues. • Breastfeeding, Discomfort (Mothers): Even when they are nursing, the majority of moms return to their jobs. A few mothers who work might decide to pump their milk and save it in a jar. But the strain of it all can wear down the body, causing ailments like mastitis, breast engorgement, or clogged milk ducts. • Weight Gain: Women who work and are employed struggle to find personal time and often have unhealthy eating habits that cause them to gain weight. Extended periods of inactivity brought on by sitting can cause fat to build, which can result in fatty liver, high blood pressure, and other health problems. • Nutritional Deficiency: Lack of time might lead to quick dinners that are high in calories but low in nutrients. It results in Iron, vitamin B12, and vitamin D deficiency. • Mental Health: Women in the workforce encounter "maternal bias," which is the perceived, whether intentional or inadvertent, notion that they cannot effectively perform both domestic and office tasks. More women than men report feeling tired and burned out, according to a McKinsey study. Likely to suffer from burnout or "Long-term Work-related stress that hasn't been effectively handled". Both physical and emotional symptoms, such as exhaustion, cynicism, lack of desire, headaches, tightness in the chest, nausea, stomach aches, and even more tears, might be signs of it. --- Major Challenges Faced by the Working Employed Scheduled Tribe Women: • Gender Biases: For Indian women, prejudice against them based on their gender starts at a very early age. The idea that women may labor side by side with men is incredibly difficult to comprehend. While women are viewed as weak and only able to withstand mild labor pressure at the workplace, Indian society encourages male dominance in all significant, vital, and difficult tasks. In terms of hiring, pay, and promotion opportunities, Indian women's potential and abilities have long been undervalued. In many homes, a woman's independence is only apparent because, even if she works, her whole income is provided to her husband, father-in-law, or other senior family member. Women still need to rely on someone even when they work. • Balancing Personnel and Professional Life: Maintaining a work-family balance is a major difficulty for Indian working women. She is accountable for meeting everyone's expectations, especially those of the children in the family. Professional goals and careers are still viewed as secondary for women in India. The bulk of families do not provide their working women with the emotional or moral support they need. In addition, working women face numerous official expectations and deadlines that must be met to continue working. As a result of these dual roles and pressure to perform flawlessly at all times, working women experience extreme stress in their daily lives. --- • Mental and Physical Harassment: Women believe that they need to do better than their male co-workers to succeed in the corporate field. Their supervisor will become more efficient and have higher expectations as a result. Women who have this kind of ailment experience stress. Working women experience stress due to inadequate maternity leave since they must care for their infants in addition to meeting their workplace goals. Indian working women experience workplace insecurity as well. Women who are subservient to men frequently beg their male bosses for sexual favors in exchange for the advancement and development they receive. The men in positions of authority demonstrate that they have shown some clemency or gone above and beyond in ways that women ought to return the favor. Male co-workers and superiors believe they can take advantage of their female subordinates and colleagues in the corporate sector since women are typically viewed as fragile. • Negligible Personnel Space: For Indian working women to become independent and successful in their lives, they must strike a balance between their families and careers. Women become agitated under this hassle. They strive to put in more effort to work harder, which causes them to sleep less. They eventually come to feel as though they are alone and frustrated and that no one is there to support and assist them. They experience feelings of loneliness occasionally, which causes them to struggle with numerous kinds of emotional and psychological issues. Two of the most common mental health issues that Indian working women experience are insomnia and depression. They experience a severe shortage of staff space. They don't have personal time. They know that no one will be able to relate to them, so they feel unable to express their sentiments to anyone. They have little choice except to give up the job or accept their despair as a necessary part of their working life in the face of this psychological pressure. --- • Married Working Women: A substantial majority of married women are prohibited from working, and their increased responsibilities make it harder for them to balance work and home duties. Women who provide financial support to the family or make more money than males are generally not appreciated because men are traditionally the breadwinners in the home. Wives in the workforce deal with issues at work too. Working late hours is not feasible for them. Mothers who work in most workplaces cannot leave their children in nurseries or daycares. • Negative Attitudes of Male Co-workers: Male coworkers might have quite demeaning and discriminatory attitudes at times. There is a perception that women are employed primarily to bring color to the workplace. Absenteeism, low employee turnover, and job discontent are caused by a lack of social support from coworkers and superiors in the workplace. The goal of higher authorities should be to create a welcoming and productive workplace. --- Conclusion: The issues and difficulties related to health that employed scheduled tribal women face were covered in the paper. Compared to other age groups, working women have particular health challenges. Working women often deal with concerns linked to mental health, reproductive health, hormonal fluctuations, and aging-associated illnesses. One poll found that 75% of working women had some sort of health issue. The document highlights and provides a detailed description of health, personal, and professional problems. Women face various scenarios and challenges in their quest to maintain a healthy balance between their personal and professional lives.

The challenges faced by women at every stage of life are indescribable, as they are the only beings in the world going through such dramatic changes as being born as a girl, getting married, and eventually becoming mothers. The main issue facing women in the twenty-first century is finding a work-life balance. They desire equal possibilities with men. Workplace discrimination against women, emotional and physical abuse, and inadequate leave are among the major concerns faced by employed Scheduled Tribe women. Apart from these, women are responsible for nearly all household chores, social responsibilities, and roles as mothers, wives, and housewives. The main concern of the paper is to highlight the health-related issues and challenges than working employed scheduled tribe women in the modern era face. It also aims to present a psychological and physical health perspective on these issues, challenges, and society's role in helping working women balance their lives on the psychological, physical, social, and mental levels.

Introduction For educators, the book Ambitious and Anxious: How Chinese College Students Succeed and Struggle in American Higher Education by Yingyi Ma (2020) is particularly intriguing because it presents a variety of insightful interviews and research. This book captivates the attention of academics and educators and serves as a valuable resource for all progressive thinkers in comparative education, international education, educational leadership, teacher preparation, curriculum studies, sociology of education, and educational policy. Its comprehensive exploration of the challenges and triumphs experienced by Chinese students in American higher education makes it a compelling read for anyone seeking a deeper understanding of cross-cultural educational dynamics and the implications for teaching and learning. --- Background Yingyi Ma, an Asian immigrant from China, is well-suited to assess how Chinese college students fare in American higher education because she has spent over 20 years exploring education and migration in both countries. In this book, she refers to some of the substantial writings she has done on the experiences of Chinese international students. As a result, the reader receives a very detailed cultural picture of Chinese students, parents, and the educational institutions of both nations. The book review is divided into two main themes introduced in the title, Ambitious and Anxious. In contrast to other studies on Chinese students in American higher education institutions, the Syracuse University Professor and Graduate Study Director Yingyi Ma's, book is based on years of sociological research. The volume includes online surveys, fieldwork, and one-on-one interviews that explore the experiences of various Chinese students. --- Ambition Ambitious' theme is covered in chapters 1, 3, 4 and 6. Chinese international students are described in Chapter 1 as a privileged but diverse group who are ambitious but anxious to study in the United States (US), all within the background of China's dramatic social development. The "ambitious" aspect of the title is reflected in the following few chapters, which focus on why Chinese students choose to study in the United States. Chinese international students want to develop a global perspective, choose the right major to help them reach their objectives, combine the benefits of both American and Chinese education, and contribute to China or the United States in the future. They are also concerned about the competitive environment in China, the anti-immigrant climate in America, and the convoluted and unclear admission procedures of American schools. In Chapter 3, Ma stated that in recent years, the Chinese international education sector has experienced two simultaneous streams of fresh development. One of these is the rapidly expanding international education in China's public and private sectors. The second stream refers to a tendency among Chinese families to enroll their kids in higher education in the US after High school graduation. This chapter focuses on the effects of parental education and economic status on foreign educational pathways, including students, applying to US colleges on their own and the employment of agents in college applications. Ma examines the perspectives of Chinese students on Chinese and American education in Chapter 4, along with their attitudes toward math, creativity, critical thinking, ability, and effortbased learning mindsets, the disconnect between precollege and college experiences, and academic integrity. She makes the case that while American education prioritizes critical thinking and creativity, Chinese education emphasizes conformity, rote memorization, and regimented curricula. In contrast, Chinese feel that effort promotes learning, while Americans believe that talent drives learning. Chinese parents intend to send their children to study overseas because "they want their children to have a quality education that transcends test scores" (Ma, 2020, p. 78). Ma contends that Chinese students tend to study harder than their American counterparts and that Confucianism influences their willingness to obey lecturers. In the meantime, some Chinese students feel lost and perplexed in the US. This is made worse if their American college is situated in a small or rural town because most incoming Chinese students come from big cosmopolitan cities. The author highlights that in Chapter 6 wealthy Chinese overseas students frequently select science disciplines based on the likelihood of employment. Ma (2020) asserts that the "strong cultural value and social approval in studying in STEM fields in contemporary Chinese society" (p. 139) continue to be critical considerations for this group. But even in these well-known areas, she adds complexity to the picture by highlighting gender differences and socioeconomic inequities that affect each student's decision-making. --- Anxious Anxious' theme is covered in chapters 2, 5, 7, 8 and 9. For these Chinese international students, the challenges of navigating the American educational system continue after their entrance and enrolment. During their undergraduate studies, many of the students in the book faced difficulties in both their social and academic lives, which is consistent with the word "anxious" in the title. The reasons why students were excluded from American peer groups owing to neo-racism and why they voluntarily withdrew into Chinese groups due to dissatisfaction with the American economy and individualistic culture are examined by Ma in Chapter 5. Chinese students were considered boisterous and exclusively formed friendships with other Chinese students. Ma believes that "the tendency to socialize with people like oneself, identified as homophily by social scientists, is human nature" (Ma, 2020, p. 109). Chinese students find it challenging to socially navigate the individualistic, party-focused, and occasionally neo-racist campus environment. In Chapter 7, Ma identifies the English language barrier as the primary rationale, premigration characteristics and institutional types as micro-contextual rationales, cultural differences, and the test-oriented educational system as macro contextual rationales for academic interactions, such as a lack of speaking up in class. They are aware of the value of class participation. Still, because they were raised in a society that values careful thought before speaking, and trained to answer only one question correctly, they experience extreme anxiety when they can't speak up right away. This understanding may push American teachers to adjust their teaching methods regarding classroom engagement activities. programs. One important claim is that the growth of global citizenship fosters students' interest and sympathy for China while encouraging criticism of American institutions and government. However, as students "become more independent and proactive in their lives" (Ma, 2020, p. 184), they and their parents may face difficulties and disputes. In Chapter 9, Ma (2020) discusses the decision-making process of Chinese international students, with over 60% intending to return to China after graduation. However, this binary decision of stay vs. return fails to capture the complexities of contemporary migration plans. Ma examines various factors, including US international education policy, family allure, the use of American graduate schools as a stepping stone, and opportunities in China as reasons for returning. Wealthy and ambitious students are more likely to return to China for better employment opportunities as it develops into a global superpower. Conversely, less affluent students wish to stay in the US for high starting wages to pay back their parents' investment in their education due to concerns about pollution and corruption in China. The book's greatest strength is its integration of American and Chinese contexts to provide a vivid picture of Chinese students. Ma also offers helpful advice on how teachers, academic staff, and higher education institutions may better assist Chinese students from when they apply until they graduate. Teachers and academics noticing an increase in Chinese students in their classes are welcome to these well-intentioned proposals. Nevertheless, despite its broad reach, the book does not address some important topics, such as mental health, academic plagiarism, concrete advice for Chinese parents or students considering studying abroad, and workable legislative recommendations to help American educational institutions better support Chinese foreign students, which in contrast, the author delineates. In addition, Ma agrees that there was positive selection bias in the online survey; students who agreed to be interviewed were also favourably chosen. Most of the conclusions could be more novel to Chinese domestic readers, despite the author's adequate depiction of the cultural shock and educational struggles that Chinese overseas students frequently experience. Given China and the United States' geopolitical tensions and experiences, particularly during the pandemic, future research should analyze the following: student decision-making processes regarding studying abroad, the policies or supports available in a specific institutional, regional, or global context, and why Chinese students are so excited about studying abroad. The author should look beyond the surface level social and economic factors and into the underlying logics of capital and value in international higher education. --- Conclusion Overall, for Chinese international students studying in the US, the book covers most of their life decisions. From their initial decision to attend American universities, to how they behaved and felt while there, and what happens afterward by filling in the blanks with knowledge and theoretical links. Therefore, this research book can aid educators in comprehending the challenges and issues associated with global education.

In contrast to other studies on Chinese students in American higher education, Syracuse University Professor and Graduate Study Director Ma's analysis is based on years of sociological research, including online surveys, fieldwork, and one-on-one interviews to explore the experiences of various Chinese students as individuals instead examine Chinese students as a collective. Ma looks at the goals, reflections, experiences, and future ambitions of Chinese students studying in the United States and the political, social, and economic contexts of both American and Chinese society. Examined is how these students' parents and the educational system have influenced them.

Background: Prejudice against transgender & gender-diverse people persists & is associated with physical & mental health harm. This study describes & characterizes comparative data between countries on gender self-definition/expression & its relationship to gender incongruence diagnosis. --- Methods: We used snowball sampling for a face-to-face survey in France (N = 379; 2010), Italy (N = 167; 2015-2016), Brazil (N = 391; 2016), & Chile (N = 377, 2018). Participants were 18+ years & identified as transgender. An open-ended item was used to capture the self-designation of gender: ''How would you describe your gender identity in your own words?'' We conducted chi-square bivariate analyses and multivariate regression models to examine variation in gender selfdefinition across countries & its relationship to obtain a change of legal sex/gender markers between countries & incongruence diagnoses. --- Results: The preliminary results indicate that self-definitions vary across countries. In France, categories were man, trans man, woman, trans woman, & trans. In Brazil & Chile, a traditional cultural category not in European countries was expressed: travesti. Results showed that a ''non-binary'' had to be included too. Results showed that lower percentages of trans persons in Chile (22% of trans men & 15% of trans women, Brazil (25% & 12%, respectively) & Italy (10% and 21%, respectively) changed their legal gender markers, as compared to France (34% and 35%, respectively) (p < 0.000). The results showed differences between countries considering the selfdefinition made by each participant regarding obtaining gender incongruence diagnosis with higher rates of diagnosis in Italy and France (p < 0.001). --- Conclusions: These findings show that transgender identity varies between countries & over time. The results indicate the importance of self-identification in trans-health studies, which have implications for global policy and research on the health of transidentifying persons. --- Abstract citation ID: ckad160.430 Coping with stress due to gender prejudice in Chilean transgender people: New findings using a qualitative approach Jaime Barrientos J Barrientos 1 1 Faculty of Psychology, Complutense University of Madrid, Madrid, Spain Contact: jbarrien@ucm.es --- Background: Like other nations, in Chile, transgender people confront high levels of prejudice operating across structural, interpersonal, and individual levels. The Minority Stress Model indicates that prejudice-related stress is related to worse health indicators. Coping has been used to understand how people deal with this prejudice-derived stress. This study describes and characterizes how gender 'prejudice is managed and coped with among transgender people in Chile. --- Methods: We used a snowball sample to recruit 26 transgender Chileans. The inclusion criteria were to be Chileans or lived in Chile last 6 months, identify as transgender and be 18 years old. We used a semi-structured interview guide with open-ended questions to capture the subjective self-designation of gender identification. Interviews lasted approximately 75 minutes. We used thematic and critical discourse analyses to identify themes and subthemes. --- Results: The results indicate that all participants experienced prejudice at different times and varied intensities. Prejudice occurs at home, where parents don ´t accept this identity, & at school in the form of bullying. Prejudices were also suffered in health centers & hospitals, where doctors exercised prejudice. Prejudice also depended on the period of the transition process. Prejudice was most intense at the beginning of the transition process & decreased as transition progressed. The results showed that trans-identifying persons used the following coping strategies: self-concealment, performing their gender (e.g., more feminine appearance), & advocacy for their rights & education. Each strategy is used in varied situations & by how one defined oneself. --- Conclusions: Coping strategies & the concept of coping must be revisited among trans-identifying persons. The coping strategies used are relevant for planning clinical and social interventions aimed at trans people who still live in prejudice due to their identity in many countries. --- Introduction: The sexual and gender minority (SGM) community is subjected to discrimination in healthcare settings due to the lack of knowledge and hostile attitudes among healthcare professionals globally. This study assesses the knowledge and attitudes of doctors in two hospitals in Sri Lanka towards SGM people & identifies various factors associated with their knowledge & attitudes. --- Methods: This cross-sectional study was conducted among 112 Medical Officers in two Sri Lankan hospitals. Data were collected through an online self-administered survey created using the modified SEKHQ (Sex Education and Knowledge about Homosexuality Questionnaire) & AHQ (Attitudes Towards Homosexuality Questionnaire). The response rate was 97.3% (N = 109). Cutoff scores were created to determine whether the knowledge and attitudes were 'good', & we used the Pearson correlation to assess their relationship. The association between attitudes and various factors was analyzed using the t test and we report p-values under 0.05. --- Results: The preliminary results indicated that most Medical Officers had 'good' knowledge (70.6%; n = 84) & attitudes (94.5%; n = 103) toward SGM people. A moderate & positive linear correlation (r = 0.567) between knowledge & attitudes was noted, such that better knowledge aligned with better attitudes. Sociodemographic factors, such as sex, marital status, & hometown of the participants, & professional factors, such as years of experience & graduation from university, showed no association with attitudes. In contrast, a strong association between self-perceived religiosity (higher religiosity) & negative attitudes was identified (p < 0.05). --- Conclusions: The knowledge and attitudes of doctors in the selected hospitals are satisfactory, & knowledge is a possible tool in shaping the attitudes toward the SGM community in Sri Lanka. Self-perceived religiosity harmed attitudes, which calls attention to specific education efforts needed among more religious providers. --- Background: Asian American and Pacific Islander (AAPI) sexual and gender minority (SGM) young and emerging adults are an especially high-risk group to consider in mental health research, holding multiple marginalized identities & report discrimination based on race/ethnicity & immigration status at double the rate of overall SGM youth. There is a need for extensive national studies that capture the experience of AAPI SGM youth to comprehensively elucidate the mental health burden on this often-overlooked population in the COVID-19 era. This study aims to describe the national landscape of AAPI SGM university student mental health & treatment usage. --- Methods: We data from the Healthy Minds Study, conducted between September 2021-May 2022 (n = 89,255) across 133 campuses in the United States. We used bivariate analyses & crosssectional logistic regression models to evaluate mental health symptoms, risk/protective factors, & treatment utilization across AAPI SGM students. --- Results: Preliminary findings indicate that 78% of AAPI SGM respondents report the presence of one or more positive screens for depression, anxiety, eating disorder, suicidal ideation, or non-suicidal self-injury. Among these students, approximately 57% report utilizing therapy or psychotropic medication. Experiences of discrimination & financial stress were the strongest correlates of mental health symptoms. Selfreported experiences of discrimination based on race, culture, & sexual orientation were associated with higher odds of treatment utilization for AAPI SGM domestic students but not for international students. --- Conclusions: The data underscore the need to consider the adequacy of current approaches in supporting AAPI SGM mental health, as well as unique ways to foster protective institutional & intrapersonal factors & increase investments to culturally responsive, gender-affirming treatment & prevention programs that address mental health disparities already looming in minoritized communities. Childhood obesity is a global public health problem in Europe and worldwide, influenced mainly by the nutrition and physical in/activity behaviours which are impacted by the structural food environment in which the child and his/her caregivers make lifestyle decisions. Individual eating behaviour is a complex societal practice, influenced by structural factors of the obesogenic environment with several health risks. Overweight and its associated chronic diseases (NCDs) reduce life expectancy in OECD countries by 2.7 years on average and 8.4% of the health budget of OECD countries will be spent to treat the consequences of overweight over the next thirty years. Including direct and indirect effects, overweight and obesity reduces GDP by 3.3% on average in both OECD countries and EU28 Member States. Joint Action 'Best-ReMaP -Healthy Food for a Healthy Future' (www.bestremap.eu)of 24 participating EU Member states (MSs) aims to contribute to positive changes in food environment in EU, by contributing to the improvement the quality of the food offer in EU, while placing public health at the centre of food systems-related policies and practice. With an ultimate goal to support EU and national efforts to reduce the burden of NCDs, Best-ReMaP addresses the selected food policies from three interrelated angles, which could influence children's food choices: (1) food reformulation (how the composition of the processed foods can be better monitored and producers more motivated to reformulate for healthier food options at the European and national levels); (2) reduction of food marketing (how the traditional and digital food marketing and advertising activities could be better monitored and regulated), and (3) public food procurements -PFP (how public institutions could procure foods that's healthier, of higher quality and more sustainable). Different actions have been considered, allowing for the possible sustainable implementation of the three up-mentioned policies, such as: three policy frameworks, food system indicator for the EU Semester, EU level branded

lower for those that knew 1-5 (-0.2), it was not significant (95% CI -0.8, 0.5). Among SGM, 67% experienced discrimination. In adjusted models, we found that transgender & nonstraight participants experienced more discrimination. The qualitative findings found that ''othering'' occurs in many contexts, such as housing, employment, healthcare, and virtually, but trans persons are most impacted. One participant shared, ''A transgender [person] may face more discrimination than a gay based on their physical appearance.'' Conclusions: SGM Rwandans are widely ''othered'' with negative implications for their ability to live authentically and participate in everyday experiences. However, results indicated that if non-SGM persons were acquainted with LGBTQ+ community members, discrimination is lessened.

Macro-sociological changes have long been speculated to affect suicide rates across age groups. 1,2 In the late 1870s, Enrico Morselli suggested that the suicide rate decreases at times of war when compared with times of peace. 3,4 Later, in the late 1890s, Émile Durkheim went on to further confirm this counterintuitive inverse relationship between war and suicide rates. He attempted to explain this phenomenon via what he called 'the social integration model'. This postulated that the drop in suicide rates results from a shift in the focus of individuals from their own suicidal wishes to a more collective goal of tackling the external threat. 5 Several European studies that investigated how the first and second world wars affected suicide rates across France, Great Britain, and Scotland were in support of Durkheim's assertion. [6][7][8] Over 200 000 Irish men fought in the First World War, of whom 50 000 are believed to have died; this is equivalent to an annual death rate of 225 per 100 000 of the population. 9, 10 The effect of the First World War on the Irish suicide rate has received limited attention from sociological and psychological researchers. This study sets out to investigate such an effect, if any. --- Method Suicide data in Ireland between 1864 and 1921 were gathered from the archive section of the Central Statistics Office's website. 11 We chose this range to focus the attention analysis on the effect of the First World War. We adopted an interrupted time series design. We model the natural logarithm of suicide rates per 100 000 for the years 1864-1921 using autoregressive integrated moving average with explanatory variable (ARIMAX) approach, that was successfully used before in a number of medical and non-medical studies. [12][13][14] We then calculated the coefficient for an indicator variable for the effect of First World War non-zero only for the years 1914-1918 and zero otherwise. Statistical analysis was performed using the R statistical package version 3.1.2. (http://beta.r-project.org). --- Results A noticeable slow-rising trend was present in terms of the suicide rates in Ireland from 1864 up to the year 1913. The average suicide rate for this period was 2.49 per 100 000. However, a sharp decline was noted from the year 1914 onwards, with an average of 2.64 suicides per 100 000 (Fig. 1). This trend was clear even when the suicide rates were calculated for men and women separately. The year 1912 witnessed the highest overall suicide rate of 3.763 suicides per 100 000 of the population and the highest suicide rate for men at 5.938 per 100 000, whereas the year 1910 witnessed the highest female suicide rate of 1.957 suicides per 100 000 of the population. The highest male-to-female ratio in terms of suicide rates was 6.17 and was observed in the year 1920. The year 1866 witnessed the lowest overall suicide rate of 1.213 suicides per 100 000 of the population and the lowest suicide rate for men at 1.666 per 100 000, whereas the year 1920 witnessed the lowest female suicide rate of 0.586 suicides per 100 000 of the population. On investigating the effect of First World War on the overall suicide rate, the coefficient in the interrupted ARIMA model was -0.172 (95% CI -0.305 to -0.040) which was statistically significant (P=0.011). The odds for death by suicide for the total Irish population during the 1914-1918 period were calculated as 0.842 (95% CI 0.787 to 0.901). This translates to a reduction in the suicide rates for men by 13.6% (95% CI 9.9 to 21.1). However, the coefficient for the effect of First World War on female suicide rate was -0.103 (95% CI -0.340 to 0.134) which was not statistically significant (P=0.394), although the confidence interval contains effect sizes comparable to that of the other groups. On the other hand, the coefficient for the effect of First World War on male suicide rate was -0.210 (95% CI -0.374 to -0.045) which was statistically significant (P=0.013). The odds for death by suicide for males during the 1914-1918 period was found to be 0.811 (95% CI 0.768 to 0.963). In other words, during the 5 years of the First World War there was a significant reduction in suicide rates for men by 18.9% (95% CI 3.7 to 24.2). --- Discussion At the time of the First World War, Ireland was part of the British Empire, and Irish soldiers served in the British Army. Although the psychological consequences of this war on Irish soldiers and the Irish public were studied sparsely, these may be reasonably believed not to differ profoundly from their British and European counterparts. In his investigation of suicide rates between 1901 and 1965, Lester found that suicide rates were lower during wartime in Great Britain. 5 However, this was not a large effect. In a study performed in the late 1940s, a sharp decrease in suicide rates in France, specifically in Paris, was noted during the First World War by Lunden. 4 The rates of French suicides, as Lunden established, continued to decrease even in the decade following the First World War. According to our findings, the Irish case has a number of similarities to findings by these researchers. The overall trend has taken a downward direction after the year 1914 as can be seen clearly in Fig. 1. However, applying more advanced statistical procedures, only the decrease in total suicide rate and male suicide rates can be supported by statistical evidence. Females' suicide rate reduction during wartime was not different from peacetime. Divergence of male and female suicide rates was thought to be a more recent phenomenon. 15 Indeed, our paper shows support for this as the trends were roughly similar between the two genders. An important limitation to this investigation is the potential under-reporting of suicide deaths that may have been worsened by the difficulties faced by local registrars, whose knowledge, training and experience may vary considerably, during wartime. However, to our knowledge, this is the first study to specifically evaluate the effect of the First World War on Irish rates of suicide. Data were only available for the whole Irish population, i.e. the 32 counties, and it could have been more interesting to investigate the effect of the First World War on people living south and north of the borders separately. Irish rates of suicide were reduced during the First World War most notably for males. This provides some further support to Durkheim's social theory of suicide indicating that Irish men may have focused on the collective goal of defending their island rather than their suicidal wishes during the 1914-1918 war.

Since the proposition of the social integration theory by Émile Durkheim, macro-sociological changes have been speculated to affect suicide rates. This study investigates the effect of the First World War on Irish suicide rates. We applied an interrupted time series design of 1864-1921 annual Irish suicide rates. The 1864-1913 suicide rates exhibited a slowrising trend with a sharp decline from the year 1914 onwards. The odds for death by suicide for males during the 1914-1918 period was 0.811 (95% CI 0.768-0.963). Irish rates of suicide were significantly reduced during the First World War, most notably for males.

Introduction The prevalence of Alzheimer's disease and related dementia (ADRD) is higher among Hispanics and Blacks than non-Hispanic Whites in the United States [1]. Among the proportion of people with dementia who live in the community rather than in assisted living facilities (70%-81%), most are cared for by family or friend caregivers [1]. A systematic review by Petosa and Smith found that peer social support is an effective contributor to meeting one's health goals [2]. Experimental evidence in behavioral science specifically highlights the critical role of dyad or triad friendship relations in social support [3]. Although social scientists have reported a strong correlation between beneficial behavior and group cohesion in triad friendships since the mid 19 th century, triad friendships and their associated benefits were rarely observed in previous social media-based studies of minority dementia caregivers [4]. Social network analysis is commonly used to assess social structures such as the composition of groups (e.g., large groups, small groups, triads, and dyads) and dynamics (e.g., relationships, links, and temporal interactions) using network and graph theory [4]. Social network analysis of online communities, particularly Twitter, may provide insights to aid the design of culturally sensitive and customized social support interventions for Hispanic and Black family caregivers for persons with dementia [4,5]. This study aims to apply social network analysis to a large corpus of Tweets to gain insights about Hispanic and Black dementia caregiving networks. --- Methods We applied network analysis techniques to publicly available Twitter messages (Tweets) mentioning dementia (keywords/hashtags: #dementia, #demencia, #Alzheimers). We used the Twitter Application Programming Interface (API), Python, and a High-Performance Computing (HPC) Cluster (https://osf.io/qruf3/) to extract these messages from a random sample of publicly available Tweets collected daily using via the Twitter API from September 1 to December 31, 2019 (n= 2,742,539 Tweets). Our team's behavioral domain expert and clinician first extracted and categorized U.S.-based Tweets from the initial corpus (n= 549,380 English Tweets, n= 185,684 Spanish Tweets). Second, we applied a Twitter bot detection algorithm to remove bot-generated Tweets using the Botometer Python API (https://github.com/IUNetSci/botometer-python). Third, we applied a lexicon-based demographic inference algorithm to automatically identify Tweets likely authored by Black or Hispanic individuals (n= 114,511 English, n = 1,185 Spanish, https://osf.io/qruf3/). Fourth, we applied Social Network Analysis to the winnowed Tweet corpus to automatically detect similar communities and to identify stakeholders with a high degree of network centrality. Fifth, to avoid algorithm dependency, we applied and compared the results of five clustering algorithms: Leiden, Principal Component Analysis, Louvain, CONCOR, and Newman. Sixth, network measures at the macro, meso, and micro levels were calculated to compare Black and Hispanic dementia caregiving networks within Twitter using the ORA meta-network analysis software. Seventh, we visualized Black and Hispanic dementia caregiving networks within Twitter at macro, meso, and micro levels. Lastly, behavioral science experts and a clinician evaluated the results according to their clinical meaningfulness for the design and recruitment strategy of a social support intervention for Hispanic and Black dementia caregivers on Twitter. The larger study was approved by the Institutional Review Board (IRB). --- Results Dementia caregiving-related Tweets potentially created by 5,321 Black users were disseminated to 280,042,783 users, with retweets outnumbering original messages by a factor of 11. In contrast, the dementia caregiving-related Tweets in Spanish created by 409 users were disseminated to 6,141,424 users at a ratio of 11,798 retweets to each original message. The top 10 stakeholders who disseminated dementia caregiving-related messages in English were identified as media outlets, a lay person, a psychologist, a social worker, and an association; among Spanish-language tweets, the top stakeholders were an individual, a media outlet, a lawyer, a community organization, and an economist. 123 groups (17.0%, Louvain modularity value: 0.802) were found in the Black dementia caregiving network, whereas 14 distinct groups (11.0%, Louvain modularity value: 0.801) were detected in the Hispanic caregiving network. Both networks contained a similar proportion of dyads or triads (Hispanics: 88.2% dyads or triads, Blacks: 88.9%), while the Black caregiving network included a slightly larger proportion of isolates (Hispanics: 0.8%, Blacks: 4.0%) (Figure 1). --- Discussion and Conclusions This study examined the characteristics of macro, meso, and micro-level social network structures among Hispanic and Black dementia caregiving networks on Twitter. In the macro-level social networking structure, a substantially larger number of Black dementia caregiving network users were engaging in the conversation than in the Hispanic dementia caregiving network in the U.S. (5321 users, 3941 retweet activities vs. 409 users, 291 retweet activities) over three months. According to the U.S census in 2020, the total percentage of the population identifying as Black is smaller than the total number of Hispanics (13.4% vs. 18.5%). Consistent with the existing literature on the strong presence and cohesiveness among Black communities in Twitter in the U.S., our findings confirms that cohesive communities among Black networks on Twitter are present in the context of dementia caregiving. Indeed, more community groups were observed in the Black dementia caregiving network than in the Hispanic dementia caregiving network in the U.S. (123 groups 17.0% vs. 14 groups, 11.0%) in the meso level social networking structure. Social cohesiveness, a determinant for population health (Healthy People 2030), has been referred to as the way in which individuals within a society are bound together by attitudes and behaviors. Social cohesion and social support has been associated with decreased depression [6], stress and emotional burden among primary family caregivers of older adults [7]. A novel finding of this study is that the Hispanic dementia caregiving network included a very small proportion (0.8%) of isolates who express themselves without quoting others' messages. Not only is this number smaller than in the Black caregiving network (4.0%), but it is unusual in the context of social networks that develop around diseases such as HIV or COVID-19 on Twitter. Further, the social science-based concept of the optimal number of community members, which in these cases range from two to a hundred people, has not been explored in the context of providing social support for dementia caregivers in the Twitter space. Studies with an interventional design using Twitter are needed to investigate each community's optimal number, which then will enable interventions to deliver social support messages meaningfully and costeffectively to racial/ethnic minority dementia caregivers. The Louvain social network clustering algorithm was selected after comparing the utility of the five clustering algorithms listed above. The performance of several of the alternative clustering algorithms on our dataset was suboptimal for the following reasons: 1) Leiden: degree of clustering performance is not available; 2) Principal Component Analysis: results included one large dominant cluster, which is clinically less meaningful; 3) CONCOR: prone to subjective bias; 4) Newman: clustering modularity score was slightly lower than that computed via Louvain (0.801 vs. 0.802). In conclusion, this study provides useful baseline information on the composition of existing large groups, small groups, and isolates among Hispanic and Black dementia caregivers on Twitter, which will help guide the design and future recruitment strategies of social support interventions involving community engagement and partnership in these minoritized communities.

We applied social network analysis (SNA) on Tweets to compare Hispanic and Black dementia caregiving networks. We randomly extracted Tweets mentioning dementia caregiving and related terms from corpora collected daily via the Twitter API from September 1 to December 31, 2019 (initial corpus: n= 2,742,539 Tweets, random sample n= 549,380 English Tweets, n= 185,684 Spanish Tweets). After removing bot-generated Tweets, we first applied a lexicon-based demographic inference algorithm to automatically identify Tweets likely authored by Black and Hispanic individuals using Python (n= 114,511 English, n = 1,185 Spanish). Then, using ORA, we computed network measures at macro, meso, and micro levels and applied the Louvain clustering algorithm to detect groups within each Hispanic and Black caregiving network. Both networks contained a similar proportion of dyads and triads (Hispanic 88.2%, Black 88.9%), while the Black caregiving network included a slightly larger proportion of isolates (Hispanic 0.8%, Black 4.0%). This study provides useful baseline information on the composition of existing large groups and small groups. In addition, this work provides useful guidance for future recruitment strategies and the design of social support interventions regarding emotional needs for Hispanic and Black dementia caregivers.

Socioeconomic status as a barrier to accessing postgraduate study Existing initiatives to widen participation in higher education (HE) have focused on enhancing access to undergraduate study for students from lower socioeconomic (SES) backgrounds (Herbaut & Geven, 2020). Whilst widening participation developments aim to encourage changes to the accessibility of undergraduate study for students from lower SES backgrounds, they do not focus on accessibility beyond undergraduate study for students who wish to progress to postgraduate researcher (PGR) roles (Universities UK, 2021). In the UK, recent studies have found students from lower socio-economic households to have lower rates of transition to postgraduate study and are 28% as likely to gain a postgraduate degree as their more advantaged peers (Mateos-González & Wakeling, 2022;Wakeling & Laurison, 2017;Wakeling et al., 2017). Despite the PGR student body being perceived as essential in sustaining the academic workforce (Christie et al., 2005) and the number of PGRs rising dramatically within the UK HE sectors (Morgan, 2015; Universities UK, 2021), the experiences of students wishing to progress to doctoral level study (e.g., PhD) appear to have been neglected by researchers and HE institutions (Mattocks & Briscoe-Palmer, 2016;McPherson et al., 2017). Consequently, it is necessary to identify potential areas of focus for supporting students from lower socioeconomic backgrounds achieve postgraduate degree qualifications. Higher drop-out rates amongst undergraduate students from lower socioeconomic backgrounds (Lewis et al., 2021) and less desire to progress to PGR roles, are unsurprising given the association between student experience and socioeconomic status. Bourdieu's (1986) social reproduction theory suggests social class consists of economic capital (financial wealth), cultural capital (familiarity with the dominant culture) and social capital (networks and contacts). The theory suggests the dominant culture (e.g., students with higher economic, cultural and social capital) replicates the characteristics of those already assimilated to that culture, leaving students with lower economic, cultural and social capital to occupy the non-dominant cultural space. As students move away from their peers of a lower class as defined by Bourdieu (1986) towards the elite field of BARRIERS TO POSTGRADUATE STUDY 3 HE, they are reported to experience discomfort, intimidation, withdrawal, lack of confidence and isolation (Reay, 2021). The existing evidence base on what support students from lower socioeconomic backgrounds may require, especially when considering postgraduate education, is limited. Mateos-González and Wakeling (2022) explored patterns of progression to postgraduate study amongst UK students who had completed an undergraduate degree in the years 2015/16 and 2016/7. Whilst the authors conclude that educational attainment in undergraduate degrees can mitigate the impact of barriers specific to social class, it remains the case that students from lower social class backgrounds are underrepresented in research degrees. This research rationalises improvements to the inclusivity of doctoral degrees. It does not however, explain the trend that students from higher socioeconomic backgrounds are more likely to access research degrees, which participatory research approaches with undergraduate students could shed light on. Socioeconomic status is not a protected characteristic (Equality Act, 2010) and consequently, class inequalities often go unrecognised for postgraduate study or research, making the barriers for some students progressing from undergraduate education challenging to detect. Understanding the barriers to accessing postgraduate study and research posts through the lens of class-related inequalities is an important first step to providing necessary student support. --- The CLASS (championing lower-class academic and social success) programme The authors of this paper are all PhD students and early career researchers in the field of applied healthcare. Driven by their own experience in academia and the lack of empirical evidence explaining the disproportionate number of working-class PGRs and academics, we developed the CLASS (championing lower-class academic and social success) programme. To be as inclusive as possible, CLASS is open to any student who self-identifies as working-class. The programme aims to harness the lived experience of working-class individuals to not only uncover the barriers to accessing postgraduate study but offer potential solutions at an institutional level. To address these issues, the CLASS programme proposes the following aims and objectives: --- Programme Aim To… 1) identify barriers that exist for students who identify as working class that impact their level of motivation or ability to study at postgraduate level. 2) work with students to develop strategies at an institutional level for overcoming these barriers. --- Programme Objectives To … 1) understand and address the barriers, challenges and concerns related to academic progression for individuals who identify as working-class. 2) share barriers, challenges and concerns with decision makers to implement initiatives that can improve access to postgraduate opportunities for people who identify as working class and address gaps to work towards a more inclusive environment. --- The CLASS Programme During 2022, three interactive CLASS workshops were piloted online and in-person. All sessions were developed with student input and facilitated an informal, trustworthy environment. The initial scoping session prompted discussion around defining student's experiences as workingclass academics, and what benefits and barriers they perceived to PhD study. Based on the student feedback shared within the initial scoping session, a programme of events was developed. Students conceptualised their working-class identity as a cultural way of being, a social group who satisfied their needs rather than wants, perceived as individuals who work harder than their middle-class counterparts to afford a living. Working class was seen as working to survive, fighting a system to be valued and respected. Some students considered this term old-fashioned, preferring 'lower socio-economic background' instead. Finally, many students felt passionate about identifying as working-class, enabling them to be their authentic self, within the middle-class spaces they now occupy. Financial issues were a key barrier raised by students who thought that PhDs were selffunded, most being unaware of stipends and that these were tax-free. A lack of awareness about the financial support that could be available to students was apparent, with students worried about having to save in advance or be employed elsewhere whilst studying. Students were not aware that there were tax free stipends, council tax exemption, free childcare allowance, postgraduate government loans and opportunities for combined teaching and research roles, all avenues of income. Feelings of imposter syndrome, not belonging or fitting in with the 'lecturer upper middleclass' stereotype were discussed, alongside the impression that academics lacked understanding of their lived experiences as working-class students. A lack of comprehension of academic language and representation and not relating to current lecturers, perceived to be middle/upper class contributed to a lack of interest in a career in academia. How students were perceived by family and friends if they undertook a PhD also mattered. Many students felt proud of their working-class status and did not want this status to be perceived by friends and family as something they were trying to escape. These preliminary workshops have enabled us to gain an initial understanding of the barriers, challenges and concerns related to academic progression for individuals that identify as working-class, first-generation students or students that have successfully completed access courses (Objective 1). Furthermore, we have begun to increase student's awareness of networks and different career opportunities. It is our intention to continue to focus on these programme objectives through our research, design and development of upcoming resources and sessions. --- Considering Future CLASS Initiatives Looking ahead to the next academic year (2022/2023), first, we plan to conduct an electronic Delphi study, a systematic and qualitative method to achieve consensus of opinion through several rounds of questions (Skulmoski et al., 2007). The study will achieve consensus on the barriers surrounding access to PhD study for students who identify as working class. Future research will also explore and receive feedback from students on potential solutions implemented at an individual and institutional level. We will share barriers, challenges, and concerns with decision makers to design initiatives that work towards a more inclusive environment (Objective 2). Informed by our research findings we then intend to widen the access and availability of resources and sessions developed, making these more readily available to students across the UK and potentially internationally. It is our intention to then develop a virtual platform which will provide students with a portfolio of new and developed resources, including live online workshops hosted by ourselves. For a visual summary of the key findings and next steps for the CLASS pilot workshops discussed, please see supplementary file 1. --- Conclusion We consider individuals, but more so institutions, to be the agent of change for rectifying the barriers that exist for students who identify as working class that impact their level of motivation or ability to study at postgraduate level. We are interested in facilitating a movement towards an academic environment that responds to the needs of those from wider class backgrounds, rather than simply expecting and placing the ownership on individuals to socially adjust. Through shining a light on the lived experience of working-class, prospective PhD students, we intend to work with HE institutions to facilitate their progression into and experience within, PGR roles.

Whilst the widening participation programme aims to increase the accessibility of undergraduate study for students with a lower socio-economic status, much less support is available for students wishing to progress to postgraduate study. Postgraduate study risks becoming a discipline exclusive to those from upper-middle class and upper-class backgrounds, with too few role models from lower socioeconomic backgrounds encouraging uptake. To explore class-related inequalities in academia reported by existing data through the lens of access to postgraduate study, we developed, and piloted, the CLASS (championing lower-class academic and social success) programme within our university. The programme aims to harness the lived experience of working-class individuals to uncover the barriers to postgraduate study and to develop strategies at an institutional level. An initial understanding of the barriers and challenges current students experience have been captured in our pilot programme. Future CLASS initiatives include assessment of these barriers at a national level to harness findings through the development of strategies with universities.

Female genital mutilation (FGM) is a practice that the World Health Organization (WHO) estimates to affect 200 million women globally. The practice of FGM is often attributed to the Middle East, sub-Saharan Africa, North Africa and, to a lesser extent, Asia; however, it is now being witnessed in cities worldwide with high numbers of FGM-practising communities. The WHO defines FGM as 'all procedures that involve partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reason'. While FGM has no health benefits, in certain cultures, the practice confers upon women full social acceptability and integration into the community and serves as a rite of passage to womanhood and marriage (Mpinga EK, Marcias A, Hasselgard-Rowe J et al. Female genital mutilation: a systematic review of research on its economic and social impacts across four decades. Glob Health Action 2016; 4:9). This systematic review aimed to assess the dermatological impact of FGM on women and the role dermatologists can play in the fight against the practice. A systematic review was carried out in accordance with the PRISMA guidelines. PubMed (n = 98), Cochrane (n = 1), CINAHL (n = 8) and Embase (n = 38) were searched for articles published between January 1990 and January 2023 with the phrase 'female genital mutilation and skin or dermatology'. A total of 148 studies were initially identified; following screening, 21 articles were deemed suitable for inclusion and analysed. The literature highlighted that the main dermatological consequences of FGM were severe keloid formation, hypertrophic scars, vitiligo lesions, clitoral neuromas and, most commonly, epidermal inclusion cysts (Dave AJ, Sethi A, Morrone A. Female genital mutilation: what every American dermatologist needs to know. Dermatol Clin 2011; 29:103-9). A study of women in Somalia who had been admitted to the hospital following complications due to FGM noted that 55.1% of women (n = 65/118) had developed epidermal inclusion cysts. The literature suggests women often feel shame approaching clinicians for help; however, without support, these women can experience years of dyspareunia, dysuria, pruritus, pelvic pain and obstetric complications, as well as increased transmission of sexually transmitted infections and HIV following damage to the vaginal epithelium. By analysing the literature, it is clear further research into the dermatological consequences of FGM is necessary so that a conversation can be had about the ways in which dermatologists can effectively support survivors of FGM. It is important that each woman is recognized as an individual with her own story to tell, her own lived experience and her own humanity. --- Abstract citation ID: ljad113.282 GD08 Migrant dermatology --- Marta Costa Blasco and Anne Marie Tobin Tallaght University Hospital, Dublin, Ireland Conflict, war or economic hardship often causes refugees to flee their communities. The recognition of refugees as a diversified group from a medical aspect is one of importance as they have a range of health needs that differ from the native population. Based on a review of the published literature and cases we have reviewed in our dermatology department, we would like to outline an overview of the challenges associated with managing skin conditions for migrants and refugees, as well as key opportunities to improve care for this community. The initial barrier experienced is primarily related to communication difficulties. Healthcare providers meet obstacles in trying to communicate effectively with refugees as translation services are not always readily available and the waiting time involved for such services results in a further delay in patient management. It came to our attention that refugees often do not communicate all their issues or symptoms because of other complex social issues that take precedence over their symptoms. A separate, substantial issue arises given the lack of documentation regarding their medical background and previous and current treatments. Other challenges faced are the costs associated with accessing pharmaceutical products and not having primary care physicians. Furthermore, staying in temporary accommodation makes it more likely that they will not receive follow-up appointments, resulting in future missed appointments. Overall, refugees are a vulnerable cohort and a substantial multidepartment effort should be made to ease their integration into national healthcare systems. --- Historical abstracts --- Orals

difference of 10.32 tonnes of carbon emissions. The provision of peripheral dermatology clinics has a significant positive impact on the environment and greatly reduces the distances travelled by patients. Our study suggests that satellite clinics could reduce carbon emissions by 10.32 tonnes annually. This equates to 138 flights from Dublin to London, or 12 900 takeaway coffees. This study has demonstrated that the provision of peripheral clinics can make healthcare more sustainable, by reducing the number of carbon emissions being produced.

7 (0.3%) with sleep disturbance and 41 (1.7%) with adjustment disorder. Prevalence of ADHD was higher in children exposed to parental depression compared with those not exposed (4.5% vs 2.8%, p≤0.03). Psychotropic drug prescriptions were higher in children exposed to parental depression compared with those who were not exposed (2.9% vs 1.6%, p≤0.03). Multivariate regression analysis revealed that increased exposure to IPV as well as depression was associated with increased risk of ADHD diagnosis compared with non-exposure (OR 4.0, 95% CI 1.5 to 10.9; see table). Exposure to parental depression was also associated with increased risk of child psychotropic medication prescription (OR 1.9, 95% CI 1.0 to 3.4). There were no significant associations with exposure to IPV only or with both exposures for any other mental health condition. CONCLUSIONS-Exposure to parental IPV and parental depression within the first 3 years of life is associated with increased risk of ADHD diagnosis prior to 6 years. Early exposure to parental depression is associated with increased risk of psychotropic medication prescription. A substantial body of research has documented that exposure to childhood adversity, including witnessing intimate partner violence (IPV) and parental depression, influences millions of children annually, and is associated with elevated psycho-pathology in youth. 1 However, much of the existing research is limited in ways that impede causal inference and clear clinical implications. Bauer and colleagues should be commended for their study, which found that children whose parents reported IPV and depressive symptoms before age three had increased risk of developing attention deficit hyper-activity disorder (ADHD) between 3 and 6 years of age, and children whose parents reported depressive symptoms (in the absence of IPV) were more likely to be prescribed psychotropic medications. This study overcomes many common limitations by incorporating valuable design characteristics, including: (1) a prospective design to establish temporal ordering; (2) recruitment from primary-care clinics, resulting in findings that are broadly generalisable; (3) a preschool-age sample, representing a developmental period for which prospective research is limited; (4) use of billing codes and pharmacy claims to ascertain outcomes, which avoids biases associated with parental report and (5) simultaneous consideration of IPV and parental depression, as these adversities often cluster together. This study has important implications for clinical practice because it demonstrates that simple surveillance strategies in clinics are able to identify families experiencing risk factors for mental health problems or psychotropic drug treatment in preschool-age children. Clinicians can use this information to identify families in need of intervention and children who would benefit from prevention-oriented interventions to mitigate risk for psychopathology. Future research is needed to understand whether early identification can be improved by using more robust brief screening measures. It will be important for future studies to evaluate the specificity of these findings for ADHD; it is currently unknown whether this is a developmentally specific outcome that broadens to other forms of psychopathology as children develop. Identifying the psychosocial and neurobiological mechanisms underlying these associations may facilitate the development of novel interventions.

QUESTION-Question: Does exposure to parental depression or intimate partner violence (IPV) during the first 3 years of life have an effect on a child's subsequent mental health? People: A total of 2422 children (52% boys, Hispanic/ Latino 45.5%, Black 40.6%, White 10.5%) visiting health centres served by the Child Health Improvement through Computer Automation (CHICA) paediatric primary care system, from birth to age 3 years, and again when aged between 37 and 72 months.

in 5 Although teen birth rates have been falling for the last two decades, more than 365,000 teens, ages 15-19, gave birth in 2010. Teen pregnancy and childbearing can carry high health, emotional, social, and financial costs for both teen mothers and their children. Teen mothers want to do their best for their own health and that of their child, but some can become overwhelmed by life as a parent. Having more than one child as a teen can limit the teen mother's ability to finish her education or get a job. Infants born from a repeat teen birth are often born too small or too soon, which can lead to more health problems for the baby. Repeat teen births can be prevented. --- Health care providers and communities can: ◊ Help sexually active teen mothers gain information about and use of effective types of birth control. ◊ Counsel teens that they can avoid additional pregnancies by not having sex. ◊ Connect teen mothers with support services that can help prevent repeat pregnancies, such as home visiting programs. *A repeat teen birth is the 2nd (or more) pregnancy ending in a live birth before age 20. National Center for Chronic Disease Prevention and Health Promotion Division of Reproductive Health Too many teens, ages 15-19, have repeat births. Nearly 1 in 5 births to teens, ages 15-19, are repeat births. ◊ Most (86%) are 2nd births. ◊ Some teens are giving birth to a 3rd (13% of repeat births) or 4th up to 6th child (2% of repeat births). ◊ American Indian and Alaskan Natives, Hispanics, and black teens are about 1.5 times more likely to have a repeat teen birth, compared to white teens. ◊ Infants born from a repeat teen birth are often born too small or too soon, which can lead to more health problems for the baby. Working together, a sexually active teen and her doctor or other health care professional can decide on the best birth control method. ◊ More than 9 in 10 (91%) sexually active teen mothers used some form of birth control, but only about 1 in 5 (22%) used the most effective types of birth control. ◊ White (25%) and Hispanic (28%) teen mothers are almost twice as likely as black teen mothers (14%) to use the most effective types of birth control. ◊ Long-acting reversible birth control can be a good option for a teen mother because they do not require her to do something on a regular basis -such as take a pill each day. ◊ Hormonal implants and IUDs are two types of long-acting reversible birth control. These are some of the most effective forms of birth control. Percentages: --- How many teens have repeat births? Less than 15% --- 15-19% Greater than 20% Sexually active teens should use condoms to prevent sexually transmitted diseases and consider using another type of birth control to further reduce the risk of pregnancy. --- Risk of pregnancy with typical use --- Female condom • Use correctly every time you have sex --- Sponge • Use correctly every time you have sex --- Rhythm method • Use correctly every time you have sex --- Spermicide • Use correctly every time you have sex --- Withdrawal • Use correctly every time you have sex *The most effective methods also include sterilization, but because this method is very infrequently used by teens, it was not included in the table. 3 --- ◊ Advise teen mothers that births should be spaced at least 2 years apart to support the health of the baby, and that having more than one child during the teen years can make it difficult for teen parents to reach their educational and work goals. ◊ Remind sexually active teens to also use a condom every time to prevent sexually transmitted diseases, including HIV/AIDS. --- Parents, guardians, and caregivers can ◊ Talk about how to avoid repeat births with both male and female teens. http://www.cdc.gov/teenpregnancy/parents.htm ◊ Check with your insurer about coverage of preventive services. In some cases, preventive services, such as birth control methods and counseling, are available with no out-of-pocket costs. ◊ Talk with community leaders, including faith-based organizations, about using effective programs that can help prevent repeat teen pregnancies. --- All teens, including teen parents, can ◊ Choose not to have sex. ◊ Use birth control correctly every time if they are having sex. Use condoms every time to prevent disease. ◊ Discuss sexual health issues with their parents, partner, health care professionals, and other adults and friends they trust. ◊ Visit http://www.hhs.gov/opa to find a family planning clinic near them for birth control if they choose to be sexually active. --- What Can Be Done

About 1 in 5 sexually active teen mothers use the most effective types of birth control after they have given birth.

Based on an ethnographic study of the Swedish digital BDSM, fetish and kink platform Darkside, this paper theorizes opacity in two ways: first, as a way of discussing tactical uses of Darkside between modes of revealing and concealing, and second, as a way of conceptualizing the platform as a borderland between intelligibility and unintelligibility. Sexual liberation is often understood in a framework of progressive, Western modernity and particular forms of public visibility and pride, whereas a lack thereof is inevitably linked to oppression, secrecy and closeted shame. And yet, a focus on public visibility as the universally empowering method of progressive sexual politics and as grounds for recognition obscures the significance of sexual expressions that are marginal, ephemeral and less than public, or public in other, more subtle ways (cf. Edenborg 2017, Stella 2012). Swedish kink communities are at once marginalized and seemingly mainstream, navigating a tricky balance between pop cultural visibility and lingering stigma. Digital practices on Darkside are usually neither about concealed, closeted shame, nor an unequivocal desire for full transparency and public recognition. While governed by activist visions of proud openness, the platform primarily takes shape through tactical investments in obscure, partly concealed, but nonetheless proud forms of kink expression. Darkside provides an opening for shared vulnerability and collective forms of 'radical secrecy' (Birchall 2021), which grants both privacy and degrees of public kink visibility to its members. Then again, the users are highly aware of the permeable boundaries of platforms. Pictures are thus routinely cropped, angled or blurred in ways that make identification difficult. By moving between modes of revealing and concealing, sexual expressions on Darkside resonate with what Nicholas De Villiers (2012) terms 'queer opacity.' Opacity, here, is as a set of queer tactics which challenge the binary construction of the closet and by resisting legitimization via public outness invent new forms of illegible sexual expression (see also Uibo 2021, 156-185). In the work of the Caribbean writer, poet and philosopher Édouard Glissant (1997), opacity is a similar tactic of the oppressed. Glissant argues that the understanding and acceptance of the other within Western thought is based on transparency and measured against an ideal, normative scale which inevitably reduces the other. He therefore insists on the need to "clamor for the right to opacity for everyone," referring to an ontological right of the oppressed to be non-transparent, non-categorizable, not fully understood and simply exist as different (Glissant 1997, 194). This right to opacity is a form of resistance to surveillance and imperial domination, which within digital media studies has spurred discussions on resistance against data-driven surveillance technologies through forms of concealment and camouflage (see Birchall 2016, Blas 2014, de Vries & Schinkel 2019). Opacity implies a lack of clarity; something opaque may be both difficult to see clearly as well as to understand. Kink communities exist to a large extent in such spaces of dimness, darkness and incomprehensibility, partly removed from public view and, importantly, from public understanding. Kink certainly enters the bright daylight of public visibility in some ways, most obviously through popular culture. And yet, there is something utterly incomprehensible about how desire works, something which tends to become heightened in the realm of kink as non-practitioners may struggle to 'understand.' By exceeding categories of identifiable difference, or of identification altogether, a digital sexual politics of opacity could help provide recognition without a demand to fully understand sexual otherness. Opacity here works to overcome the risk of reducing, normalizing and assimilating sexual deviance by comprehension, and instead open up for new modes of obscure and pleasurable sexual expressions and transgressions on social media platforms.

Building on and expanding discussions of the value of anonymity and pseudonymity in digital cultures in general (Hogan 2012, Marwick & boyd 2011, van der Nagel 2017, van der Nagel & Frith 2015), and in queer digital cultures in particular (e.g. Cassidy 2013, Dhoest & Szulc 2016), this paper explores notions of opacity as modes of resistance to dominating regimes of visibility on and beyond social media platforms. Across queer, postcolonial and digital media theorizing, opacity provides a way of thinking through the tension between the visible and the invisible, challenging the idea of public visibility and identification as that which drives data cultures and legitimizes deviant sexual practices and expressions. In line with discussions of tactical, queer uses of social media in terms of, for example, disconnection (Light 2014, Sundén 2018), reluctance (Cassidy 2018) and invisibility (Tudor 2018), opacity affords yet another way of theorizing resistance to platform power and user control. When large social media platforms keep careful track of their users' identities and movements for the sake of algorithmic capture, to refrain from transparent identification can be a radical act (cf. Birchall 2021, Blas 2014, 2018).

Introduction: The term "entrepreneurship" generally defines the mechanism by which new products, services, and organizational processes are recognized realized as a sustainable part of the society. Societies depend on entrepreneurs to drive job growth, innovate results to pressing problems, and found technologies. Although profit is essential for a sustainable organization, it's not always the end goal. This is the reason that social entrepreneurship was advanced and implemented. Social entrepreneurship is an original form of business, which successfully combines social aims and commercial practice. It has emerged as an answer to chronic social problems: unemployment, poverty, community fragmentation etc. Every entrepreneurship is to a certain amount social entrepreneurship, and social entrepreneurship has as a goal to show the public sector how to be more effective and efficient. Social entrepreneurship is about the inventiveness and the intelligence of the social entrepreneurs to do something good or something needed by society. --- OBJECTIVES: --- • To help & create fair, equitable and sustainable societies with a high quality of life for all citizens --- • To grow a successful social enterprise supporting our communities --- • To encourage people to be more confident and 'get involved' with their personal development --- • To create a culture of social responsibility, both across the organization and communities --- METHODOLOGY: The above study has taken primary as well as secondary sources of data. The primary data collected from the social entrepreneurs through questionnaire as well as secondary data from various books and internet. --- LIMITATIONS OF THE STUDY: • Due to time constraint, the study has restricted to only to the respondents of Udupi city people. --- • The sample size is limited to 28 respondents. --- Social problems: Interpretation: Out of 28 respondents 50% of the respondents are identified unemployment, 7.14% of the respondents are identified Gender discrimination,28.57% of the respondents are identified Urbanization and 14.29% of the respondents are identified Lack of craftsmanship as the social problems In the above survey majority of the respondents are viewed that unemployment is the major reason for social problems. --- 3.Measures to reduce the social problems Out of 28 respondents 21.43% of the respondents are responded generation of employment, No one responded for gender equity programmes, 5.72% of the respondents are responded establishment of industries in rural area and 42.86% of the respondents are responded skill based education. Interpretation: Majority of the respondents are viewed that skill based education is the measure to reduce the social problems. --- Measures for the Eradication of social problems: The above table reveals that 21.43% of the respondents are responded providing of subsidies to small scale industries ,10.71% of the respondents are responded providing of tax holiday for newly established juvenile concern,42.86% of the respondents are responded liberalization of procedure for the establishment and 25% of the respondents are responded establishment of training centre. Interpretation: Majority of the respondents are opinioned that liberalization of procedure for the establishment is the measure for the eradication of social problems. --- 5.Primary responsibility of development of social entrepreneurship --- Primary responsibility No --- SUGGESTIONS: • Generating employment opportunities --- CONCLUSION: Social entrepreneurs are visionaries who try to bring about positive change in the society by practically applying their social entrepreneurship ideas and strategies to resolve social problems in the society. Their aim is to identify and create efficient change makers, who will in turn motivate the mass to develop their own ideas, solutions and strategies to resolve these social issues. Social entrepreneurs focus at utilizing the various available resources to create a better and progressive society. By this study it is concluded that through Social entrepreneurship a Sustainable Development of the society is possible. --- Interpretation : Out of 28 respondents 21.43% of the respondents are responded for unclear social purpose, 3.57% of the respondents are responded for failure to keep up with the time,35.72% of the respondents are responded for mismanagement and 39.28% of the respondents are responded for a lack of sufficient funding . In the above survey majority of the respondents are viewed that lack of sufficient funding is the reasons for the failure of social entrepreneurs --- FINDINGS: • All respondents are aware about social entrepreneurship --- • Most of the respondents said that skill based education is the measure to reduce the social problems and primary responsibility of development of social entrepreneurship is Government --- • Majority of the respondents are viewed that lack of guidance, unfavorable environment and lack of public acceptance are the main hindrances for the growth of social entrepreneurship

Social entrepreneurship is becoming a popular form of social responsibility and a way to resolve a variety of imperative social problems. In order to lift social entrepreneurship for a society it needs a precise environment where such ideas can arise and develop into an active business activity. This paper aims to examine the current social entrepreneurship activities and response, problems measures towards social entrepreneurship, role of development, attitude and encouragement to social entrepreneurship qualities required for social entrepreneurship, hindrances, Expected impact of social entrepreneurship , stakeholders success problems failures in establishment of social entrepreneurship in Udupi city was discussed in this paper.

► http:// dx. doi. org/ 10. 1136/ tsaco-2020-000646 ► http:// dx. doi. org/ 10. 1136/ tsaco-2020-000644 ► http:// dx. doi. org/ 10. 1136/ tsaco-2020-000650 ► http:// dx. doi. org/ 10. 1136/ tsaco-2021-000700 --- DIVERSITY IN THE SURGICAL WORKFORCE Racial and gender-based diversity in medical student applicants, matriculants and graduates has increased over time. 1 Underrepresented minority groups, however, continue on the basis of race in medical schools and especially in general surgery residency training programs which lag behind other clinical fields. 2 Efforts to increase matriculant diversity require an understanding of the interests, perceptions and experiences of those in minority groups much earlier in the process. The conversation of addressing the underrepresented minority applicant pool cannot be had without facing the systemic racism within our educational system that disproportionately disadvantages minority groups. From public school funding and resources to college preparation, students' educational experiences vary widely based on race. 3 Supplemental pipeline programs exist throughout the country focused on underrepresented minorities to provide science education, career exposure and mentoring. While these programs cannot completely overcome the inequities, there are limited data that shows success in professional development and applying to surgical subspecialities. 4 5 Creating a primer for acute care surgery-specific pipeline programs for a variety of educational levels to be implemented locally could be beneficial in increasing diversity in surgical workforce. General surgery residency without question is a tough road with overall attrition at approximately 18% nationwide. 6 7 Concerningly, a higher ethnicity-based attrition rate has been shown among Hispanic compared with non-Hispanic residents. 7 In a survey of general surgery residents, Black, Asian and Other residents were less likely to feel they "fit in" at their programs compared with White residents. 8 Black and Asian residents were more likely to report that attendings would think worse of them if they asked for help with Black residents also being less likely to feel they could count on their even peers for assistance. 8 Current diversity of program residents correlates with underrepresented minority faculty highlighting that minority residents are choosing programs with representative role models. 9 Even beyond accepting a diverse class of general surgery residents with the hopes of those residents completing acute care surgery fellowships, cultivating an environment of trust and support is critical to matriculation though all phases of training. --- EQUITY IN PATIENT CARE Our perceptions of people are created by sociocultural influences that can develop into unconscious implicit biases. Health disparities based on race and ethnicity have been shown to exist for many years and are, in part, attributable to bias and structural violence. 10 Studies of healthcare professionals as early in their careers as medical students, identified that 69% had implicit bias in favor of the White people over other races. 11 Similarly, a previous survey of acute care surgeons showed that 74% demonstrated an unconscious preference toward White people. 12 Although direct effects on clinical outcomes have been difficult to show, implicit bias does negatively affect the overall patient care environment. 13 Interestingly, increased racial diversity of acute care surgeons in addition to other healthcare staff has been shown to mitigate the existence of implicit bias with lower levels of racial bias on webbased testing. 14 Acute care surgeons treat a diverse and often disadvantaged patient population; therefore, addressing such bias through staff implicit bias training is necessary to be a true patient advocate. The most pervasive healthcare disparities as it relates to acute care surgery are interpersonal violence and trauma recidivism with homicide being the leading cause of death for non-Hispanic Black men aged 1 to 44 years. 15 Risk factors for trauma recidivism which lead to a higher risk of death from both injury and non-injury causes include male sex, Black race and a penetrating mechanism of injury. 16 Hospital-based violence intervention programs encompass the participants with broad social services and often mental health resources with culturally aware case managers from the time of injury. These programs have been shown to be effective with proper implementation including measures to minimize loss to follow-up. In a systematic review, those programs with adequate sample size and a minimum of 6 months of follow-up consistently showed a reduction in injury recidivism and improved conflict resolution. 17 A comprehensive primer is available for institutions to create and implement programs highlighting options to maintain funding. 18 These programs are critical in full patient recovery and should be routine in trauma centers as meeting the outreach requirement within trauma center verification. --- INCLUSION IN SURGICAL LEADERSHIP Underrepresented racial minority groups persist within academic surgery and are therefore present in acute care surgical leadership. --- Open access 3.1%, respectively. 2 An assessment of the Association of Medical Colleges Faculty Roster showed that Black assistant professors had lower 10-year promotion rates across all specialties when compared with Whites. In addition, retention rates were higher for White assistant professors than all racial minority faculty groups leaving us to question why. 19 While minority surgeons addressing microaggressions and bias from patients is being discussed more openly in recent years, the subjective components of the promotion process also allow for potential bias necessitating transparency. Promoting minorities within acute care surgery programs is crucial to a comprehensive patient care environment and the recruitment of traditionally underrepresented racial groups. 7 Unfortunately, there is no simple solution to address diversity, equity and inclusion specific to acute care surgery. The disparities that we see in overall surgical workforce, trauma patient care and acute care surgical leadership are merely a ramification of the systemic racism ingrained within the fabric of this country. There are methods to start to unravel it, but the process involves skills and approaches far removed from the operating room where we are most adept. The initial step is to identify our intrinsic implicit biases that limit us then to address the systems issues through both local and national approaches of program implementation and advocacy efforts. The American Association for the Surgery of Trauma has a broad influence to develop the necessary multifaceted approach not with placating statements or symbolic gestures but through actual change.

encouraging me to submit an essay.This essay was conceptualized, drafted in its entirety and finalized by BLS.

Statement of Need Taguette fills a specific research need for qualitative researchers who cannot afford access to the software to do their work. For commercial CAQDAS packages, the lowest subscription price is 20 USD/month, and the lowest desktop application price is 520 USD (Knowledge Bank, 2018). There have been fewer than twenty open-source CAQDAS packages available ever, and fewer than five are being currently maintained, including Taguette. Taguette directly supports qualitative inquiry of text materials (see Figure 1). It is unique in that it provides a free and open-source tool for qualitative researchers who want real-time collaboration (see Figure 3). Taguette has already been used in multiple research publications, which we have compiled in a Zotero library (Taguette Zotero Library, n.d.), and also is being self-hosted by research institutions on behalf of their communities (example: Digitalization Research Cluster, Leiden University). --- Taguette Taguette is a web application written in Python (Python Software Foundation, 2021) with the Tornado Web Framework (Facebook Inc and contributors, n.d.). It is designed to run both on a desktop machine, in single-user mode, or on a server, where it allows real-time collaboration. In addition, we have been running a server at app.taguette.org for anyone to use since March 2019, where we have about 2,000 monthly active users. Taguette is multiplatform, with installers provided for MacOS and Windows, a Docker image, and on the Python package Index (PyPI). It is available in 7 languages and has been downloaded over 12,000 times. --- Importing Documents Work in Taguette begins with importing a document. We support a variety of text formats, including HTML, RTF, EPUB, PDF, DOCX, Markdown, and more. Documents are converted to HTML using the ebook-convert command, part of the Calibre ebook manager (Goyal & contributors, n.d.) or wvWare (McNamara & contributors, n.d.) for old Microsoft Word 97 .doc documents. A copy of Calibre is included in our installers so that users don't have to set up any additional software. After conversion, the document is sanitized to remove unwanted formatting and embedded media, and avoid security issues such as cross-site scripting. --- Analysis After a user has imported a document into Taguette, they can then qualitatively highlight sections of text (see Figure 1). Those highlights are organized in hierarchical tags that can be created, merged together, and recalled at will (see Figure 2). Data for all projects including documents, tags, and highlights is stored in a SQL database, which allows for easy exploration and scripting should the user need to go beyond the capabilities offered by our interface. In single-user mode, Taguette automatically creates a SQLite database in the user's home directory, and performs schema migrations automatically when a new version of Taguette is installed. Taguette can also use the other SQL backends supported by SQLAlchemy (Bayer, 2012). --- Live collaboration The multi-user version of Taguette allows for live collaboration of multiple users in a single project. It is possible to add other accounts as collaborators to your project, with a choice of permissions: some users can only tag, some can change documents, and others have full control including adding or removing collaborators. From then on, any change made by a different user is reflected immediately to the other users. This allows for faster annotation of large projects, without having to exchange partially processed documents via email for example. Taguette is currently the only free and opensource CAQDAS package that supports this. --- Exporting Taguette offers a variety of exporting options. A user can export a codebook as a document or spreadsheet, which is the list of all the tags, with their description and the number of associated highlights, throughout the project. Another option is to export a highlighted document, where the sections highlighted by the user are marked and each annotated with the associated tags. Finally, it is possible to export a list of all the highlights across documents, either for all tags or for a specific tag or hierarchy of tags (see Figure 4). It is also possible to export a project as a SQLite3 database (Hipp, 2000), in Taguette's native schema, that contains all the information necessary to continue work on another instance of Taguette. It is even possible to import them on our hosted version, app.taguette.org, or to export from there to a local copy. Older versions of the schema are automatically recognized and converted to the latest version if needed. --- Related Work Other currently maintained open-source CAQDAS packages include: QualCoder (Curtain, n.d.), qcoder (Elin Waring et al., n.d.), and qdap (Rinker et al., n.d.). qcoder and qdap are both R packages that support qualitative analysis of text, and require knowledge of R and RStudio to use. Both provide an interface to use the results of qualitative analysis with the rest of the R ecosystem. QualCoder is a desktop application (made with Python and PyQt5) that allows users to qualitatively analyze text and audiovisual materials. Each currently maintained tool fulfills different needs across the qualitative community, including Taguette. Previously maintained qualitative include Aquad (G. L. Huber & Leo Gürtler, n.d.), RQDA (Huang Ronggui, 2018), and the Coding Analysis Toolkit (CAT) (Texifter, 2010). In addition, we have recently started an OpenCollective to support the development of Taguette, with the initial goal to cover the cost of a dedicated server for our hosted service. We are grateful to the backers for their kind donations to the project.

Taguette is a free and open-source computer-assisted qualitative data analysis software (CAQ-DAS) (Knowledge Bank, 2018) package. CAQDAS helps researchers using qualitative methods to organize, annotate, collaborate on, analyze, and visualize their work. Qualitative methods are used in a wide range of fields, such as anthropology, education, nursing, psychology, sociology, and marketing. Qualitative data has a similarly wide range: interviews, focus groups, ethnographies, and more.

fundamental societal transformation, and far-reaching changes are indeed expected in the way that work is organised. Across a vast range of working worlds, digitalisation is being accepted, negotiated and given form in very different ways and with varying, albeit often interdependent, consequences. In this volume, this development is conceived as a process of social and technological transformation with three main characteristics: first, it is technically enabled by an intensification of the permeation of information technology; second, the grounds for its introduction were socially prepared in confrontations with earlier forms of informatisation and automation of work; and third, it is socially mastered and given a specific form within enterprises, institutions and, ultimately, also within broader segments of society while, at the same time, being discursively negotiated among a range of actors including industry federations, private enterprises, unions, governments, research institutions and the public sphere. During these processes of self-perpetuation (Verselbständigung)1 entirely new qualities are emerging (Kallinikos, 2011;Malsch & Schulz-Schaeffer, 2007). Dynamics of scalability and acceleration (especially in the platform economy) are common (Choudary, 2015;Huws, 2017), but even more important is the extent to which human tasks are being delegated to technology in the form of autonomous machine-learning algorithms that make selection, optimisation and problem-solving decisions (Decker et al., 2017). The momentousness of the impacts of self-perpetuation processes is particularly evident in the use of machine learning and artificial intelligence (AI). These are already being used for hiring decisions and diagnostics in diverse fields of application ranging from hospitals to industrial plant maintenance. They fall into two broad categories: algorithms and networked systems. The algorithms lack transparency, either because they are kept secret deliberately or because they are the unfathomable product of machine learning. In networked cyber-physical systems, humans, plant equipment, materials and parts interact autonomously, insofar as these systems can regulate themselves and carry out micro-transactions. The dynamic of self-perpetuation has implications across all fields of work, with the potential for transforming labour markets, forms of corporate organisation, business processes, value chains, labour processes and activities, as well as access to the labour force. Moreover, this development challenges the institutional system because it affects companies as socially-designed places, social partnership and co-determination, health and safety regulation, qualification systems, wages, welfare systems and employment relationships. It, therefore, has technical, social and legal consequences, which might be intended or unintended. Self-perpetuation might be empowering for some actors who might disappear from some processes and contexts, while others might experience this development as a form of incapacitation, in which processes increasingly evade control and overstrain societal regulation by existing institutions. Nevertheless, several questions remain. How can this self-perpetuation be embraced theoretically? What or who are its drivers? Which interdependencies appear to be increased or weakened by its development? Does it lead to the loss of formative capacity by social actors, and if so, which ones? Looking at self-perpetuation makes it possible to take into account changes in technological logics, their influence on labour processes and how these have changed historically. For example, it makes it possible to examine how the current digital transformation and the development of AI compare with earlier waves of technological change, such as how the early 20th century compared to the current digital transformation and artificial intelligence. This special issue examines these aspects, bringing together contributions that approach the topic from diverse perspectives and disciplines. Some of the contributions focus on conceptual considerations, while others adopt an empirical approach. On the conceptual side, Konstantin Klur and Sarah Nies develop a critical concept of self-perpetuation that addresses the relationship between social domination and technology in their article, 'Governed by digital technology? self-perpetuation and social domination in digital capitalism' . In ' Artificial intelligence in the practice of work: a new way of standardising or maintaining complexity?' , Michael Heinlein and Norbert Huchler focus on AI as a contingency-generating technology, showing how new forms of self-perpetuation relate to domination and the subordination of living labour. By emphasising the concept of relational autonomy and describing various selectivities, they relativise the dynamics of self-perpetuation and thereby connect contingency-theoretical approaches with approaches that emphasise the limits of ('intelligent') digitalisation for the fruitful analysis of current work practices. This speaks to the interdependence of technicallyand socially-induced self-perpetuation. Lene Baumgart, Pauline Boos and Bernd Eckstein deploy systems theory in 'Datafication and algorithmic contingency -how agile organisations deal with technical systems', which examines obstacles to self-perpetuation. They focus particularly on the interplay of social and technical systems to show how formal and informal interactions form barriers to self-perpetuation. Other contributions examine self-perpetuation in greater detail empirically. Michael Homberg, Laura Lükemann and Anja-Kristin Abendroth use a historical lens to investigate the self-perpetuation of work from home. In 'From home work to home office? Combining work and family. Perpetuating discourses and use patterns of tele(home)work since the 1970s' , the authors analyse gender-and parenthood-specific discourses to show how certain possibilities embrace dynamic, self-reinforcing tendencies which are then 'self-perpetuated' . In 'The self-perpetuation of the promise of care robots: how doubtful application scenarios become promising' , Ingo Schulz-Schaeffer, Kevin Wiggert, Martin Meister and Tim Clausnitzer also use discourse analysis, this time to investigate the extent to which the success of robotics as a particular form of digitalisation is a result of discursive practices of sense-making. Examining field trials of robots in social care settings, they examine the decoupling of promises from actual technical developments and the ways in which the failures of these technologies are rendered invisible, thus rendering the promises self-perpetuating. Mona-Maria Bardmann, Caroline Ruiner, Laura Künzel and Matthias Klumpp, in their contribution, 'In control or out of control? worker perceptions of autonomy and control using self-reliant digital systems at airports' , illustrate some of the ways that self-reliant digital systems (SDS) are partly out of control, in that they process information independently and without worker influence but, in doing so, show that it is precisely the perception of control by the workers -and thus the self-perpetuation of technology -that proves to be central to the ways in which these employees carry out their daily work, thereby giving insights into some unintended elements of self-perpetuation. While analysis and critique are widely represented in the texts up to this point, Luke Munn develops a positive blueprint of digitalisation and self-perpetuation. As a substitute for the contentious usage 'dumb technology' , he draws on indigenous Māori language to develop the concept of 'tika technology' in 'Tika technology: an alternative blueprint for digitalisation', offering two real-world examples to provoke ideas about how the self-perpetuation of technology -and its critical aspects -might be contained in the future. Across these diverse contributions, no single definition of self-perpetuation can be formulated. However, it is clear that the level, extent and direction on which self-perpetuation becomes effective can only be defined situationally. Across disciplinary and theoretical boundaries, all these articles, in their different ways, emphasise that this is a social process. This collection thus demonstrates the importance of the social dimensions of self-perpetuation to any analysis of the dynamics, drivers and temporalities of the transformation of working worlds. Selfperpetuation may be inherent in the actual social relations in which the development of the technology is embedded but often this can only be revealed by examining the discourses that accompany this development and demonstrates how self-perpetuation is socially conditioned. Another common thread that runs through all the contributions is the insight that, while the concept of self-perpetuation is central to the discussion of digitalisation, it is by no means linear, its form determined as much by barriers to its development as by the constellations of interests that shape it. This contextual binding is another theme that links the articles in these pages. The contributions gathered together here demonstrate the importance of the concept of self-perpetuation not only to academic scholarship but also to broader social concerns. In the modern era, societies have usually defined themselves as entities made up of collective actors who establish principles and norms and design measures to shape their own institutions, regulations and working conditions. However, many facets of the current wave of digitalisation seem to put this capacity for active social shaping at risk, for technical, social, property-related and temporal reasons. The trend towards self-perpetuation (whether intentionally or not) may lead to it being bypassed or evaded to a greater extent than has been the case for earlier technical transformations. In order to find ways to address these new challenges and to regain (or not relinquish) the sovereignty to shape things, further research is needed. Such research should seek to understand and explain the dynamics of self-perpetuation as well as open up a broad social debate on possibilities for action and intervention. This special issue is only a first and modest step towards the development of such a debate. We have tried to establish the concept of 'self-perpetuation' here and make the term visible in debates about digitalisation for use in future scholarship, but many open questions remain. For example, under which particular circumstances might the processes of self-perpetuation be reversible or influenceable? Is self-perpetuation a manifestation or a driver of multi-temporality? We hope that, by initiating a discussion on self-perpetuation, we have created the basis for it to be taken up and fruitfully continued in the academic community. © Manuel Nicklich and Sabine Pfeiffer, 2023.

It is evident from current debates that an important new trend associated with digitalisation is the emergence of new processes, with wholly new qualities, which can be regarded as a form of 'self-perpetuation' (Verselbständigung). This article introduces the concept of self-perpetuation, the topic of this special issue, with the aim of clarifying it, making it visible in academic debates about digitalisation and examining its usefulness as an analytical tool. The contributions to this volume discuss conceptual as well as empirical aspects of this development. In addition to providing critical accounts of how self-perpetuation emerges and illustrating some of the barriers to its expansion, these articles also examine aspects of the discourses that have accompanied its historical development as well as providing glimpses into how these dynamics could be redirected in a more emancipatory fashion in the future. Taken together, these contributions demonstrate the importance of the concept of self-perpetuation for deepening our understanding of digitalisation, both as a social phenomenon and as a topic of academic research.

Results: 213 total posts (107 pre-Dobbs and 106 post-Dobbs) were randomly selected for thematic and sentiment analysis. Posters in the post-Dobbs period were significantly younger than posters in the pre-Dobbs period (25.5 years vs. 31.7 years, p = 0.05). Posters in the post-Dobbs period were also more likely to mention their sexual dysfunction or raise questions regarding their sexual function post-operatively (p = 0.03). Notable discussion themes pre-Dobbs focused on post-operative concerns (n = 31), actionable advice (n = 38), or second opinions (n = 50). Patients also sought to reflect upon their experiences with their vasectomy (n = 30). While similar themes were noted post-Dobbs, more posts focused on describing pre-operative anxieties (n = 36), raising second thoughts regarding a scheduled vasectomy (n = 36), and acknowledging in some way the importance or value of having an online community such as r/vasectomy (n = 60). There was no significant difference in the length of posts (p = 0.44) or the number of positive, neutral, or negative sentiment posts (p = 0.98) between time periods. Conclusions: Online discussion forums may provide insight into patients' experiences with vasectomies during a contentious sociopolitical time when contraceptive options are changing. After the Dobbs decision, patients seemed to express increased pre-operative anxiety and doubt regarding their decisions to get vasectomies, but also expressed greater appreciation for the online community in r/vasectomy. This overall mix of feelings may explain any lack of difference in positive and negative sentiment in posts between the time periods. Disclosure: No.

In June 2022, the U.S. Supreme Court overruled Roe v. Wade, the 1973 case establishing a federally protected right to abortion, through the case Dobbs v. Jackson. Subsequent research has demonstrated an increase in the number of men seeking vasectomy consultations as men take more ownership of family planning. We hypothesized that there might be a similar, paralleled change in online discussions about vasectomy following the court's decision. Objective: We sought to characterize themes and tones in social media discussions regarding vasectomies before and after the Dobbs decision. Methods: We analyzed vasectomy-related discussions on Reddit, a large social media platform, using qualitative analysis and natural language processing-based sentiment analysis. Using the Reddit API, 1000 posts from 1 year before Dobbs and 1 year after were extracted from the subreddit group r/vasectomy. The group has 13,400 active members. Qualitative analysis was performed to determine overall themes within discussion posts. Poster age and comments about male sexual dysfunction were noted. Sentiment analysis was performed using the validated software VADER, which is specifically tuned expressions on social media platforms and assigns posts scores that can be interpreted as having positive, neutral, or negative sentiments.

WHO IS SELF-EMPLOYED IN LATER LIFE? EVIDENCE FROM SIX WAVES OF THE HEALTH AND RETIREMENT STUDY C.J. Halvorsen, Washington University in St. Louis, Saint Louis, Missouri, United States More than one in five working Americans aged 50 and older are self-employed, yet we know relatively little about those who embark on this work. With data from six biennial waves of the nationally-representative Health and Retirement Study of Americans past 50 years of age, this study aims to document the characteristics of self-employed older adults in comparison to wage-and-salary workers and those who left the workforce. Using multinomial logistic regression with cluster-robust standard errors and sampling weights, this study considers sociodemographic factors; measures of human, social, and financial capital; and risk tolerance as predictors. Among older Americans, results indicate that age, being male, volunteering, risk tolerance, and reporting better health, earnings, and wealth were positively associated with self-employment. Having health insurance had a negative association. This study builds upon previous scholarship while contributing to discussions about later-life self-employment and who has access to this work in later life. As the US population ages, more workers will be called upon to provide care for older relatives and friends, often during their prime earning years. The National Alliance for Caregiving reports that 70% of employed caregivers of both older adults and family members with disabilities adjusted their work to manage caregiving responsibilities leading, for some, to reduced wages and reduced retirement savings. This paper uses longitudinal data from the nationally-representative 1979 National Longitudinal Survey of Youth for years 1994 through 2014 to examine the relationship between employment benefits (paid sick leave, paid vacation leave, and flexible work hours) and retirement savings over the life course among both male and female workers (ages 50-57 in 2014) who report a caregiving role. Among these older working caregivers, findings suggest that those with more paid vacation days and access to flexible work hours have higher retirement savings. Policy implications are discussed. --- EMPLOYMENT BENEFITS AND RETIREMENT SAVINGS AMONG OLDER U.S. WORKING ADULTS --- PREDICTING WORK STRAIN AMONG EMPLOYED INTERGENERATIONAL FAMILY CAREGIVERS A. Steffen, University of Missouri-St. Louis, Saint Louis, Missouri, United States Over half of the women who provide assistance to older family members are also in the paid labor workforce. Benefits and challenges accrue from these multiple roles, from income and strengthened identity to role overload and work strain. This presentation examines variables associated with work strain reported by employed daughters caring for older parents. The Stress Process Model (Pearlin et al., 1990) informed hierarchical regression analyses testing the relative strength of predictors for job-caregiving conflict in a sample of 89 intergenerational family caregivers. After controlling for hours worked, assistance with IADLs and degree of cognitive impairment in the older adult, both preparedness for caregiving and perceived stress were significant predictors of work strain (F (5,79) = 7.24, p < .001). Attention to resources to support family caregiving can improve the quality of work experiences for employed family caregivers. --- SESSION 1360 (PAPER) FAMILY CAREGIVER SUPPORT AND POLICY NATIONAL FAMILY CAREGIVER SUPPORT PROGRAM: EXPLORING THE LINK BETWEEN PROCESS AND CLIENT-REPORTED EFFECTIVENESS J. Campione, Westat This study investigates the relationship between a program process of the National Family Caregiver Support Program (NFCSP) and client-reported effectiveness of caregiver services. The study sample includes survey response data from 43 AAAs combined with survey responses from 364 caregivers who received NFCSP caregiver services from one of the 43 AAAs in the preceding 6 months. The program process was the AAA-reported frequency of assessing caregiver program satisfaction. Caregivers were asked, "Have the services you received from {Agency} enabled you to provide care longer

This study examined the effect of a Paid Family Leave program in California (CA-PFL) on employment among older female caregivers. We also examined differences in the relationship between the availability of paid family leave and employment in socioeconomic subgroups of older women. Data came from multiple years (2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014) of the Current Population Survey (CPS) (N = 68773 individuals). Applying Difference in Difference (DiD) approach to remove potential selection biases related to program participation, we used a logistic regression to estimate the effects of PFL. CA-PFL predicted a significant increase in the likelihood of working and decrease in the likelihood of not employed. By subgroups, the positive PFL effect was found only among the early middle-aged, the near-poor, and those had the highest level of education. PFL may increase employment stability by allowing family caregiver workers to accumulate human capital; however, the less advantaged may continue to have a limited benefit.

Questionnaire development. Most of the survey questions were drawn from the former two surveys in the series of Australian Housing Conditions projects. This has ensured that researchers can analyse the datasets longitudinally (acknowledging that the survey series is repeat cross-sectional as opposed to a true longitudinal panel sample). These questionnaires were developed by the investigators. To enable comparison across jurisdictions and time, several new crossover questions were drawn from a variety of continuing and long-standing international housing and household surveys, including the English Housing Survey and the Australian Housing and Urban Research Institute's Australian Housing Aspirations (AHA) Survey 19 . Other relevant international surveys were reviewed for relevance, including the American Housing Survey and the English Private Landlord Survey (https://www.gov.uk/government/statistics/ english-private-landlord-survey-2021-main-report). The research team also designed some entirely new questions for the survey. These questions were intentionally designed to capture pressing and emerging policy issues in housing, especially regarding the changing role of homeownership in Australia. Some examples include whether renters plan to buy property, whether renters or homeowners own multiple properties, and for what reasons these participants own additional properties. The survey was organised into three parts. Following the respondent screening questions at the outset of the questionnaire, the first part asked participants to answer basic questions regarding their housing profile, i.e., whether they rent or own their home, the type of dwelling they inhabit, and the length of their tenure. Participants were also asked to share details about their home's conditions pertaining to heating and cooling, affordability, security, and satisfaction with the dwelling quality. This section ended with a focus on participants' future housing intentions. The second section focussed on housing and its impact on health, including whether participants had ever been injured due to their dwelling being unsafe or of poor quality. The final section of the survey posed questions relating to household demographics and finances. Sampling. All participants were required to be over the age of 18 to participate in the survey. The survey was provided in English. Data collection quotas were applied so that the data is reflective of the distribution of households across Australian states and territories. Quotas were also applied to replicate tenure and rental type distributions. In recognition of the emerging importance of rental tenure and the call for detailed work on this tenure, the sampling frame was weighted to oversample rental households. This variation is illustrated in Table 1, with the highest number of private rental, social rental, and homeowner responses being recorded in New South Wales as a result of the state's higher population compared to other Australian jurisdictions. Participants were recruited through online and offline methods to minimise technology affinity bias. Offline methods include telephone or face to face recruitment. Online methods include recruitment through social networks, loyalty websites, affiliate traffic, and the panel's own newsletters. The market research agency utilised a representative panel that is targeted to align with Australian Bureau of Statistics (ABS) Census data (see Supplementary Table 1). As a result, the sampling was designed to be broadly representative of the Australian population. 1 shows the final sample by location (state or territory) and tenancy type (homeowner, social, or private rental). In accordance with the ethics approval, all respondents gave their informed consent at the start of the survey. Their consent was attained under the conditions that the data were de-identified prior to analysis or sharing, that the data were securely stored, and that the data were to be used for research and policy purposes only. --- Data collection. --- Data Records The 2022 AHCD is lodged with the Australian Data Archive (reference number 100133) 8 . Both sensitive and non-sensitive versions are accessible to researchers and the public via https://dataverse.ada.edu.au/dataset.xhtml?persistentId=doi:10.26193/SLCU9J upon registration and request. The data are as received from the commissioned agency except for minor changes. The sensitive portion of the dataset is under separate access conditions at the data repository due to its inclusion of sensitive variables such as postcodes and annual income. This is consistent with the repository's efforts to protect participants' personal data and limit re-identification. These measures also ensure that the research team can maintain a record of the researchers who request access to these sensitive portions of the data. Some parts of the non-sensitive data have been aggregated to remove the sensitive elements (such as the annual income variable), and some questions have been removed (such as the postcodes). While the non-sensitive dataset poses a lower risk of re-identification of participants due to these modifications, users still must register to the data repository to gain access to the dataset, albeit these are lighter controls relative to the sensitive dataset. Registration to the repository is required by our ethical committee to ensure that all researchers have read and agreed to the conditions of use. The only other manipulation to the dataset that has occurred is the shortening of labels to avoid truncation in STATA. Both versions of the dataset contain all survey responses except for open-ended questions and responses to "Other (please type in)". These responses are only accessible to the research team to protect participant privacy and prevent any possible reidentification of data. The details of the two versions (sensitive and non-sensitive) of the AHCD are provided in Table 2. The AHCD files accessible via the ADA are available in.csv,.sas,.sav, and. dta formats. --- technical Validation Data checking and cleaning protocols. All data processing requirements were conducted in-house by the commercial provider. While potential issues with the data were addressed via logic checks at the programming stage (e.g., restricting the types of data which can entered), a range of data checks were also completed upon commencement of fieldwork, including after the pilot survey. This process involved the following data cleaning and validation activities: • Confirmation that the survey logic was working correctly; • Validation that data were captured as per the required format and with only permissible values (e.g., that the correct question format was adopted such as multiple versus single responses); • Verification of correct labelling of variables and values; • Verification of any inconsistent response categories; and, • De-identification of data to protect the privacy and confidentiality of individuals who participated in the survey. Following fieldwork, data were exported to Q and SPSS, which was reviewed and validated by the agency's project team members. They performed a final check of survey logic, and verbatim responses were cleaned of any identifying information, including names and contact details of individuals before draft and final datasets and files were provided to the University. Subsequent testing of data quality was undertaken between December and April by the investigators. The market research firm undertook a variety of measures to ensure that participants' privacy was safeguarded. These include: • Only collecting personal information required as part of the research; • Not disclosing any personally identifiable information that was collected, unless with the participants' prior consent to do so; • Providing participants with the firm's privacy policy; and, • Complying with a range of data storage and privacy protocols, frameworks, and international standards. --- Usage Notes To maximise the utility of the AHCD for housing and urban research, users may consider adding functionality to the dataset by geo-coding responses (postcodes available in the sensitive version only), or by formulating design and/or non-response weights. The sensitive human data contained in this dataset is available for any user who reads and agrees to the Data Usage terms at ADA. These are required to protect personal data from participants. Users of the dataset must agree to these conditions: • Do not re-distribute the data (the agreement is for a single person, every collaborator needs to apply); • Do not sell the data; • Do not attempt to identify any participant; and, • Do not attempt to contact any participant for any reason. --- Code availability No custom code was used. --- author contributions Emma Baker: conceptualisation; writing-original draft preparation; writing-review and editing; funding acquisition. Claire Morey: conceptualisation; writing-original draft preparation; writing-review and editing; project administration. Lyrian Daniel: conceptualisation; writing-original draft preparation; writing-review and editing; project administration; funding acquisition. Andrew Beer: conceptualisation; writing-review and editing; funding acquisition. Rebecca Bentley: conceptualisation; writing-review and editing; funding acquisition. Steven Rowley: conceptualisation; writing-review and editing; funding acquisition. Kerry London: conceptualisation; writing-review and editing; funding acquisition. Wendy Stone: conceptualisation; writingreview and editing; funding acquisition. Christian A. Nygaard: conceptualisation; writing-review and editing; funding acquisition. --- Competing interests The authors declare no competing interests.

For the past two decades, researchers and policy makers have known very little about conditions within Australia's housing stock due to a lack of systematic and reliable data. In 2022, a collaboration of Australian universities and researchers commissioned a large survey of 22,550 private rental, social rental and homeowner households to build a data infrastructure on the household and demographic characteristics, housing quality and conditions in the australian housing stock. this is the third and largest instalment in a national series of housing conditions data infrastructures.

Introduction Cell phones are integrated into the daily lives of many people in modern societies. Mobility, immediate access, and the freedom to communicate at any time and place are significant advantages of cell phone use (Leung & Wei 2000). Heavy cell phone use among adolescents and young adults is creating a subculture with a powerful impact on interpersonal communication and cultural norms (Nurullah, 2009). Cell phones can serve as a social facilitator, promoting social interaction (Campbell & Kwak, 2011). However, some individuals use cell phones to create a social barrier for avoiding interactions with others in public (Humphreys, 2005). We used an ethological approach to assess the use of cell phones in dyadic interactions in public settings. We predicted that cell phone use would be contagious in a dyad, e.g., that use by one individual would increase the short---term likelihood of cell phone use by the companion. We also predicted that women would use cell phones more frequently than men would in same---sex dyads, consistent with previous research findings (Wei & Lo 2006;Humphreys 2005). --- Methods Detailed observations of cell phone users were collected in public settings on the University of Michigan campus and in the surrounding area. Dyads were observed in East Quad and Mosher---Jordan dining halls and university area commercial dining facilities (Amer's Deli, Bruegger'ʹs Bagels, and Starbucks). Observations were collected from January to April 2011 and varied by time of day; intentionally avoiding peak dining hours. Persons observed appeared to be between 16 and 25 years of age, typical of the local student population. The collected observations lasted between 3 to 20 minutes, starting when the person(s) sat down at a table and ending when the person(s) left the table. The timing and frequency of cell phone use were recorded for all observed persons in 10---second intervals, as this interval length was easy to follow with a timer and was deemed to represent an appropriate reaction time interval by lab members. We arbitrarily labeled individuals A and B and examined the likelihood that person B used their phone in the 10---second interval before, during, or after person A's cell phone use. We did not assess whether or not every individual had a cell phone or what type of phone it was, though individuals without phones would reduce the chances of supporting our primary hypothesis. We tested whether there was a feedback effect of mutual influence in a reciprocal interaction (See Kenny, Kashy, & Cook, 2006). --- Results Overall, individuals used their cell phones in an average of 24% of the 10---second increments, ranging from 8% to 48%. Individuals were significantly more likely to use their cell phones when the other person in the dyad used their cell phone in the preceding time increment. This effect was bidirectional, Spearman'ʹs rho = .162, p = .004 for B following A and Spearman'ʹs rho = .235, p < .001 for A following B. In contrast, pairs were not significantly more likely to use their cell phones simultaneously in the same time interval, Spearman'ʹs rho = .067, p = .067. Individuals in female---female dyads tended to use their cell phones more frequently (32% of increments) than those in male---male (25%) or mixed sex (22%) dyads, χ 2 (335) = 6.14, p = .046, d = .22. --- Conclusion Observations confirmed our prediction of contagious cell phone use in public dyads, further advancing the understanding of the role of cell phones in contemporary socialization. We believe that our results can be interpreted in relation to social exclusion and inclusion. When one person in a dyad engages in an external phone conversation, either verbally or through text messages, the co---present person in the dyad is excluded and thus uses her/his own cell phone to promote feelings of social inclusion. S/he may also use her/his cell phone to demonstrate connection with outside social networks to proximate others (Ling 2002). This function may be particularly important for women, who used cell phones more frequently than males in both this study and past research (Wei & Lo 2006;Humphreys 2005). Mimicry and imitative behavior may also play a role in contagious cell phone use. Individuals may see others checking their incoming messages and be prompted to check their own incoming messages, though this may be less likely to explain repeated contagious events over the span of a few minutes. Future research may compare these patterns to other demographics and settings. These results may contrast with those for older adults, who may not use cell phones as frequently.

Cell phone use is increasingly prominent in public settings and may shape face---to---face social interactions. We used an ethological approach to examine cell phone use in public dyadic interactions, recording detailed behavior sequences. Naturalistic observations in university dining halls and nearby commercial dining facilities indicated that one individual's cell phone use is a frequent precursor to the companion's cell phone use. Cell phones create an alternative outlet for one's attention and may both promote and interfere with live social interaction. These results have important implications for the role of information technology in modern social interactions.

Introduction Antibiotic resistance is associated with reduced efficacy of antibiotic treatment, which translates into an estimated 25 000 extra deaths annually within Europe. 1 The distribution of antibiotic resistance between countries is not equal. 2 The reasons for this are not causally proven, but inter-country variation in resistance rates has been associated with income inequality and antibiotic consumption. 2 In addition, policies at the national level relating to the control of antibiotic consumption and, in Europe, the density of general practitioners and their remuneration method have been suggested to influence rates of antibiotic resistance. 3,4 National-level analyses, however, do not explain the intra-country distribution of antibiotic resistance or the mechanisms that may give rise to antibiotic resistance. Studies investigating intra-country distribution of resistance have used antibiotic consumption as a surrogate marker for antibiotic resistance. A study of Swedish children identified that parental educational level, parents being born outside Sweden, environmental exposure to smoking, economic stress and parent-reported access to personal support were associated with antibiotic consumption. 5 In England and Scotland, antibiotic prescribing by general practitioners has been related to social deprivation. 6,7 In the USA, antibiotic consumption has been shown to be associated with population rates of obese persons, children ≤2 years of age, prescribers per capita and females. 8 In general, increasing social deprivation-which includes measures relating to: income; education, skills and training; living environment; barriers to housing and services; and health and disability-is associated with increased antibiotic consumption, but there is also evidence that increasing antibiotic consumption may be related to increased per capita income. 9,10 Whilst there is evidence to link increasing social deprivation to increasing antibiotic consumption, associations between social deprivation and antibiotic resistance have not been determined. This retrospective secondary data analysis used the antimicrobial susceptibilities of Escherichia coli isolates derived from urine samples and neighbourhood characteristics to determine whether components of social deprivation were associated with increased rates of antibiotic resistance. --- Materials and methods --- Antibiotic resistance data Antimicrobial resistance surveillance data were collected from 2778 urinary E. coli isolates collected from patients presenting to healthcare practitioners based in the community (Leeds and Bradford, UK) during 2010 -12. 11 Isolates were therefore derived from patients resident in their own homes and community-based healthcare institutions (residential care facilities, for instance), but not from hospitalized patients. Data associated with isolates did not include identifiable patient-level data; we cannot therefore confirm that all isolates are patient-unique. Resistance to eight antibiotics was considered: ampicillin, amoxicillin/clavulanic acid, cefalexin, ceftazidime, cefuroxime, ciprofloxacin, nitrofurantoin and trimethoprim. This use of pseudo-anonymized data removed the need for ethics consent. Approval for the use of the data was obtained from the Information Governance team at Leeds Teaching Hospitals NHS Trust. --- Neighbourhood-level data Patients' postcodes were linked to neighbourhood deprivation scores via lower super output areas (LSOAs) using GeoConvert (http://geoconvert.mimas.ac.uk/). --- Adjusted OR Living conditions (quintiles) Living conditions and antibiotic resistance in E. coli Super output areas are a set of geographies designed specifically for statistical purposes. LSOAs have an average population of approximately 1500 persons, which is considered a small population size. So each postcode corresponds to a neighbourhood-level LSOA and each neighbourhood-level LSOA has a neighbourhood-level deprivation score. The deprivation scores for each LSOA were obtained from the 2010 Indices of Deprivation. 12 This dataset assigns a deprivation score to each LSOA, reporting on five deprivation domains, which were considered independently. The five domains are: income; education, skills and training; living environment; barriers to housing and services; and health and disability (see Supplementary data available at JAC Online for further details on the components of the deprivation domains). Quintiles were created for each of the five deprivation domains (within the dataset) and used for analysis. LSOAs were grouped according to rural or urban setting based on the rural/urban area classification (RUAC). 13 Population density (persons per hectare) based on the 2010 census was obtained from the Office for National Statistics (https://geoportal. statistics.gov.uk). --- Statistical analysis Multilevel logistic regression analysis was used to estimate the independent effect of structural components on the odds of a patient having a resistant bacterial infection. We considered structural components to be neighbourhood characteristics that exist above the level of individuals. A separate model was developed for each of the eight antibiotics using a defined model-building strategy. We used a four-stage model-building strategy, at each stage testing for the statistical appropriateness of the more complex model: Model --- Results Single-variable associations with resistance for each antibiotic are shown in Table S1. All eight final multilevel models represented a significantly good overall fit (P,0.05) with the inclusion of LSOA as a second level supported by significant variance at that level (all P, 0.05). Increasing age was a significant predictor of increased resistance for all eight antibiotics; male sex was associated with significantly increased odds of ampicillin and nitrofurantoin resistance (Table S2). Increasing population density was associated with increased odds of resistance to amoxicillin/clavulanic acid, cefalexin, cefuroxime, nitrofurantoin and trimethoprim, but the rural/urban nature of LSOAs was not associated with resistance to any antibiotic (Table S2). Only two deprivation domains remained significant predictors of antibiotic resistance in the final multivariable models: living conditions (all eight antibiotics) and education, skills and training (cefuroxime, nitrofurantoin) (Figure 1 and Table S3). One or two quintiles of living conditions were associated with significantly increased Correlation between levels of antibiotic resistance and magnitude of the association between living conditions and individual-level odds of resistance. Each data point represents a single antibiotic ranked according to percentages of resistant isolates within the dataset: ceftazidime (5.0%), nitrofurantoin (6.5%), cefalexin (7.3%), cefuroxime (9.3%), ciprofloxacin (10.0%), amoxicillin/clavulanic acid (18.9%), trimethoprim (34.6%) and ampicillin (54.8%). The OR is the adjusted association between antibiotic resistance and living in the quintile of Leeds with the most-deprived living conditions versus the least-deprived living conditions. Error bars show 95% CIs of the adjusted OR. Associations have been adjusted for age, sex, population density, rural/urban nature and education deprivation (cefuroxime and nitrofurantoin only). Nomamiukor et al. odds of resistance for each antibiotic; in each case, the quintile with the worst living conditions had the highest OR compared with the quintile with the best living conditions (Figure 2). The magnitude of these associations varied from an OR of 3.03 (1.27 -7.17) for ceftazidime to 1.33 (1.07 -1.75) for trimethoprim. Where overall rates of resistance were relatively low, the effects of living conditions on odds of resistance were greater (Figure 2). --- Discussion This study has demonstrated that relative neighbourhood deprivation is associated with antibiotic resistance. In particular, we have identified that being in the most-deprived quintile of the population with respect to living environment, across all eight antibiotics studied, was associated with an increased risk of antibiotic resistance compared with living in the least-deprived quintile. Whilst previous studies have related deprivation to antibiotic consumption as a proxy for antibiotic resistance, this study makes the association between neighbourhood deprivation and antibiotic resistance without relying on consumption as a proxy for resistance. Deprivation indices can be derived using a number of domains, such as income and the living environment. This study suggests that living conditions are consistently associated with antibiotic resistance, after adjusting for other significant predictors within a multivariable analysis. The living environment deprivation index is composed of indoor living conditions (e.g. thermal comfort) and outdoor conditions (e.g. air quality). These factors are known to impact negatively on health and our findings may result indirectly from the adverse health impacts derived from a poor living environment. 15,16 For example, adverse health status may increase antibiotic use or healthcare utilization, and so increase the selection and transmission of antibiotic-resistant bacteria. The absence of associations with income and health and disability were unexpected, but may be due to methodological limitations. We have been unable to adjust for individual-level income and health outcomes that may, in addition to the structural effects of the living environment, be associated with the risk of antibiotic resistance. We found increasing age to be associated with resistance, in keeping with previous reports and likely due to increased antibiotic consumption by older age groups. 17 Increased antibiotic resistance was significantly associated with increasing population density for five of the eight antibiotics studied. This association has been reported previously. 18 A possible explanation is that as population density increases, so does the transmission of antibiotic-resistant strains. The effect of living environment on antibiotic resistance appears to be increased when the prevalence of resistance for a specific antibiotic is lower. The mechanism behind this is unclear, but this effect has also been seen at a national level in relation to income. 2 A possible explanation is that sustained antibiotic consumption in a population over a period of time increases an individual's probability of contact with an already-resistant organism, such that the potential for deprivation to contribute to the selection of antibiotic resistance within an individual is reduced. This study supports existing evidence for the association between deprivation and increased rates of antibiotic resistance, suggesting that living conditions are strong predictors of increased antibiotic resistance rates. Further studies are required to explore this relationship by incorporating individual-level data with neighbourhood characteristics. --- Supplementary data Tables S1 to S3 and further information on deprivation domains are available as Supplementary data at JAC Online (http://jac.oxfordjournals.org).

The objective of this study was to measure the associations between domains of deprivation and antibiotic resistance of Escherichia coli. Methods: Routine surveillance data for antibiotic susceptibility of E. coli isolates were obtained from urine specimens taken from patients presenting with suspected urinary tract infection in 2010-12 to healthcare practitioners based in the community in Leeds and Bradford. Eight antibiotics were included in the analyses. Postcodes were linked to lower super output areas (average populations of 1500). The 2010 Indices of Deprivation were used as neighbourhood characteristics for each lower super output area. Multilevel logistic regression models were used to estimate the independent effect of structural components on the odds of resistance to each antibiotic. Results: With respect to living conditions, residence in the most-deprived areas compared with the least-deprived areas was associated with increased odds of antibiotic resistance for all eight antibiotics analysed. The magnitude of these associations included an OR of 2.04 (95% CI 1.03 -3.07) for cefalexin, 2.16 (95% CI 1.16 -4.05) for ciprofloxacin, 2.47 (95% CI 1.08 -5.66) for nitrofurantoin and 1.33 (95% CI 1.07-1.75) for trimethoprim. Conclusions: Social deprivation in the form of living conditions is associated with increased antibiotic resistance for E. coli. This evidence suggests there is a need for further individual-level studies to explore the potential mechanism for these associations.

Ellen Ash was an elderly woman with severe dementia, who lived in Glasgow. She died in 2013 after she was smothered and her house was set on fire. Her son, Jeffrey, went to the police the next day to confess to both. 1 He was her carer and seems to have been under immense stress. Social care is under intense pressure but also scrutiny. Over the past few months this complex case has been discussed at wide ranging, interdisciplinary meetings involving health and social care staff. In Scotland, social and health care are integrated in law. But in practice? In the months before her death Ash was admitted to hospital for various reasons, including hypothermia, and with an area of necrotic tissue. "Neglect" and "vulnerability" were mentioned in her case notes. After her death a public significant case review found multiple failings and errors. Communication between social work and health teams was found serially wanting, and services such as day care were offered but never materialised. 2 Nothing about the current health and social care system suggests that something similar couldn't happen again. It seems as though health and social care professionals hardly know each other. How many of us haven't faced a patient who's judged to need residential care but declines it? How many families do we know with a precarious home situation involving some-but probably not enough-care input? How many people are lost to follow-up? How many referrals to an agency are rejected? We may not know which agencies are even involved. How often are we unsure whether an appropriate review has been completed? Social care has become fragmented by design. In Glasgow, Cordia was set up as an arm's length company to provide home caring services rather than staff being directly employed by the council (some suggest that this was done for the council to avoid equal pay claims 3 ). This has meant that home carers, who used to be directly employed by the council and worked from inside the social work department, are now outside it. To me, social care seems to be filled with committed and overworked people in an immensely hierarchical, rule bound system. Referrals into and out of care agencies are regulated, with many time consuming assessments. The community team is dissolving, and our district nurses no longer work, long term, from the practice as part of our team but "horizontally," across many. This may be "agile," but it loses the longer term, soft knowledge on which harder decisions are based. No basic record exists between district nurses and GPs, social work, and care agencies to say who's involved. I can alert social workers to concerns, but what then? Everyone is working over capacity, in workplaces not designed to ensure that professionals have the minimum information to do the job safely. Home carers, who used to be directly employed by the council and worked from inside the social work department, are now outside it Forget high tech, big data innovation: we first need to sort out the basics of how the NHS, social workers, and care agencies work together. It is inherently, fundamentally, an unsafe system. And this is tragic, because the home carers and social workers I meet are entirely devoted to their jobs and work way beyond their hours and job specifications to do their work well. I've spent the past couple of weeks reading manifesto commitments, but nothing's as dull as sorting this. Teams are important in healthcare, to bring skills together and ensure that a plan is shared, organised, and implemented. The skills are willing; the organisational ability is not. Having time to discuss difficult issues with a fellow professional offers the kind of support that we know makes care better and the job easier, but it keeps getting squeezed out. Time to think, consider, and reflect with our social work and carer colleagues: when did we last have that? And isn't everyone the worse for it? Competing interests: See www.bmj.com/about-bmj/freelancecontributors/margaret-mccartney. Provenance and peer review: Commissioned; not externally peer reviewed. Follow Margaret on Twitter, @mgtmccartney margaret@margaretmccartney.com For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe

JEFFREY-ASH. 2 Adult Protection Committee. Glasgow City Council. Significant case review undertaken on behalf of Glasgow APC on Mrs Ellen Ash. https://www.glasgowadultprotection.org.uk/ CHttpHandler.ashx?id=30627&p=0. 3 Braiden G. Ruling threatens 4000 equal pay claims. Glasgow Herald 7 Jan 2012. www. heraldscotland.com/news/13044157.Ruling_threatens_4000_equal_pay_claims/.

Introduction Diversity is a strength and important source for innovation in any field, and comes with different expertise and, oftentimes, different values. In interdisciplinary environments the differences among professionals of various disciplines can become pervasive. Inclusion should transcend unconscious bias and stereotypes, in efforts to build inclusive, diverse collaborative environments capable to address societal challenges [1]. Ensuring diversity and interdisciplinarity comes with tremendous potential to mobilize the talented human capital for improvement in health and care for all through innovation [2]. Around the globe, women play important, instrumental roles in health care changes, but their presence in Science, Technology, Engineering and Mathematics (STEM) remains low [3], as shown in the graph below. In health care, women make up the majority in the health care workforce using digital health information systems. Women are still significantly underrepresented in top leading positions and decision making, still at the same time, very receptive in using health information systems [1]. Although more participation in professional meetings and increasingly more female presenters, as shown in the table below, concerns are valid. Data also suggests that women are underrepresented in roles such as keynote speakers compared to the expected representation [6]. Acknowledging diversity and actively engaging women and girls in projects, adoption and utilization of social and digital innovation will help strengthen the interdisciplinary community [2], whilst, at the same time, afford leaders stronger supporting structures as a base to push forth with inclusion for innovative solutions. This paper presents outcomes of workshops carried out in MedInfo2019 and MIE2020 (online), the methodology of organizing the workshops and collecting results. --- Methodology Inclusion and gender diversity are necessary to bring out the untapped potential in health informatics, addressing diversity gaps in use of digital health technology is timely, if not overdue. Women's empowerment and active engagement is good not just for the person who benefit but is likely to bring new perspectives and energy for change. At the company level, a growing body of evidence shows that more gender equality is good for bottom lines. Greater diversity of leadership styles and inclusion of more perspectives improves the quality of decision-making. If given the opportunity, women could be leading innovators in the age of automation and artificial intelligence and could help to ensure that algorithms are free of gender bias. Furthermore, among the new jobs that will be created will be many in fields like education and health care, where women have traditionally thrived. According to MGI research, more than 100 million jobs could be created over the next 10-15 years as health care and education needs grow. It is not exactly yet clear how automation will affect women's employment. Gender diversity could be a starting point for active inclusion of other underrepresented groups. Tapping the power, potential and energy embedded in diversity are key drivers to wider adoption of digital health innovations. Leadership and mentoring pathways can harness opportunities to connect with leaders within and across fields. When considering the need for interprofessional training, the concept of peer mentoring when mentoring is considered as a bidirectional activity is a topic worthy of reflection. The first four authors organized a workshop at MedInfo2019, which formed the basis for a MIE2020 panel, organized online due to the COVID-19 pandemic. In MedInfo2019, the audience and speakers coauthored an online document 3 that referred main issues concerning diversity in health informatics. With these issues as background all authors joined an online panel in MIE2020. The panelists argued that diversity, equal opportunity and equality are important to tap the full potential of ongoing developments, in addition to being core values that our community aspires to. --- Results Several key areas were addressed by panelists and formed the basic for discussion on next steps for the health informatics community in Europe and globally. Constrains to the advancement of gender equity, points to divides between specialties in health informatics, and warrant strategies to help overcome diversity challenges. In particular, recent changes in policy and emerging initiatives for empowering women and girls in global health across disciplines, comes with inspiration and direction. The discussion on diversity highligh strategies to value professional contributions as important qualities that adds to interdisciplinarity in Health Informatics, effective strategies to improve diversity in community. --- Leadership and Mentorship pathways to sustain innovation. Different strategies for peer mentoring were proposed to complement traditional and reverse mentoring to build capacity, and support sustainable, intergenerational communities in the presence of the accelerated digital transformation of health and care. Special mention was attributed to the UN Sustainable Development Goals (SDGs), in particular SDG 3 (good health and wellbeing), SDG5 (gender equality), SDG8 (decent work and economic growth), SDG10 (reducing inequality), and SDG17 (cross-sectoral collaborative actions). In an everchanging healthcare environment, empowering women for leadership roles is vital to sustain innovation and stay ahead of times. The McKinsey Global Institute (MGI) has estimated that advancing gender equality could add $12 trillion per year to the world economy by 2025. In their study of 90 entities and 50000 managers, MGI notes that companies with more women in executive teams have a 56% higher operating profit, highlighting that gender-balanced organizations produced results that were far more predictable, sustainable, and profitable. Many companies, like Medtronic, are taking bold steps towards elevating women in a holistic approach building an inclusive, diverse and equitable workspace for women, by providing a variety of development programs for managers, including unconscious bias training and facilitating networks of women and men that promote change (15000 members, 118 hubs, 68 countries). --- OECD: Women at the core of the fight against COVID-19 crisis The COVID-19 pandemic is harming health, social and economic well-being worldwide, with women at the center. First and foremost, women are leading the health response, making up almost 70% of healthcare workforce exposed to risk of infection. Women shouldering much of the burden at home, as school and childcare facility close, and being in longstanding gender inequalities of unpaid work. Women also face high risks of job & income loss, increased risks of violence, exploitation, abuse or harassment during times of crisis and quarantine. Thus, the pandemic unveiled important gendered implications that call for immediate policy action. --- Gender equity, unconscious bias and work culture Gender inequality is quite prominent in the health sector, where care is led by men and delivered by women representing 70% of the workforce, with a 28% gender pay gap. Stereotypes, blind spots and bias are part of our daily lives, including in the very definition of gender, which is often implied as binary [7]. There are ways we can train ourselves to make note of these. One way is by thinking about strong women leaders or seeing positive images of underrepresented groups can temporarily change unconscious biases. A second is by working together in structured settings to solve shared problems can dramatically alter people's attitudes about diversity. Finally, we should strive to understand that a person with biases will not necessarily always act in biased ways. It is possible to consciously override bias [8]. For women to thrive, individuals need to have passion to drive diversity, make it a personal priority, and show perseverance over time [9]. At the same time organizations need to rely on proof before jumping to solutions, install regular, robust processes to ensure equity and lastly, implement and support critical programs that support women's unique needs. In 2013, in 'Women Rising' [10] the presence of second generation bias: a paucity of role models for women, gendered career paths and gendered work, women's lack of access to networks and sponsors, and double binds: feminine qualities and leadership mismatch. Proposed actions to support women's access to leadership are: educate women and men about second-generation gender bias, create safe "identity workspaces" to support transitions to bigger roles, "acceptably disruptive," and anchor women's development efforts to leadership purpose rather perception. --- Traditional Mentoring, Peer Mentoring and Reverse Mentoring Mentor as a word has its roots in Homer's Odyssey. Mentor was appointed by Ulysses to provide guidance to his son Telemachus when he left Ithaca for the Trojan war. Mentors became popular again in the 18 th century, signifying experienced persons providing guidance and moral support to help a less experienced person develop successfully. Peer mentoring is a relationship between people at the same career stage or age, in which one person can provide support, knowledge and skills transfer to the other in one-on-one relationship. Reverse mentoring is when younger generation persons provide mentorship to senior colleagues or professionals. Reverse mentoring is particularly relevant with the accelerated pace of digitization. Several universities have organized mentorship programs. the Université Paris Saclay has organized a mentoring program open to female PhD candidates and all faculty with monthly mentor/mentee meetings, where discussion groups on mentoring topics (e.g. self-confidence, work life balance), workshops (e.g. networking, crafting an elevator pitch), and career stories are shared. The program since its inception in 2018 has supported more than 45 mentor/mentee pairs per year with 15% male faculty and 25% mentors from industry. Key points highlighted by the program is the value of pairing across disciplines in the health and life sciences, as well as the importance of benevolence and confidentiality, exposure to a diversity of experiences, and empowerment. --- Discussion and conclusions Although there are concrete efforts to promote diversity, knowledge and policy gaps in sustainable global health workforce development persist. The COVID-19 pandemic has demonstrated notable lack of evidence-informed policymaking. Current policies miss an integrated approach when considering gendered dimensions of organization and delivery of health care, stereotypes and complexity of lives of women and men; intergenerational gaps; ageism, discrimination v. inclusiveness, understanding issues. Health Informatics is an area where we need to build capacity for diversity. Several activities underway directed toward mentoring seem to bear fruit and need to scale up. The role of associations like EFMI and IMIA in catalyzing cooperation with the industry to advance diversity is key in the accelerated digital transformation of the health sector. In particular, the yEFMI program, just started by EFMI, educational offerings and the diversity taskforce of AMIA point in the right direction and need to be scaled up.

Diversity, inclusion and interdisciplinary collaboration are drivers for healthcare innovation and adoption of new, technology-mediated services. The importance of diversity has been highlighted by the United Nations' in SDG5 "Achieve gender equality and empower all women and girls", to drive adoption of social and digital innovation. Women play an instrumental role in health care and are in position to bring about significant changes to support ongoing digitalization and transformation. At the same time, women are underrepresented in Science, Technology, Engineering and Mathematics (STEM). To some extent, the same holds for health care informatics. This paper sums up input to strategies for peer mentoring to ensure diversity in health informatics, to target systemic inequalities and build sustainable, intergenerational communities, improve digital health literacy and build capacity in digital health without losing the human touch.

Inequality as an Intrinsic Property of Science In his 1963 book, Little Science, Big Science (1), Derek Price observed that inequality in science is inherently high and called it "undemocracy" (1, p.59), meaning that a great scientist's value for science far exceeds that of ordinary scientists. While a few elite scientists make fundamental contributions, most carry out routine tasks. Scientific outputs and rewards are much more unequally distributed than other well-being outcomes, such as education, earnings, or health (1,2). Where status is concerned, very high inequality is recognized and accepted among practicing scientists, who compete for extraordinary honors such as a Nobel Prize (3). One source of inequality in science is what Robert Merton called the "Matthew effect" (4), referring to Matthew 25:29 in the Christian Bible: "For unto every one that hath shall be given, and he shall have abundance: but from him that hath not shall be taken even that which he hath." The Matthew effect means that eminent scientists receive disproportionately greater recognition and rewards for their contributions to science than lesser-known scientists for comparable contributions. As a result, a talented few can parlay early successes into resources for future successes, such as university support, research grants, graduate students, and productive collaborators, accumulating advantages over time. While science rewards all participants through a skewed tier system with the most significant rewards going to the top-performers, science has certain attributes that resemble a "winner-takes-all" market: high visibility of top winners, a large contestant base, accumulation of advantages, absence of physical or cultural boundaries, and intense competition (4,5). Thus, many scientists feel that merely being good at their jobs is not enough. Competition is all about priority --a scientist's claim to be the first to make a big discovery (3,6). Whatever their cause, high inequality in scientific rewards is often defended on two grounds. First, given the positive externalities of science (7), the more skewed rewards are, the greater the incentive for outstanding scientific work that will ultimately benefit all of humanity (8,9). Second, as a profession, science is supposed to practice what Merton called universalism (10), a norm which dictates that evaluation in science be based solely on merit rather than on functionally irrelevant factors such as gender, race, nationality, age, religion, and class (2,10). This merit-based system makes high inequality seem fair and acceptable. --- Changes in Science Before the nineteenth century, science was mainly a small-scale, personal pursuit enjoyed by a few leisure-class amateurs. Over the next two centuries, however, it expanded enormously into an institution characterized by certain distinctive features: a huge, well-paid, professional workforce; large-scale government and industrial support; reliance on the university as institution; graduate student labor; and a peer-review, flat system of evaluation (7). More recently, advances in internet technology have facilitated the rapid dissemination of research results to a vast readership (11). While these features of the new, "big science" have made scientific production faster and more voluminous than in the old "little science," they have also rendered the evaluation of scientists less substance-specific and more "numbers-based." Scientists today are increasingly likely to be judged by whatever numbers they can generate in terms of publications, citations, research grants, prestigious awards, research team size, and memberships in elite academies than by their actual scientific contributions (7). This tendency may have been amplified by increasing specialization, such that scientists in one specialty area find it difficult to understand content in another. In addition, university administrators, faced with uncertainties and competing demands for scarce resources, have strong incentives to use externally generated and validated indicators (12). --- Has Inequality in Science Increased? More empirical research is needed to answer this question. I believe that two trends have caused inequality in science to rise over time. First, given science's concentration of high rewards to a select few, the large increase in the population of scientists ( 7) means a higher concentration over time and thus an increase in inequality. That is, winners in science have relatively more to gain today than those in the past. Second, the tendency towards numbersbased evaluations has exacerbated the Matthew effect, a mechanism for generating inequality in science. As with income inequality in the U.S. in general, inequality in academics' salaries has trended upwards, both between private and public universities and among universities of each type (13). For individual academic scientists, salary inequality has increased substantially since the 1970s, across all ranks and diverse fields (14). --- Illustrations: Inequality in Science at Work Here are two examples of intensified inequality in science today. First, many new science Ph.D. recipients from American universities in recent years have been unable to obtain regular academic positions and instead are taking post-doctoral fellowships, or other forms of non-tenure track employment (7). (One source of this problem may be the large supply of well-trained foreign students and immigrant scientists (7).) The work by these temporary employees contributes directly to the success of senior scientists who head large scientific teams. Second, internet technology, a globalized economy, inexpensive air transportation, and relatively peaceful world politics have created an unprecedentedly interconnected world (15). In this new global environment, a successful scientist filled with ideas at a prestigious university in America or Europe can design studies and have them carried out by dependent collaborators in less developed countries, such as China, where labor-intensive scientific work can be conducted at lower costs. Such collaborations are complementary and can lead to mutual benefits ( 16), while at the same time amplifying inequality across individual scientists, as more successful scientists are much more likely than less successful ones to be centrally located in global collaborative networks facilitated by new communication technologies. --- Contextual Sources of Inequality in Science Scientists are situated within and affected by research institutions, which, in turn, are located in and affected by different societies. Hence, inequalities across individual scientists are generated and reinforced by social forces at contextual levels. Below, I will discuss contextual sources at two levels: institution and country. The importance of institutional environment to scientists is well documented (2,17,18). Scientists affiliated with prestigious institutions are more productive and better rewarded than those who are not. Hence, greater institution-level inequality serves to intensify the individual-level inequality of scientists. There is some evidence that institution-level inequality in resources has increased over time. In Fig. 1, I present the 1990-2010 trends in the Gini coefficients for (i) total research expenditure, (ii) federal research expenditure, and (iii) endowment for U.S. universities (19). The Gini is a commonly used measure for inequality, ranging from 0 for absolute equality, to 1 for absolute inequality. As Fig. 1 shows, institutional inequalities in the three resource measures have all been very high throughout the period, with most Gini coefficients well above 0.70. Despite already high levels of inequality, however, the Gini coefficients trended upwards during the period. By the end of the period, the Gini in federal research expenditure had reached 0.82, with Ginis in total research expenditure and endowment trending respectively to 0.81 and 0.76. Part of the reason for the increases was an expansion in institutions that participate in research. If we restrict our analysis to a limited set of universities that have always been active in research, there is no clear trend. Large country-level differences in scientific activities have long been noted (20). Historically, the world center of science has shifted several times, from Renaissance Italy to England to France and to Germany, before crossing Atlantic to the United States in the twentieth century (21). In the past nine decades, America has dominated the world of science (7). However, just as between-country income inequality has narrowed in the world, mostly due to a rise of income in China (22), between-country differences in science have also narrowed, thanks to the globalization of science (7,16). Measuring between-country inequality in science is not easy. One possibility is to track changes in research outputnumber of published articles -as a crude measure of scientific activity. In Fig. 2, I present trends between 1990 and 2011 in science/engineering publications that are tracked by Thomson Reuters' InCites and Essential Science Indicators databases by major countries. I use the U.S. productivity level as a reference so that all lines indicate ratios of a country's productivity to that of the U.S. While the relative increase in research productivity was modest and non-monotonic for Germany, Japan, and the United Kingdom, the increase was pronounced for India and dramatic for China. By 2011, China's article output was about two thirds that of the U.S., a remarkable surge given its low 5% level back in 1990. Of course, the comparison of total productivity by country in Fig. 2 is misleading because it does not control for population or economy size. The main focus here is on trends, which point towards the narrowing of country differences, mainly due to the growth of science in China. --- Conclusion Inequality has been, and will always be, an intrinsic feature of science. Few scientists produce truly path-breaking work. Those scientists with exceptional achievements are highly recognized in science and society at large and receive generous financial resources and institutional support for their work. Inequalities in science in recent years have been affected by two concurrent changes -the globalization and expansion of science and the increasingly widespread use of internet technology. These two forces have conflicting effects on different levels of inequality in science. At the levels of individual scientist and institution, they have tended to intensify inequality. At the country level, they have narrowed it. However, we need to remember that the most significant consequences of these two forces for science have been positive overall: Gini for resource inequality across U.S. universities, 1900-2010 Ratios in total number of science/engineering articles of a country to that of the U.S., 1990-2011. Source: Thomson Reuters' InCites and Essential Science Indicators databases. --- Supplementary Material Refer to Web version on PubMed Central for supplementary material.

Inequalities in scientists' contributions to science and their rewards have always been very high. There are good reasons to propose that inequalities in science across research institutions and across individual scientists have increased in recent years. In the meantime, however, globalization and internet technology have narrowed inequalities in science across nations and facilitated the expansion of science and rapid production of scientific discoveries through international collaborative networks. In recent years, academic scholarship, along with public discourse, has become increasingly preoccupied with social and economic inequality, which has risen in many countries. Thus, it is surprising that more research attention has not been paid to the large inequalities in the world of science. In this article, I present an overview of these inequalities, focusing on their social origins, trends, consequences, and contextual sources. Before doing this, let me define "inequalities in science." In this essay, "science" refers primarily to basic, natural science, although most of my general conclusions are also applicable to the social and applied sciences. By "inequalities," I mean differences across scientists in three major domains: resources, research outcomes, and monetary or nonmonetary rewards. While inequalities ultimately exist at the individual level, they are influenced by contexts.

Significant shifts have occurred in religious groups on every continent as a result of the COVID-19 pandemic. The response of religious leaders to the epidemic has been met with unprecedented difficulties, one of which is the requirement to strike a balance between the spiritual requirements of their communities and the requirement to safeguard public health. In this editorial, we will investigate how religious leaders all across the world are responding to the COVID-19 pandemic, including the triumphs and problems that they have encountered, and we will highlight some of the lessons that can be learnt from their experiences. The requirement for religious leaders to adjust to new practices of their faith has been one of the most significant obstacles that they have faced. In order to prevent the virus from spreading further, the governments of numerous countries have imposed regulations that prohibit public meetings of any kind, including religious services. Online services, social media, and other types of virtual interaction are some examples of the new ways that religious leaders have been forced to discover new ways to connect with the people they serve. This represents a huge transition for many different religious traditions, which have traditionally placed a large amount of importance on being part of a physical community and interacting with others. In spite of these difficulties, religious leaders all over the world have risen to the occasion and put in place a variety of safeguards to protect their congregations against the virus. During services, several places of worship have begun requiring guests to wear masks and increasing the amount of physical space that exists between worshippers. These are just two examples of the many social distance policies that have been introduced by religious organizations. A number of religious leaders have both encouraged the people in their communities to get vaccinated against the virus and tried to debunk myths and misunderstandings around the vaccination. In addition to these initiatives, religious leaders have also played an essential role in the provision of spiritual and emotional support to the communities in which they serve during the pandemic. This has included organizing virtual gatherings and prayer groups, in addition to providing online counseling and support services. In many instances, religious leaders have also made efforts to provide practical help to those people who have been impacted by the pandemic. For example, they may have provided individuals in need with food and other critical goods. In spite of these attempts, the response of religious leaders to the COVID-19 pandemic has also been met with opposition and criticism. Several people have accused religious leaders of not taking the threat posed by the virus seriously enough, as well as of disregarding the advice of public health officials by continuing to organize big meetings. Others have leveled criticism at religious leaders for their alleged role in the dissemination of false information and conspiracy theories concerning the virus and the vaccination. In spite of these obstacles, there are significant things that may be picked up from the way religious leaders responded to the pandemic. One thing that can be learned from this experience is how critical it is to remain flexible in the face of ever-evolving threats and to seek out novel approaches to maintaining connections with communities. Another thing that may be learned from this is how important it is to put public health and safety first, even when there are tremendous emotional and spiritual needs to be met. In conclusion, the response of religious leaders illustrates not just the significance of social and communal assistance during times of crisis, but also the vital role that religious organizations may play in giving this support. In conclusion, the COVID-19 epidemic has provided tremendous issues for religious leaders all over the world. These leaders are tasked with navigating the need to strike a balance between the protection of public health and the fulfillment of spiritual and emotional needs. The response of religious leaders to the pandemic has been met with a number of challenges and critiques; yet, there are valuable lessons that may be gained from their experiences. It is vital that religious leaders continue to adapt to the changing epidemic and develop new methods to support their congregations, while simultaneously emphasizing public health and safety. This is because the pandemic is continuing to evolve. --- This Issue This issue features ten articles with some authors from abroad: Malaysia, India, Nigeria, and Australia. Using a qualitative research design and case study methodology, the first study examines how social media influences the perception of religious moderation among millennials. The research demonstrates that religious moderation can be internalized via social media intermediaries such as videos, articles, and persuasion techniques. The findings of this study indicate that the distribution of religious materials that address contemporary issues can enhance the implementation of religious moderation among the millennial generation without compromising the essence of religious education. In order to examine the efficacy of religious moderation in dealing with pluralism in Indonesia, additional research is advised. The second study sought to analyze the cognitive process of Islamic bank customers regarding usury and the differences between Muslim and non-Muslim bank customers' perspectives on usury practice in the bank. Interviews with twenty customers of Bank Syariah Indonesia Manado, ten Muslims and ten non-Muslims, revealed that only four of ten Muslim participants became customers of the Islamic bank due to their belief in the bank's usury-free status. In addition, all customers agreed that loan sharks' lending practices should be classified as usury, whereas not all customers viewed the current banking industry's lending practices as usury. The third research aims to create a learning taxonomy for Islamic education that accommodates emotional, intellectual, and spiritual aspects, based on neuro-theology, neuro-philosophy, and neuro-education. Hierarchical thinking in Islamic education was found to have relevance to six brain components, which can be narratively synthesized into a learning taxonomy. The brain components and hierarchical thinking were integrated and synthesized through a systematic review. This study shows the potential for future theoretical discourse on the development of learning taxonomy in Islamic education. The fourth article presents a literature review on the environmental responses of non-Islamic religions in Indonesia. The study examines Christianity, Hinduism, Buddhism, and Confucianism and concludes that these religions respond to the crisis by emphasizing environmental conservation, safeguarding the environment, glorifying God's creations, and emphasizing the value of beauty and aesthetics. The research emphasizes the significance of theo-ecology and moral teachings in addressing environmental issues and promoting sustainable practices. The study's primary data came from articles published in scientific periodicals, and it was conducted online. The fifth article qualitatively analyzes the process of national fiqh actualization and its role in shaping an attitude of religious moderation in Indonesia. The study concludes that national fiqh seeks to build a nationalist humanistic paradigm to reduce differences and has an orientation to unity and integrity in maintaining national sovereignty wrapped with nationalism. The actualization of national fiqh is crucial in building Indonesia's religious moderation by appreciating the teachings of Islam in a complex and contextualist manner, strengthened by cultivating moderate, fair, tolerant, humanist, ethical, religious, and nationalist attitudes. The sixth article presents a discussion on the significance of cultural awareness for medical professionals who treat Muslim patients, particularly within the framework of Islamic medical ethics. The doctrine of monotheism stands at the heart of Islam, and the religion's divine law is intended to govern every facet of human existence. A "consensus decree" that includes a varied representation and a transparent decision-making process is frequently chosen when it comes to making decisions on medical care. This research identifies fundamental concepts in Islamic medical ethics, with the goal of assisting medical professionals in developing a deeper understanding of Muslim patients' cultural contexts and providing treatment that is more sensitive to such contexts. The seventh article offers a solution for the problem of developing students' piety through the use of blended learning by mixing online and offline teaching methods. The strategy places an emphasis on active participation from students as well as the use of digital tools like YouTube, Google Classroom, and Interactive Mentimeter. The study finds that collaborative and contextual learning meets students' needs in developing piety and contributing to Islamic civilization in the future. The study links blended learning media with the development of piety among students in the Chemical Analysis department. Classroom action research and literature studies are used to make this connection. The eighth article investigates the extent of religious interactions and the relationship between devotees of various faiths in Osogbo. Despite the open relationship between people of diverse faiths, the study is historical and descriptive, revealing that the actions and inactions of people of other faiths in Osogbo pose a threat to social cohesion in the community. The article suggests that followers of the three religions engage in discussion and mutual understanding in order to achieve peaceful coexistence within the community. Using a normative-juridical research approach, the ninth article examines Baitul Maal Wa Tamwil's bankruptcy settlement from the perspectives of both positive law in Indonesia and Islamic law. According to the study, the major cause of bankruptcy was a variety of internal issues, such as limits in material legislation, human resources, legal culture, and supporting infrastructure. The ideal solution would be a new bankruptcy regulation that would incorporate the different provisions that are still scattered across several existing laws and regulations. The ninth article looks at Muhammad Umer Chapra, a notable scholar in Islamic economics, and his writings, which include The Future of Economics: An Islamic Perspective and "The Islamic Vision of Development in the Light of Maqid Al-Sharh." The study examines whether Chapra's thesis is consistent with the concepts of maqashid al shariah proposed by other Muslim thinkers, as well as the five fiqh legal maxims. The study results reveal that Chapra's ideas are consistent with maqashid al shariah and the five fiqh legal maxims. , G. (2021) Ag Ahmed, M. A., Ly, B. A., Diarra, N. H., Traore, F. B., Diarra, D., Kande, I. F., Dembele, M., Doumbia, S., & Alami, H. (2021). --- FURTHER READINGS --- Addo Challenges to the implementation and adoption of physical distancing measures against COVID-19 by internally displaced

The Covid-19 pandemic has presented significant challenges for religious leaders around the world, who must balance the need to protect public health with spiritual and emotional needs. Despite these obstacles, religious leaders have risen to the occasion and implemented protective measures for their communities, including social isolation and vaccination encouragement. Through online counseling, virtual gatherings, and practical assistance, they have also provided spiritual and emotional support. Lessons learned include the significance of adapting to new technologies, putting public health and safety first, and the vital role of religious institutions in providing community and social support during times of crisis.

gamers to earn money as YouTuber and as professional gamer. Gamer can also design games which are more suitable for them as they are the testimonials of online gaming, they will be more aware about taste requirements of online gamers. --- Profile of Teenagers and youth: Teens: A teenager, or teen, is someone who is 13 to 18 years old. They can also be described with the term "adolescence". This age group people are usually highly active and are about to finish their childhood and enter into adulthood. This age group children can be found in their schooling, they are also highly interested in spots and gaming activities. This age group individuals will in their schooling and are highly dependent on parents for economic resources. In this stage, the brain still developing into a person's early or mid-20s. A person becomes a teenager when they become 13 years old. It ends when they become 18 years old. Teenagers who are between 13 and 17 years old are considered both children and teenagers in most countries. Teenagers who are 18 years old may be regarded as both teenagers and adults. According to national health mission India number of teenagers in India is currently 235 million, which is an opportunity for gaming companies which targets teenagers as potential consumers. The life of a teenager can be subject to daily change. Constantly exposed to new ideas, social situations and people, teenagers work to develop their personalities and interests during this time of great change. Before their teenage years, these adolescents focused on school, play, and gaining approval from their parents. Because of their interest gaming and low self-control over their gaming participation this age group is targeted by gaming companies. --- Youth: Youth is the time of life when one is young. The word, youth, can also mean the time between childhood and adulthood (maturity), but it can also refer to one's peak, in terms of health or the period of life known as being a young adult. Youth is also defined as "the appearance, freshness, vigor, spirit, etc., characteristic of one, who is young". Its definitions of a specific age range varies, as youth is not defined chronologically as a stage that can be tied to specific age ranges; nor can its end point be linked to specific activities, such as taking unpaid work, or having sexual relations. Among 100 respondents,36 members stated that they have learned communication skills,10 respondentsstated that they got to learn multitasking skills, 16 respondents stated that they got to learn good memory power. 26 members of total respondents stated that they got to learn concentration skills and 22 members stated that they are not sure about the skills they learnt by plying online games. Among 100 respondents, 53 respondents stated that online gaming improves teamwork and collaboration skills. 8 respondents opined that online gaming does not improves teamwork and collaboration skills, and 39 of respondents are not sure about it. Out of 100 respondent, 7 respondents strongly disagreed, 4 respondents disagreed, 25 respondents were stated neutral, 44 respondents agreed and 20 respondents strongly agreed with the statement-online gaming helps improve strategic and critical thinking skills. Out of 100 respondent, 5 respondents strongly disagreed, 12 respondents disagreed, 29 respondents were stated neutral, 43 respondents agreed and 11 respondents strongly agreed with the statement-about building career as professional gamers. Out of 100 respondent, 18 respondents strongly disagreed, 22 respondents disagreed, 25 respondents were stated neutral, 27 respondents agreed and 8 respondents strongly agreed with the statement-online gaming can be good source for earn money. --- Hypothesis testing: Hypothesis 01: H0: There is no significant relationship between age-group and gaining cognitive benefits by online gaming. H1: There is significant relationship between age-group and gaining cognitive benefits by online gaming. --- Cognitive skills* Age-group cross tabulation --- Options

With commencement of online games like Pub-g and Free fire and also, the availability of smart phones at affordable price led to growth in online gaming consumer base in past decade. Like two faces of a coin online gaming too has its own pros and cons, this study is conducted to explore positive side of online gaming. The main aim of this study is to identify the potential benefits of online gaming towards teens and youth. In this study both exploratory and descriptive research design are use gain better understanding of online gaming communities. For this study data was collected through structured questionnaire converted into Google forms circulated through various online gaming groups in WhatsApp and other social media platforms. From 100 respondents who belongs Ballari districts, Karnataka. And data is analysed using SPSS. The results of the study shows that online gaming has benefits on mental health such as stress reduction and other benefits such as social network, social interaction skills. Additionally, online gaming improves the strategic and problem-solving ability. And some of the respondent also opined that getting expertise in gaming will help them to build their career as professional gamers.

Introduction The 2022 Drug Statistics Report from the National Anti-Drug Agency (NADA) shows that Malaysia has a total of 137,176 people involved in drug abuse. Terengganu shows figure of 13, 314 people involved in drug and substance abuse. The same statistics also show that a total of 8,594 people have received rehabilitation treatment in institutions and 64,335 people have received rehabilitation treatment in the community (NADA, 2021). The Community based Treatment (CBT) program involves the function and commitment of many stakeholders joining hands to support recovery from substance abuse. Rehabilitation in the community refers to the collective efforts of community entities to support the recovery of substance abusers. The main goal of community rehabilitation is to improve the quality of One of the components of the CBT has included the family as a social support system for drug users. The concept of social support consists of three main characteristics, namely the strength of support, the characteristics of the support network, and the form of support provided. First, the strength of support is the amount of support that drug users receive; second, the characteristics of the support network are the number of people or units that make up the support network. Third, the forms of support refer to both tangible forms, such as food, and intangible forms, which are emotional support (Nargiso, 2012). Miller et al ( 2014) found that social support can reduce the risk of prolonged dependence for substance abusers undergoing out-of-facility rehabilitation. For families, social support through active family involvement can provide emotional relief from the pressures of addiction and trigger a sense of wanting to change (Afandi et al., 2009;Saleem et al., 2013). However, families also face obstacles in providing social support such as knowledge, emotions, and exclusion. This obstacle poses a challenge that undermines comprehensive social support for drug users (Ghazali et al., 2017). The La Bodega La Familia model is a program-based model to support the recovery process of drug users. The program was first developed in 1995 in collaboration with the City of New York and the State of New York. This program has shown that drug user recovery can be interrupted when the family does not have the skills to support recovery. This model also shows that it is more difficult to engage families when they have unmet needs, such as health care, housing, and other social services. Therefore, the community must take this place to provide social support to drug users and their families (Sullivan et al., 2002). Families who are willing to provide social support, this model finds that close relationships with drug users while in institutional treatment must continue to prevent drug users from relapse. Support through close relationships, doing activities together, communication, overcoming difficulties together, and providing the necessary help are forms of social support that can be given to drug users (Fontaine et al., 2012). The relationship between family and drug users can be explained through Systems Ecology Theory. This theory looks at the micro level; the family is the closest unit to the drug user and has a direct relationship. While at the meso level, the community has a relationship with drug users through a structured but still close relationship with drug users. These relationships influence each other, where a good environment promotes effective recovery while an unhealthy environment reduces the effectiveness of the recovery process (Kazemzadeh, 2014) --- Research Objective This paper aims to assess the readiness of families to support the Community Based Treatment (CBT) through social support for drug users in the state of Terengganu. --- Methodology This paper uses quantitative methods. The research design is a survey that is distributed to the families of drug users who are following the rehabilitation process in Terengganu. Data was collected using the Family Social Support Questionnaire (SOSK) by (Ghazali, 2017). The four indicators for this questionnaire are emotional, informational, instrumental, and spiritual support. Respondents consisted of 177 family members consisting of mothers, fathers, grandmothers, grandfathers, wives, siblings, and children of drug users who are following the rehabilitation process at rehabilitation institutions in the state of Terengganu. Respondents were selected based on purposive sampling, and respondents were selected based on family consent to participate in this questionnaire. The data was analysed using SPSS descriptive analysis to obtain frequencies and mean values. --- Findings and Discussion Social support provided to drug users is evaluated using the same measurement indicators, which are four forms of social support involving emotional support, spiritual support, informational support, and instrumental support. --- Family Social Support The analysis found that emotional support (mean=7.34, S. P=1.264) was the highest social support given by respondents, followed by spiritual support (mean=6. The acceptance and appreciation given is at a high level, while the involvement given is at a medium level. Therefore, it is understandable that the respondents consist of family members who have accepted and appreciated drug users who want to change but have not yet been fully involved in assisting recovery. Involvement in this study refers to the presence and willingness of the respondents to follow the recovery process and program followed by the addict and act as a facilitator to the necessary and beneficial recovery resources to promote recovery. This simple involvement can also be understood as drug users are still accepted and not marginalized from the family. ii. Spiritual Support A comparison of the three dimensions of spiritual support found that religious appreciation (mean=6.6615, standard deviation=1.587) was the highest support given compared to religious awareness (mean=6.6152, standard deviation 1.607) and punishment control (mean=5.779, standard deviation=1.748), as shown in Table 3 below. Spiritual support is delivered more through religious appreciation, than awareness and punishment control. This shows that respondents emphasize the faith aspect of drug users in undergoing rehabilitation. The step of instilling faith in oneself helps create a sense of contentment, thus allowing drug users to view recovery from a more positive perspective. It also encourages a sense of dependence on God over other things, building a strong user personality. The appreciation of religion is only emphasized on the practice of prayer, fasting and reading the Quran in a simple way. In addition, respondents also have difficulty imposing control on users due to lose rules at home. The control factor is a very important element to curb relapse and the effectiveness of the rehabilitation process in the community. --- iii. Information Support Informational social support is delivered through guidance (mean=7.34, standard deviation=1.728) followed by advice (mean=5.84, standard deviation =1.895) and information (mean=4.99, standard deviation=0.915) as in Table 4. Guidance is more often conveyed to drug users through suggested methods of recovery to ensure that drug users can face any difficulties throughout the recovery process. Guidance has relevance to the dimension of respondents' involvement in emotional social support. Meanwhile, advice and information are given in a simple manner with information approaching a low level. Therefore, it is understandable that respondents have difficulty in providing useful information related to drugs, the effects of abuse as well as effective rehabilitation information. On the other hand, advice in general such as needing to stop addiction is more given to drug users. --- iv. Instrumental Social Instrumental social support is the lowest level of support given to drug users. In summary, the following --- Families in Community Based Treatment (CBT) The involvement of the family in CBT as a source of support through the component of extended care and maintenance of recovery where the role of the family is referred to as a protector against relapse. The community return phase is a critical phase because drug users are faced with real tests such as relationships with old friends of users and drug dealers and stigma. Families acting as protectors for drug users must have the ability to provide the form of support that drug users need. Based on the findings, the level of social support provided by families found in the state of Terengganu is still moderate, thus becoming a concern because the rehabilitation program followed by drug users with NADA is not well supported by the family. The drug recovery process is lifelong. If the respondent continues to channel support at a moderate level, it will have a negative impact on the effectiveness of the RPDK program and the i-recovery module. The increasing number of relapsed drug users affects the indicators of the effectiveness of the rehabilitation program, thus further explaining the endless drug threat in Malaysia. Rehabilitation in the institution does not happen forever. Therefore, the respondent needs to take a serious role as a continuation and reinforcement so that the continuation of the rehabilitation process does not happen halfway. NADA through the District Drug Rehabilitation Treatment Committee (JKPD), Peer Counsellors (PRS) and Recovery Mentors are support groups in the community that can be used by families to increase their skills in helping drug users. Because of that, the family's openness, long-term commitment and the family's willingness to add new input can protect drug users in recovery. --- Conclusion The high number of cases and the modest social support of families show that the families of drug users found are still not fully prepared to support the rehabilitation efforts carried out by the government. It conforms to the idea of implementing the La Bodega La Familia model, where the family of drug users has a hard time playing a role in helping recovery because they are faced with a lack of information and skills in dealing with drug users in the family.

Rehabilitation in the community refers to the cooperation of all parties directly or indirectly involved with drug users. The family is a resource of support for drug users in recovery and plays an important role as a protector against relapse. However, the role of family in providing social support is often debated. Therefore, this study was conducted to assess the strength of family social support in assisting the government-run community based treatment programme (CBT). Data were collected using a family social support questionnaire from 177 family members of drug users in Terengganu who were selected using a purposive sampling method. The data were analysed using descriptive analysis (mean) and SPSS. The study found that three of the four forms of social support (spiritual, informational, and instrumental) were moderately provided, and emotional support was highly provided. In summary, family involvement in support for rehabilitation treatment programs in the community still needs to be improved for families to effectively support CBT.

trust and commitment from both organizations. 5,6 Of Chicago's 77 community areas, Austin is the most densely populated with over 98,514 residents. It is 90% African American and 24% of Austin residents live below the poverty line. 7 The Westside Health Authority (WHA), established in 1988, is the primary community health organization committed to using the capacity of local residents to improve the health and well-being of Austin residents across the lifespan. WHA has a long history of successful community-based, actionoriented, coalition building beginning with its organizing efforts to stop a local hospital from closing. Furthermore, while working with academics and foundations, it has trained community members to conduct health research in Austin since 1992. 8 Based on results from this work, WHA implemented its --- METHODS This section describes the methods and results for three main research projects that resulted from the initial Partnership-Build ing Seed Grant and illustrate the partnership's growth as well as describe how students were involved in community activi ties and research. A timeline of partnership activities leading to and following each project is found in Figure 2. Institutional review board approval was received from NU for all three projects. When obtaining consent, research investigators provided a verbal overview of the project in a group or one-on-one format, allowed time for questions and answers, and provided a consent form copy to participants. Two individuals declined to participate in project three owing to the time commitment; otherwise, all invited community residents consented in projects one and two. --- Project One This project focused on concerns about low levels of PA in --- Project Two This project was based on the results from the focus groups and discussion with the CHAs, who suggested a peer-based approach to increasing PA. The goals of this project were to --- Project Three The academic investigators led this project, but the The PA promoters recruited eleven participants (8 women, 3 men; average age 66.5 years; range, 54-81). The PA promoters were paid $100 monthly for 3 months for their recruitment efforts and counseling sessions. Outcome measures pre-and post-intervention were the 6-minute walk test (6MWT), 16,17 Short Form Health Survey, 18 Self-Efficacy for Exercise Scale, 19 and accelerometer measures for 1 consecutive week. Outcome measures were not significant except the average 6MWT distance, which increased by 91.6 meters (greater than a minimally clinically important difference). 20 Accelerometry data showed that 93% of time was spent in sedentary behavior and 7% in light, with negligible periods of moderate/vigorous activity. Accelerometry results in this small sample revealed the need to focus on reducing sedentary behavior. As a result of this pilot study, we found that contact with PA promoters led to a clinically meaningful increase in 6MWT (a proxy for functional capacity) with the potential to increase PA in --- LESSOnS LEArnED In project one, a lesson learned by community partners was their significant contribution in recruiting focus group partici- Students' comments throughout their experiences in Austin reflected a deeper appreciation and respect for the social, economic, and environmental context of their future patients. We believe their community engagement has shaped their future practice. However, formal assessment of students' perspectives and attitudes related to their experiences was not done. Academic and community partners plan to assess change in students' perceptions over time on their professional roles in the community, impact on career, and working in a diverse community. 24 Review of student perspectives after their community experiences will help to identify factors influencing their professional preparation. The funding from ARCC has been critical to the development of this partnership. Funding for community members, academic faculty, staff involvement, and purchasing project or organizational equipment is important when considering sustainability. We were fortunate in initial support from ARCC, which provided structured time and regular meetings to work toward shared project goals. We recently received additional financial support for our partnership though Community-Engaged Research Team Support (CERTS), an NIH-funded NUCATS grant. CERTS facilitated monthly meetings and further defined research questions and approaches focused on WHA's Body and Soul program, which is the basis of the partnership's upcoming project four. --- COnCLuSiOnS Initial projects built the partners knowledge of each other and community and academic capacity. WHA and Austin residents working with the academic partners were critical to obtaining knowledge of the community. The projects started with small, achievable goals and as trust in the partners' commitment developed we have become more deeply engaged with a broader number of activities. We have become reliant on each other for volunteers; community members come to class to discuss their life experiences and the students are essential manpower for community events. WHA and PTHMS are committed to this partnership and believe that health professions student engagement in the community is a powerful learning experience in understanding and respecting the social, economic, and environmental context of future practice to improve health outcomes in underserved communities. We also believe that CBPR and the engagement of student health workers can improve health outcomes in underserved communities and, specifically in this case, improve the PA of Austin residents. --- ACKnOwLEDgMEnTS The authors thank the Austin residents, WHA CHAs, PA promoters-especially Ms. Orlean Huntley, who shared her views on her roles in all three projects, and the PT students who have been involved with and contributed to the partnership.

acial disparities in health across the United States remain and in some cities (e.g., Chicago) have worsened despite increased focus at federal and local levels. [1][2][3][4] One approach to addressing health inequity is CBPR, in which community members participate as partners in research and are invested in responding to and disseminating the results. CBPR's collaborative relationships between community and academic partners share a focus on health concerns of importance to the community. 5,6 Building these meaningful and productive partnerships takes time to develop

disease attributable to CKD and be used to inform further research on areas in which policies could be implemented to optimise CKD prevention, early detection, and treatment at different stages of CKD and different levels of health systems. The framework presented here reflects the UK context but can be adapted for different country contexts. Method: The framework development included two stages. First, a scoping review of the literature in this field was conducted. The literature review included peer-reviewed articles, grey literature, policy documents, academic reports and congress and conference reports. The second stage saw the validation of the framework by a multidisciplinary expert panel in the UK. This expert panel was composed of eight UK experts in the fields of nephrology, public health, primary care, organ donation and transplantation, and other disciplines. --- Results: The framework outlines a holistic patient pathway from pre-CKD development to kidney failure along with the corresponding interdisciplinary level of care. The framework stresses the need to implement a population-wide approach focused on preventative care strategies, chiefly on the risk reduction of kidney failure. Underlying aetiologies and disparities in access to care were found to be inherently linked to disease progression and health outcomes. Data systems were identified as vital to ensuring continuity of care between primary and specialty care which in turn could lead to improved patient outcomes. The use of greener energies coupled with a reduction in the incidence of renal failure requiring dialysis could reduce substantially the environmental footprint of this disease. The burden of disease reflects the sum of the individual and system-level impact and outcomes of CKD which are labelled as economic, social, and environmental (Fig. 1). --- Conclusion: The conceptual framework underscores how underlying aetiologies, socioeconomic factors, and fragmentation of care are reflected in disparities in healthcare access, particularly in marginalised and underserved populations. The environmental footprint of this disease could be reduced through optimal standard of care. The framework can inform future research to model the burden of CKD in terms of clinical, societal, economic, and environmental outcomes in the UK and the targeting of policy interventions to mitigate these burdens across different country contexts.

The past three decades have seen an increase in the prevalence and mortality rate of chronic kidney disease (CKD). It is estimated that between 1990 and 2017, the global all-age prevalence of CKD increased by 29.3%, whilst the mortality rate rose by 41.5%. Over this period, CKD became the 12th leading cause of death worldwide, with an estimated 1.2 million deaths attributed to the disease in 2017 [1]. With global prevalence currently estimated at 10% [2], CKD is a leading cause of disability, accounting for 35.8 million disability-adjusted life years (DALYs) in 2017 [3]. This growing burden of the disease calls for robust healthcare policy interventions to improve disparities in health, socioeconomic, and environmental outcomes. The aim of this research is to build a Healthcare Policy framework for CKD that will analyse the drivers and components of the burden of disease in terms of clinical, socioeconomic and environmental outcomes. It will also incorporate current knowledge of best practices and challenges in the organisation of healthcare services to mitigate these burdens. The framework will facilitate the analysis of the burden of

Introduction With the development and progress of society, the status of Chinese women is improving, and the power of discourse is increasingly enhanced. More and more women in positions of power in the workplace, women's sense of self is also growing. With the opening up of society, the traditional Chinese idea that a woman without talent is virtuous is also changing. In today's society, people are paying attention to and discussing whether women should give up work and return to the family. It is found that female education level has a significant positive correlation with family income. With the increase in female education level, family income will also increase. The increase in female education negatively affects the number of children, indirectly increasing the family income. The number of children plays a mediating role in the influence of female education on family income [1]. With the increase in women's income, the relationship between men and women is equal, and then the construction of equal family relations is promoted [2]. Women with different levels of education have different expectations for their children's future development and therefore have different requirements for their children's education level. The educational level of parents and the educational time of children are directly proportional to the quality [3,4]. At the same time, scholars have found that students from socially advantaged families are more likely to receive better education and attend elite universities than students from socially disadvantaged families [5]. In contrast, more educated mothers pay more attention to early education to help their children grow up [6]. Thus, education is more conducive to the growth of the next generation. Female education is conducive to social progress and ideological inspiration [7]. At the same time, after receiving an education, women are more able to get rid of the shackles of traditional family concepts, pay more attention to protecting their rights and interests, and identify with themselves more [8]. The housewife's due rights in the family are damaged, the power level of the family is low, relatively passive, hidden behind more efforts and responsibilities, the housewife's subjectivity is ignored, and the status of the family is still weak compared with the husband [9]. Therefore, female education can encourage women to enter society and work, thus increasing income, improving family status, promoting gender equality, and promoting the growth of the next generation. Under such background, this paper will examine the correlation between education level and the people's agreed degree of women as housewives. Combined with previous research, women's access to high levels of education and social work can boost the development of the next generation. The purpose of this paper is to research whether the improvement of education level can promote women's self-education and efforts to enter the workplace. There is currently less research on the correlation between education level and the recognition of women as housewives, which is also the significance of this study. The rest of the paper is arranged as follows: the second part introduces data sources, variable settings, research methods and research hypotheses, the third part is the conclusion, the fourth part is the comparative hypothesis, and the last part is the summary and revelation. --- Method --- Data source This paper uses data from the 2018 China General Social Survey (CGSS). The survey scope is wide and the data volume is large. CGSS conducted the survey in 125 counties (districts), 500 subdistricts (townships and towns), 1,000 residents (village) committees and 10,000 households across the country. Through the regular and systematic collection of data on Chinese people and various aspects of Chinese society, it summarizes the long-term trend of social change, promotes the openness and sharing of social science research in China, and provides data for international comparative research. This paper mainly uses CGSS data to study the influence of education level on the identity of female housewives. --- Variable setting The explained variable of this paper is the degree of recognition of women as housewives. This variable is determined by agreeing or not " men should put their careers first, women should put their families first". The respondents chose from five values ranging from 1 to 5. The higher the value, the more the individual agreed that women should be housewives. The core explanatory variable of this paper is educational level (Education). In this paper, the educational level is divided into five levels: Primary school and below, Junior high school, Senior high school, Undergraduate, Postgraduate and above. The five levels are assigned a scale of 1-5. A higher value indicates a higher level of education. In order to reduce the bias, a series of irrelevant variables were set as control variables: Whether the respondents have religious beliefs (Religion), Health status (Health, 1-5, the higher the value, the better the health status), and life happiness (Happy, 1-5, the higher the value, the better the health status). --- Research method This paper refers to the Ordered Probit model used in the paper by Zhongwu Li and Xueliang Feng [10]. Because the explained variables were ordered discrete selections, the ordered probit model was used in this study. Firstly, the data is analyzed and processed, and then the sum command is used to make descriptive statistics on the data. Then the Ordered Probit model is used to analyze the education level (Education) and agree degree (Agree). The margin command is used to analyze the marginal effect of the data. Finally, the graph is drawn based on the margin model, and conclusions will be given by analyzing the chart. --- Research hypothesis The research hypothesis of this paper is that education level has a significant impact on women's recognition of being housewives. The higher the education level, the less they agree that women should be housewives. This assumption is based on the family tradition. The ancient Chinese traditional thought that "Too much learning does not become a woman." [11]. As Chinese society becomes more and more open, this old idea is changing. Everyone is equal, and everyone can get an education. More and more people are promoting gender equality. Therefore, the assumptions made in this paper is that education level has a significant impact on women's recognition of being housewives. The higher the education level, the less they agree with the research hypothesis that women should be housewives. As shown in Table 1, the descriptive statistics of the main variables in this paper are listed. It can be seen that the mean value of Agree is 3.135584. Therefore, most people in this sample agree that women should be housewives, which is consistent with the current situation in Chinese society. Most people still believe that women should put family first. The average value of Education is 2.058152, which indicates that the education level of the sample in this paper is relatively low. It is consistent with the social phenomenon in China. Since the opening up of society, more and more people have been able to receive an education. However, most people in the 1980s and before had fewer opportunities to receive education, leading to an overall low level of education. 1. In the Ordered Probit regression result, the estimated coefficient is the marginal influence of the corresponding parameter on the explained variable. The results of marginal effects are shown in Table 2. From the perspective of marginal effect, for every unit increase of Education, the effects on probability with an Agree degree of 1 is 0.0406377, and the effects on probability with an Agree degree of 5 is -0.0500782. As can be seen from Fig. 1, with the improvement of education level, fewer Agree to 5. According to this, education level has a significant impact on women's recognition of being housewives. The higher the education level, the less they agree that women should be housewives. --- Results --- Discussion The hypothesis made at the beginning of this paper is that education level has a significant impact on women's recognition of being housewives. The higher the education level, the less they agree that women should be housewives. After comparison with the research results, the research hypothesis made in this paper is consistent with the research results. It can be seen that the improvement of education level can promote women to receive high-level education, and also promote women to enter the society to work. Combined with previous studies, women entering the workplace can improve family income, which can refresh the family status, promote family harmony, and promote the development of the next generation and social progress. However, researches and surveys have shown that women get less resources than men in the input of higher education resources, the gender differentiation of disciplines and majors in higher education is increasingly serious, teachers and male students have prominent gender stereotypes of female students in the process of higher education, the male-centered construction of higher education textbook system, gender inequality in the results of higher education and so on [12]. At the same time, studies show that gender equality is of great significance to the community of shared future of mankind, which can promote the development of the international community [13]. It can be seen that women are still in a vulnerable position in the society. The country should improve the level of education of citizens, which can promote gender equality and further promote the open development of society. --- Conclusion This paper conducted a study on the effect of education level on women's agreement that they should be housewives, and the results of the study showed that education level has a significant effect on women's agreement that they should be housewives, and the more educated people are, the less they agree that women should be housewives. Combined with the previous studies, the high level of education and excellent economic conditions of women can promote the growth of the next generation. This suggests that women should focus on self-development rather than giving up their education and work to return to the family completely. The results of this study found that the more educated people are, the less they agree that women should give up their jobs and studies to return to the family. It can be concluded that the improvement of education level can promote the development of the next generation and social progress. The limitation of this paper is that only one question was quoted in the survey on "the recognition of women as housewives", and the analysis was not comprehensive. Future research can examine this issue in more detail.

In recent years, more and more women are appearing in major workplaces, taking up important positions, and women's self-identity is increasing. In China and the international community, there is a growing discussion about whether women should be housewives, and many people think that women should put the family first. The paper uses the Ordered Probit model to analyze the data from the China General Social Survey (CGSS). This research finds out that there is a significant correlation between educational attainment and women's recognition of being a housewife. The more educated people are, the less they agree that women should be housewives. This finding has important implications for social development. Combined with previous findings, women who receive high levels of education and work in the workplace are more likely to boost the educational attainment of the next generation. Therefore, promoting the development of education level is vital to encourage the development of the next generation and social progress.

Introduction: It is estimated that the prevalence of severe Intellectual Disability (ID) is 6 per 1,000 people. ID is sometimes the cause of Behavioral Disorders (BD) with aggressive and impulsive behaviors that make family and social life difficult. However, despite its high prevalence, the number of studies on it is very scarce. When BD appears, it should be evaluated if there is a physical or psychiatric cause that causes it and assess non-pharmacological treatments. If they are insufficient, treatments such as risperidone are used to manage BD. When these are ineffective, the use of drugs with greater difficulties in their effects and clinical management, such as clozapine, is required. Objectives: The objective is to describe the use of clozapine in patients with severe ID associated with BD. Methods: Retrospective descriptive study. Patients older than 18 years with severe ID and BD, treated with clozapine for at least two years were included. Those with medical or psychiatric comorbidity were excluded. Results: The sample consisted of 12 patients, 16.67% women (n=2) and 83.33% men (n=10), aged 47.57AE9.27 years. Prior to the introduction of clozapine, a mean of 2.67AE1.21 antipsychotics had been tested. The mean dose of clozapine was 264.24AE70.50 mg/day. The patients had received treatment for 51.57AE25.67 months, following the usual controls. None had hematological adverse effects or other serious adverse effects. Conclusions: Clozapine can be an effective and safe therapeutic alternative in the treatment of BD in intellectual disabled patients which do not respond to other treatments. The clinical benefits of clozapine treatment seem to outweigh the potential risks associated with the treatment. However, more studies are needed to evaluate the effects of clozapine in patients with intellectual disabilities. --- Introduction: The aim of this paper lies in demystifying, historicizing, and de-alienating the relationship between disability and development. Both disability and development inform each other and are informed by each other in various ways which are on one hand similar and on the other hand unique. Disability is heterogeneous in nature. Disability and development are about power, access, solidarity, advocacy, inequality, rights, voice, and support. It is about accessing accessibility. It is important to understand the politics of language-how we conceptualize persons with disabilities. Objectives: The paper theorizes the 'and' between disability and development. What is that bridging telling us? There is already an invisible 'and' which joins disability and development even before this visible 'and' was placed in between them. It is to understand how disability is related to gender, caste, class, and poverty. The paper also looks at the government policies and adds suggestions as to what can be done practically to reduce inequality for persons with disabilities for developing a new India. Methods: This research used primary sources like books, articles, government programmes, and policies to make sense of how disability is understood and experienced in India. Results: It shows how disability and development inform each other and are informed by each other. The paper shows how each person has disabling parts and "normal" parts. Representation helps one to know the multifarious dimensions of what is awful, reprehensive, acceptable, possible, desirable, etc. Representation structures reality. Hence, they are a critical component of bringing about rights. Conclusions: It is crucial to look at the needs and challenges at the ground level contextually. It is important to understand why survival is considered sufficient and not full participation. Policies need to resonate culturally as otherwise, they tend to be confined to particular lases and groups in societies with access to technology, information, and the English language. What matters is the visibility of disability.

In conclusion, the SPAIDD-G evaluations revealed a greater prevalence of psychopathology than reported in the medical records. Using psychopathological screening tools can improve the diagnostic process in residential facilities for IDD cases. Pearson's analyses revealed the need to further investigate the correlation between cognitive dysfunctions and psychopathological vulnerability, studying intelligence as a multi-component model and identifying specific behavioural and cognitive phenotypes in IDD cases.

Introduction Most studies have found that youth who do not conform to gender norms for their assigned sex have higher rates of depression and anxiety than their cisgender peers. 1,2 However, more recent research featuring smaller cohorts (ie, ranging from 31 to 73 participants) of socially transitioned transgender youth-youth who identify and live as a gender different from their sex assignment at birth-show normative or only slightly elevated rates of depression and anxiety. [3][4][5] We recruited a new, larger sample of socially transitioned transgender youth, their siblings, and age-and gender-matched control participants to test whether transgender youth experience significantly higher levels of anxiety and depression than their cisgender peers. --- Methods This cross-sectional study includes responses from 3 groups of youth between ages 8 and 14 years in a large community-recruited sample (following previous recruitment strategies 3,5 ): transgender youth (148 participants), cisgender siblings of transgender children (88 participants), and cisgender age-matched controls (139 participants). We obtained written consent from parents and verbal and/or written assent from children. This study was approved by the University of Washington institutional review board. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. We measured depression and anxiety using the pediatric short form (completed by youth) and proxy form (completed by parents) of the National Institutes of Health's Patient Reported Outcomes Measurement Information System (PROMIS) scale, which measures depression and anxiety on a 100-point scale where 50 is the population mean and 40 to 60 is the reference range (see eAppendix in the Supplement). Participants must have completed 1 or both self-reported mental health measures between November 2014 and March 2020, and none of the youth in this article ever reported on their own mental health in any other study. Fifty-two parents reported on their children in a previously published report (50 at a different time point and 2 at the same time point as in this report). 5 Data were analyzed from July to November 2020 and used R version 3.6 (R Project for Statistical Computing). P < .05 was considered significant and all tests were 2-sided. --- Results --- A --- Discussion Our results were consistent with recent smaller studies of socially transitioned transgender youth and contrast with the more severe mental health symptoms found in earlier studies of youth referred to clinics for gender-related concerns (as well as transgender teens and adults 6 ), although these --- Dr Gibson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Control 49.94 (8.84) 11 (7.9) a These measures are normed such that the mean (SD) score of 50 (10) is the national average. Lower scores indicate lower depression or anxiety. b Clinical range defined as a score of Ն63, representing approximately 10% of a representative sample of youth in the age range on these measures. c When 2 parents provided responses for a given child, their scores were averaged.

Introduction With literal and figurative roots in agriculture, Extension agents have historically connected citizens to land-grant universities by identifying research problems and communicating the research findings through their local Extension offices (Garrett, 2001). As times have changed so too have the programs Extension offers young people. But one constant is the notion that young people are the roots of 4-H. Whereas yesteryear corn and canning clubs dominated the 4-H focus, today 4-H members are engaged in programs as diverse as their interests. Within Extension, a movement is underway to identify issues relevant to today's young people and work with young people to solve those issues (Hoorman, 2002). This course is being carried out in an everevolving technological landscape. Although there remains some preference for traditional face-to-face Extension instruction compared to distance learning (McCann, 2007), today's 4-H youths are members of the "linkster" generation, so named because "no other generation has ever been so linked to each other and to the world through technology" (Johnson & Johnson, 2012, para. 1). In short, today's 4-H member is connected, is "linked," to and through technology. Indeed, never in human history have people been more connected. The Internet, smartphones, tablets, and --- Matthew Newman --- 4-H Agent Rutgers Cooperative Extension New Brunswick, New Jersey m.newman@njaes.rut gers.edu social media all contribute to making those with access to technology the recipients of knowledge and wisdom that would have been the envy of the fabled Library of Alexandria. But something is amiss. To paraphrase Shakespeare, "something is rotten." The breadth of connections available to people in this the year 2019 is enough to stagger the imagination. The depth of these connections, however, can perhaps be shallow. Furthermore, as young people lack the maturity and context to differentiate between helpful and harmful content, the opportunity exists for unsavory characters with predatory intentions to exploit them. Pandora's box has been opened, and there is no going back. We are thus at a time and place where Extension 4-H youth development programs are uniquely and strategically positioned not only to provide members research-based education but also to assist them in learning how to use technology prudently and to instill in them a sense of self-efficacy within their communities, all in a safe environment that promotes the concept of using technology through a responsible and critical lens. In this article, I present evidence-based recommendations to guide Extension personnel in applying technology to engage young people while also promoting within youths a sense of community self-efficacy and encouraging the use of technology to enhance, not replace, face-to-face communication. --- Young People Today-Linksters and the Internet Those born after 1994 are referred to by some as members of the linkster generation (Johnson & Johnson, 2012). Unlike the millennials before them, linksters did not have a transition period into the age of the Internet; they were born into it. Those born before 1994 remember watching the Internet become a part of their lives, and the prevailing thought in those early days of the Internet was that access to the worldwide web would transform education. Though a transformation most assuredly took place, the change has come at a cost. Educators today walk a tightrope. They must find a way to capitalize on the amazing resources of technology, all the while mitigating the distractions (at best) or harmful consequences (at worst) of having the world at one's fingertips (Subrahmanyam & Greenfield, 2008). Furthermore, young people are left more and more to their own devices (literally and figuratively). In the past century, through a shift from rural agricultural to urban industrial communities, the segregation of youth from adults has become more pronounced (Steinberg, 2011). Through no fault of their own, separated from adults who could guide them, linksters are heir apparent to technologies they had no hand in creating. Thus, many may lack the required discipline to understand the inherent danger at (and in) their hands. --- Using Technology to Engage Young People in Promoting a Sense of Community Self-Efficacy Despite evocative language to the contrary, I do not feel a sense of foreboding doom and gloom. Created at the beginning of the 20th century, the 4-H movement was charged with both spreading hard science and shaping character in young people all over the United States. The challenge and opportunity presented to Extension today is to create new ways to build on these valued traditions. The sense of belonging to a community, mastering skills, demonstrating generosity, and preserving independence may be even more important now, in an everconnected technological society. Young people enjoy being part of something bigger than themselves. Surveys have shown that 55% of teenagers enjoy volunteering (Corporation for National and Community Service, 2005). Furthermore, youths are an increasingly visible and active component in community development efforts (Brennan, Barnett, & Baugh, 2007). In short, just doing what they have done for over a century (and have done so to great impact), 4-H youth development programs are strategically placed to help youths use electronic technology in a responsible way that taps into young people's desire to be connected, to both their communities and their technologies. Because of the technology habits of teens, interpersonal communication is becoming depersonalized. A higher proportion of teen communication is conducted through writing on electronic media (e.g., using text messaging or Twitter) than through face-to-face or even voice-to-voice (i.e., phone) conversations (Subrahmanyam & Greenfield, 2008). With research showing that young people enjoy both being part of a larger community and using the very technology that removes them from interpersonal communication, what options exist for Extension 4-H professionals? Enter the 4-H club. For better or worse, the Internet is a powerful instrument in bringing people of shared interests together. Over a hundred years ago, one's social network was limited to how loud one could yell. Then came the telephone, and with it an increase in one's ability to be connected with others. Today, with a few strokes on a keyboard (or, knowing teens, a few swipes of a touch screen), people of all backgrounds can find common interest groups. This can be particularly appealing to a young person (Subrahmanyam & Greenfield, 2008). If youth development programs offered through 4-H can become easily searchable-can become "viral"young people will more readily discover both a place to find others with shared interests and an outlet for participating in the community service projects they so want to be involved in. Indeed, recent work focused on the relationship between teen self-esteem and community service has shed light on the interests of linksters. Research has shown that teens feel better about themselves after helping strangers than after helping close friends and family members (Padilla-Walker, Carlo, & Memmott-Elison, 2018). Additionally, research has indicated that besides increasing feelings of self-worth, contributing to the improvement of a community correlates to teens realizing improvements in other aspects of their psychological and social development as well (Brennan et al., 2007). One way to increase the discoverability and appeal of 4-H is via social media. Recent efforts by Extension professionals across the United States demonstrate the effectiveness of using this form of communication. For example, 4-H professionals have used Facebook to connect with 4-H youths and provide reminders of county programming and events (Hill, 2014), applied a standardized hashtag protocol for county 4-H programs (Davis & Dishon, 2017), and incorporated the very technology into club/county activities (Mains, Jenkins-Howard, & Stephenson, 2013). The Internet, social media, and hashtags are here to stay. Extension youth programs offered through 4-H can provide today's linksters the opportunity to delve deep into project areas with individuals having shared interests all while working on community service projects that serve a greater good. --- Conclusion Given that electronic technology can bring people of common interests together, that young people value their contributions to the greater good of the communities they serve, and that one of the tenets of 4-H is "larger service," Extension youth programs are in a position to provide youth the very outlet they crave at a time when arguably they need it most. As imperfect an analogy as it may be, let us suppose for the sake of argument that today's smartphone is yesterday's cornfield. A hundred years ago while out in the cornfield, the young person may have found him-or herself pursuing a literal rabbit hole. The rabbit hole a young person can go down today on a smartphone can land anywhere on the spectrum from frivolous to frightening. through volunteers and the community as a whole, Extension professionals must become comfortable with today's electronic technology and understand the profound impact it can have in the lives of young people, young people who may have a deeply rooted understanding of how the technology works but perhaps not so much understanding of its potential cultural and societal impacts. Becoming comfortable with and comprehending the implications of today's technological landscape is an imperative for the Extension agent of the 21st century seeking to link 4-H to linksters.

Commentaries conform to JOE submission standards and provide an opportunity for Extension professionals to exchange perspectives and ideas.

Introduction In recent years, public and academic debates about the possible impact of filter bubbles and the role of polarization in public and social media have been widespread (Pariser, 2011;Flaxman et al., 2016). In these debates, news media have been described as belonging to particular political ideologies, producing skewed views on topics, such as climate change or immigration. These contemporary debates raise the question to what extent newspapers in the past operated in filter bubbles driven by their own ideological bias. This paper examines gender bias in historical newspapers. By looking at differences in the strength of association between male and female dimensions of gender on the one hand, and words that represent occupations, psychological states, or social life, on the other, we examine the gender bias in and between several Dutch newspapers over time. Did certain newspapers exhibit a bias toward men or women in relationship to specific aspects of society, behavior, or culture? Newspapers are an excellent source to study societal debates. They function as a transceiver; both the producer and the messenger of public discourse (Schudson, 1982). Margaret Marshall (1995) claims that researchers can uncover the "values, assumptions, and concerns, and ways of thinking that were a part of the public discourse of that time" by analyzing "the arguments, language, the discourse practices that inhabit the pages of public magazines, newspapers, and early professional journals." The period 1950-1990 is of particular interest as Dutch society underwent clear industrialization and modernization as well as ideological shifts (Schot et al., 2010). After the Second World War, Dutch society was stratified according to ideological and religious "pillars", a phenomenon known as pillarization. These pillars can be categorized as Catholic, Protestant, socialist, and liberal (Wintle, 2000). Newspapers were often aligned to one of these pillars (Wijfjes, 2004;Rooij, 1974). The newspaper Trouw, for example, has a distinct Protestant origin, while Volkskrant and De Telegraaf can be characterized as, respectively, Catholic and neutral. In recent years, the latter transformed into a newspaper with clear conservative leanings. Newspaper historians have studied the ideological backgrounds of Dutch newspapers using traditional hermeneutic means to which this study adds a computational analysis of language The representation of gender in public discourse is related to ideological struggles over gender equality. Several feminist waves materialized in the Netherlands. The origins of the first feminist wave can be traced back to the mid-nineteenth century and lasted until the interwar period. It took until the 1960s for feminism to flare up again in the Netherlands. In between, confessional parties were vocal in their anti-feminist policies. During the 1960s, the second feminist wave, also known as 'new feminism', focused on gender equality in areas such as work, education, sexuality, marriage, and family (Ribberink, 1987). The increasing equality between men and women is reflected in growing female employment numbers, which increased from 27.5 percent in 1950 to almost 35 percent in 1990 (Figure 1). 1 Apart from Scandinavia, the Netherlands has the highest levels of equality in Europe. Nonetheless, in terms of education and employment, women are still lagging behind and reports of gender discrimination are not uncommon in the Netherlands (Baali et al., 2018;Ministerie van Onderwijs, 2009). --- Related Work Word embedding models can be used for a wide range of lexical-semantic tasks (Baroni et al., 2014;Kulkarni et al., 2015). Hamilton et al. (2016) show how word embeddings can also be used to measure semantic shifts by comparing the contexts in which words are used to denote continuity and changes in language use. More recent work focused on the role of bias in word embed-1 https://opendata.cbs.nl/statline/#/ CBS/nl/ dings, specifically bias related to politics, gender, and ethnicity (Azarbonyad et al., 2017;Bolukbasi et al., 2016;Garg et al., 2018). Gonen et al. (2019) demonstrate that debiasing methods work, but argue that we should not remove them. Azarbonyad et al. (2017) compare semantic spaces related to political views in the UK parliament, effectively comparing biases between embeddings. Garg et al. (2018) turn to biases in embedding to study shifts related to gender and ethnicity. This study builds upon the work of Garg et al. (2018), and applies it to the context of the Netherlands-represented by Dutch newspapers. We extend their method further by distinguishing between sources, rather than using a comprehensive gold standard data set. We also incorporate external lexicons, such as the emotion lexicon from Cornetto, the Nederlandse Voornamenbank (database of Dutch first names), the Dutch translation of LIWC (Linguistic Inquiry and Word Count) and HISCO (Historical International Classification of Occupations) (Vossen et al., 2007;Tausczik and Pennebaker, 2010;Boot et al., 2017;Zijdeman et al., 2013;Bloothooft, 2010). --- Data The data set consists of six Dutch national newspapers: NRC Handelsblad (NRC), Het Vrije Volk (VV), Parool, Telegraaf, Trouw, and Volkskrant (VK).2 These newspapers can be characterized ideologically as liberal, social-democratic, liberal, neutral/conservative, Protestant, and Catholic. For the analysis, we rely on the articles and not the advertisements in the newspapers. We preprocess the text by removing stopwords, punctuation, numerical characters, and words shorter than three and longer than fifteen characters. The quality of the digitized text varies throughout the corpus due to imperfections in the original material and limitations of the recognition software. Because of the variations in OCR quality, we only retain words that also appeared in a Dutch dictionary. We use the Gensim implementation of Word2Vec to train four embedding models per newspaper, each representing one decade between 1950 and 1990. 3 The models were trained using C-BOW with hierarchical softmax, with a dimensionality of 300, a minimal word count Figure 2 shows that the size of the vocabulary approximately doubles for some newspapers between 1950 and 1990. The variance of the targets words, however, was small (µ ≈ 0.003) and constant (σ[1.3 -9 , 2.9 -9 ]), indicating model stability. Since we calculate bias relative to each model, these differences in vocabulary size will have little impact on shifts in bias. To measure gender bias, we use three sets of targets words. First, we extract a list of approximately 12.5k job titles from the HISCO data set. Second, we select emotion words with a confidence score of 1.0, a positive polarity above 0.5 (n = 476) and a negative polarity below -0.5 (n = 636) from Cornetto. Third, we rely on the Dutch translation of LIWC2001, which contains lists of words to measure psychological and cognitive states (Pennebaker et al., 2001) --- Methodology For the calculation of gender bias, we construct two vectors representing the gender dimensions (male, female). We do this by creating an average vector that includes words referring to male ('man', 'his', 'father', etc.) or female as well as the most popular first names in the Netherlands , 1980-1990 for the period 1950-1990. 5 Next, we calculate the distance between each gender vector and every word in a list of target words, for example, words that denote occupations: a greater distance indicates that a word is less closely associated with that dimension of gender. The difference between the distances for both gender vectors represents the gender bias: positive meaning a bias toward women and negative toward men. Figure 3 shows the biases related to forty job titles. Words above the diagonal are biased towards men, and those underneath the diagonal towards women. Finally, after standardizing and centering the bias values, we apply Bayesian linear regression to determine whether the bias changed over time. The linear model is formulated as: µ i = α + β * Y i + 󰂃, with µ i the bias for each decade (i) and Y i the coefficient related to each decade (i). The likelihood function is: X ∼ N (µ, σ) with priors defined: α ∼ N (0, 2), β ∼ N (0, 2), and 󰂃 ∼ HalfCauchy(β = 1). For model training, we use a No-U-Turn-Sampler (NUTS) (5k draws, 1.5k tuning steps, Highest Posterior Density (HPD) of .95).6 For the target words Job Titles, the proposed model (Model B) outperforms a model that only We compute a linear model that combines all newspapers for the target words Job Titles, Positive Emotions, Negative Emotions, and the selected LIWC columns. Then, for the same categories, we compute individual linear models for each newspaper. The resulting models are reported in Appendix B. --- Results The combined linear models, including all newspapers, generally display minimal shifts in bias. While the effects are weak, they fall within a .95 HPD. Partly, the weak trends are related to opposing shifts in the individual newspapers, cancelling each other out. Nonetheless, the bias associated with the categories 'TV', 'Music', 'Metaphysical issues', 'Sexuality' navigate toward women (0.22, 0.12, 0.15, 0.22), with all of them starting from a position that was clearly oriented toward men (-0.36, -0.20, -0.28, -0.39). 7 Conversely, 'Money', 'Grooming', and Negative Emotion words move toward men (-0.24, -0.17, -0.16), which in the 1950s were all more closely related to women (0.33, 0.20, 0.19). For the Job Titles, we see a slight move toward women (0.05), while words from the LIWC category Occupation move marginally in the direction of men (-0.05). This suggests that job titles might be more closely related to women, while the notion of working gravitates toward men. The linear models for the individual newspapers demonstrate distinct differences between the newspapers. First, Volkskrant is the most stable newspapers with 56% of the categories not changing. 8 When bias changes in this newspaper, it 7 Numbers refer to the slope 8 Lower confidence interval < 0 and upper > 0 moves toward women 9 out the 11 categories that change. Telegraaf, NRC, and Parool generally move toward men, respectively (84%, 92%, and 80%). The bias of Trouw and Vrije Volk, contrarily, move toward women (both 72%). A noteworthy result is that in all newspapers the bias shifts toward men in the category 'money'. Moreover, they also all exhibit a move toward women for the category 'sexuality', with the clearest shift in Volkskrant, Trouw, and Vrije Volk. --- Discussion While the newspaper discourse as a whole is fairly stable, individual newspapers show clear divergences with regard to their bias and changes in this bias. We see that the newspapers with a social-democratic (Vrije Volk) and religious background, either Catholic (Volkskrant) and Protestant (Trouw) demonstrate the clearest shift in bias toward women. The liberal/conservative newspapers Telegraaf, NRC Handelsblad, and Parool, on the contrary, orient themselves more clearly toward men. Despite increasing female employment numbers in the Netherlands, the association with job titles moves only gradually toward women, while words associated with working move toward men. More detailed analysis of the individual trend within each decade is necessary to untangle what exactly is taking place. For example, which words show the biggest shift, and can we identify groups of associated words of which particular words show divergent behavior? Methodologically, this paper shows how word embedding models can be used to trace general shifts in language related to gender. Nevertheless, certain cultural expressions of gender are not captured by distributional semantics represented through word embeddings, but rather in syntax, for example, through the use of active of passive sentences. Future work will investigate how fine-tuning stateof-the-art embedding models, such as ELMO and BERT, can be leveraged to gain more contextual knowledge about words and their association with gender (Peters et al., 2018).

Contemporary debates on filter bubbles and polarization in public and social media raise the question to what extent news media of the past exhibited biases. This paper specifically examines bias related to gender in six Dutch national newspapers between 1950 and 1990. We measure bias related to gender by comparing local changes in word embedding models trained on newspapers with divergent ideological backgrounds. We demonstrate clear differences in gender bias and changes within and between newspapers over time. In relation to themes such as sexuality and leisure, we see the bias moving toward women, whereas, generally, the bias shifts in the direction of men, despite growing female employment number and feminist movements. Even though Dutch society became less stratified ideologically (depillarization), we found an increasing divergence in gender bias between religious and social-democratic on the one hand and liberal newspapers on the other. Methodologically, this paper illustrates how word embeddings can be used to examine historical language change. Future work will investigate how fine-tuning deep contextualized embedding models, such as ELMO, might be used for similar tasks with greater contextual information.

Objectives As the health care system shifts toward value-based planning and purchasing, new tools are needed to integrate social determinants of health into clinical and preventive care to improve population health and reduce health care disparities. An area deprivation index (ADI) is a multidimensional evaluation of a region's socioeconomic conditions, which have been linked to health outcomes (1)(2)(3)(4)(5)(6). We have refined the ADI, testing its association with health outcomes at various geographic levels. A simple-to-use tool such as the ADI can provide an efficient mechanism to alert health care providers to screen and refer patients for problems related to social determinants of health. --- Methods We examined the relative strength of the association between a locally calibrated ADI with regional scale metrics and 4 hospitalization rates in New York's Hudson Valley, an area that comprises 8 counties and is home to 2.3 million residents. The ADI, which is a composite measure of 17 census variables designed to describe socioeconomic disadvantage based on income, education, household characteristics, and housing (Box), was refined and provided by the University of Wisconsin's Health Innovation Program and is available for the entire United States (7). ADI values were dichotomized as the top 15% (the highest level of deprivation) and the bottom 85% according to the national threshold of 15% established by Kind et al, who found this level to be closely associated with Medicare rehospitalization rates across the country (5). Regional-level ADI was characterized by recalculating percentiles and the 15% threshold by using data from the Hudson Valley study area. Local-scale ADI was calculated by assigning each ZCTA a percentile value for ADI relative to the ZCTAs within a 10-km, 20-km, and 30-km radius. This created a type of "moving window" across the study area. If the central ZCTA was in the top 15% of ADI values when compared with its neighbors, it was flagged as having a high level of local deprivation (Figure 1). To validate ADI metrics, age-adjusted odds ratios were calculated by using SPSS (IBM Corp) on the various ADI measures serving as the exposures and hospitalizations for the selected major diagnostic categories serving as outcomes to assess the relative strengths of the associations. --- Results The 10-km local ADI estimates had the strongest associations with all hospitalization rates (higher odds ratios) followed by estimates at 20 km, 30 km, and the regional scale, respectively (Table ). A locally adjusted ADI, at least for the Hudson Valley, was more strongly associated with health outcomes than those scaled at higher geographic levels. Figure 2 depicts hospitalization rates and local ADI values above the 15% threshold. --- Discussion These findings support the need for locally sensitive relative deprivation measures; national and regional approaches do not appear to properly model the potential impact of area deprivation on health outcomes in a smaller study area. These results are striking, but they should be updated and tested for their applicability to other parts of the United States. Using smaller, more homogeneous units of aggregation (eg, census tract) may improve these findings. Also, because this was an ecological study, it was not possible to disentangle the contextual and compositional factors that may be driving these associations. However, making a simple and reliable indicator of area deprivation available to health care providers could aid in providing useful and appropriate treatment. If aligned with a patient's ZCTA, an indicator such as the ADI can facilitate referrals to local community resources and improve access to health and social services, particularly for underserved populations. Kind et al. suggested that "clinicians and health systems could, at the point of first contact, use the ADI to screen for patients returning to the most challenging environments. This would support the early targeting of more intensive transitional care services, prompt discussion of socioeconomic environment and need, and activate additional community resources for these patients" (5). Employing a dichotomized and automated "flag" for deprivation, particularly if incorporated into electronic health records, could ease the identification of social determinants of health issues and facilitate access to resources in a patient's local community. As large health care systems, including accountable care organizations, transition toward value-based planning and purchasing -in a shift from volume to value -identifying and addressing the social determinants of health of the populations they serve will become essential. In New York State, for example, beginning in 2018 Medicaid providers and their community-based partners will be required to implement, and will be reimbursed for, one or more interventions related to social determinants of health (8). Similar plans are underway in other states and nationally through the Medicare program (9,10). These types of initiatives, which will depend on reliable data such as a locally sensitive ADI, can improve access to health and social services in underserved populations, allow safety-net providers and other providers to more efficiently target their resources, and advance the integration of social determinants of health into clinical treatment and disease prevention. --- PREVENTING CHRONIC DISEASE

We assessed the appropriate geographic scale to apply an area deprivation index (ADI), which reflects a geographic area's level of socioeconomic deprivation and is associated with health outcomes, to identify and screen patients for social determinants of health. We estimated the relative strength of the association between the ADI at various geographic levels and a range of hospitalization rates by using age-adjusted odds ratios in an 8-county region of New York State. The 10-km local ADI estimates had the strongest associations with all hospitalization rates (higher odds ratios) followed by estimates at 20 km, 30 km, and the regional scale. A locally sensitive ADI is an ideal measure to identify and screen for the health care and social services needs and to advance the integration of social determinants of health with clinical treatment and disease prevention.