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Introduction Disadvantaged populations are exposed to greater concentrations of outlets licenced to sell alcohol for off-premise consumption (1)(2)(3)(4). As off-premise outlet density is related to problems such as assault, child abuse and intimate partner violence (5)(6)(7)(8), it appears greater exposure to outlets contributes to poorer health outcomes among disadvantaged populations. However, theory regarding the economic geography of alcohol markets suggests outlets will differ systematically and will not contribute equally to risk (9). Those selling cheaper alcohol are of particular interest because having lower priced alcohol available in a geographic region is associated with greater alcohol consumption and more problems for local residents (e.g., hospital admissions) (10,11). In this study we examine whether outlets in disadvantaged areas sell cheaper alcohol, potentially further contributing to health disparities. Theories describing the spatial dynamics of retail markets suggest several reasons why stores selling equivalent commodities (such as packaged alcohol) will have different prices (9). Economies of scale may allow large stores and chains to charge lower prices while maintaining profits through low margins and high volume (12). Unable to compete on price, smaller stores are forced to appeal to potential customers by alternate means (e.g. product range, customer service, amenities). Competition for market share will force prices down where nearby outlets have lower prices and where proximity to other outlets is greater (13). Lower priced alcohol may also be found in areas with lower income, due in part to demand for cheaper brands among poorer customers. Moreover, while high income areas have been theorised to exclude undesirable land uses (such as alcohol retailers) (14), these communities might also oppose the opening of cheaper outlets to a greater degree than more expensive outlets (such as high end wine merchants). Some studies relating off-premise alcohol price to neighbourhood characteristics have found cheaper alcohol in socially disadvantaged (including lower income) areas in the US (15)(16)(17), though one study found no such evidence (4). We conducted premise assessments in a random geographic sample of off-premise outlets in Melbourne, Australia. Our sample frame enabled us to account for individual outlet characteristics as well as the theoretically relevant indicators of the local alcohol market: characteristics of adjacent (lagged) outlets and of the Census areas in which the outlets were located. --- Method Sample Frame This study used data collected for a spatial analysis of off-premise alcohol sales and alcoholrelated harms within Census 2011 areas of metropolitan Melbourne, Australia. We stratified 256 Statistical Area Level 2 (SA2) regions by high versus low median household income and high versus low off-premise outlet density (i.e., counts of Packaged licences denominated by land area) (18,19), as these are important predictors of alcohol-related harms (5)(6)(7)(8). We then selected a random sample of 62 SA2 units (mean population = 14,020.2) from among the four strata. We were concerned that inner city areas with higher outlet density would predominate, so we over-sampled areas with lower outlet density. Two major classes of liquor licence permit alcohol sales for off-premise consumption in Melbourne. Dedicated liquor stores have Packaged licences, and bars and restaurants that also sell take-away alcohol have General licences. Using an online resource listing all licenced premises in the state (updated daily, including georeferences) (18), potentially eligible outlets were located in the selected SA2 regions and had either a Packaged licence (n = 273) or had a General licence (n = 195) and a separate room dedicated to off-premise sales. Virtual assessments using Google street view excluded 112 General-licenced outlets that clearly did not have dedicated space for off-premise sales (e.g., restaurants in shopping strips) (20,21). Research assistants made site visits to all other outlets to confirm they were currently in business and were eligible for inclusion, excluding a further 61. The final sample was 295 outlets, including 260 with Packaged licences and 35 with General licences. --- Data Collection Two research assistants independently conducted 5-minute premise assessments in all eligible outlets. After exiting the outlet they completed an electronic form with items describing price, alcohol volume, and operating characteristics. After Bluthenthal et al. ( 4), price was measured using the minimum purchase price for a 750ml bottle of wine (in Australian dollars), and volume was the number of paces of shelf space dedicated to alcohol sales (measured by counting paces along every shelf in the outlet). Easily assessable operating characteristics were the presence of a walk-in fridge and facilities for drivethrough sales. The Monash University Human Research Ethics Committee approved this protocol. --- Variables Using Pearson correlations for continuous measures and Cohen's kappa for dichotomous measures (22)(23)(24), inter-observer reliability for the price and shelf-pace measures (r ≥ 0.93) and the walk-in fridge and drive-through measures was very high (κ ≥ 0.73). The unit of interest for the current analysis was outlets rather than Census areas, so we measured outlet concentration using the Euclidean distance to the nearest Packaged liquor licence rather than an areal density measure. We also differentiated between independent (n = 80) and chain outlets (n = 215), identifying chains based on licencee name, operating name, and store-front signage. To identify adjacent outlets, we created Thiessen polygons around the selected outlets, clipped at the boundaries of the included SA2 units. For adjacent outlets we calculated the average alcohol volume, average price for the cheapest bottle of wine, and a dummy variable indicating whether any were chains. Census data characterised the neighbourhoods in which the outlets were located. To minimize aggregation bias, we used the smallest available Census areas, Statistical Area level 1 (SA1) units (mean population = 410.2). SA1 units are wholly nested within SA2 units. National decile scores for the Index of Relative Socio-economic Advantage and Disadvantage (IRSAD) described relative advantage (25). Given that lower priced alcohol may be sold in areas where residents have fewer material and social resources, we preferred this variable to a simple income measure for this analysis. Other extracted variables were demographic indicators which may be related to demand for cheaper alcohol: population density, median age, the proportion of residents who were Australian born, and the proportion of residents who were current students. --- Statistical Analysis A semi-logged univariable linear regression model predicted the price of the cheapest bottle of wine in each outlet according to the relative advantage decile for the SA1 unit in which the outlet was located. We then constructed a multivariable model adjusting for the outlets' own characteristics, the characteristics of adjacent outlets, and other SA1 unit characteristics. The dependent measure was normally distributed after natural log transformation, and sample weights accounted for oversampling in low outlet density areas. Spatial autocorrelation of model residuals within the clipped Thiessen polygons was very low (Moran's I = 0.072), indicating adjustment for this potential source of type I error was not required (26). Likelihood ratio tests suggested hierarchical structures nesting outlets in SA2 units did not improve model fit (p > 0.999). --- Results Outlet characteristics are presented in Table S1 (in the online supplementary material). In the univariable model, a one decile increase in relative advantage was associated with greater logged price for the cheapest bottle of wine (b = 0.038, 95% confidence interval: 0.020, 0.055; p < 0.001; data not shown). In the multivariable model (Table 1), a one decile increase in relative advantage was associated with a 0.02 unit increase in logged price (b = 0.021, 95% CI: 0.002, 0.040; p = 0.030). Extrapolating the point estimate from the multivariable model, this equates to a 1.3% increase in logged price compared to the average for all outlets. Chains and larger outlets were cheaper than independent and smaller outlets, and those adjacent to chains were cheaper than those not adjacent to chains. Greater distance to the nearest Packaged outlet predicted more expensive wine, whereas greater proportions of students predicted cheaper wine. --- Discussion This study suggests residents of socially disadvantaged areas are exposed to lower priced alcohol in off-premise outlets. This finding is consistent with other similar analyses (15,16). As exposure to cheap alcohol is related to increased risk for alcohol-related problems (10,11), differential exposure potentially contributes to poorer health outcomes for disadvantaged populations. Notwithstanding the inherent limitations of our cross-sectional design (precluding assessment of the endogeneity of lower purchase price and demand for cheaper alcohol), our results suggest the distribution of outlets selling cheaper alcohol is consistent with the spatial dynamics of typical retail markets. The greater purchasing power of chains appears to force nearby outlets to lower their prices in order to compete, and areas where local populations may prefer lower priced alcohol (e.g., greater social disadvantage, more students) have cheaper outlets. Results also suggest that greater proximity to other outlets increases competition and depresses purchase price, further reducing the total cost of alcohol (beyond convenience costs) (27). Disadvantaged populations are exposed to more off-premise outlets (1)(2)(3)(4). Here we add that the outlets to which they are exposed sell cheaper alcohol. Strategies that disrupt the market processes by which these exposures likely arise (e.g., limits to outlet density, minimum purchase prices) may reduce economic health disparities. --- Supplementary Material Refer to Web version on PubMed Central for supplementary material. --- Author Manuscript

Introduction and Aims-Greater concentrations of off-premise alcohol outlets are found in areas of social disadvantage, exposing disadvantaged populations to excess risk for problems such as assault, child abuse and intimate partner violence. This study examines whether the outlets to which they are exposed also sell cheaper alcohol, potentially further contributing to incomerelated health disparities. Design and Methods-We conducted unobtrusive observations in 295 off-premise outlets in Melbourne, Australia, randomly selected using a spatial sample frame. In semi-logged linear regression models we related the minimum purchase price for a 750ml bottle of wine to a national index of socio-economic advantage for the Census areas in which the outlets were located. Other independent variables characterised outlet features (e.g., volume, chain management) and conditions of the local alcohol market (adjacent outlet characteristics, neighbourhood characteristics). Results-A one decile increase in socio-economic advantage was related to a 1.3% increase in logged price. Larger outlets, chains, outlets adjacent to chains, outlets in greater proximity to the nearest neighbouring outlet, those located in areas with more students also had cheaper alcohol. Discussion and Conclusions-Not only are disadvantaged populations exposed to more outlets, the outlets to which they are exposed sell cheaper alcohol. This finding appears to be consistent with the spatial dynamics of typical retail markets.

Introduction Childhood maltreatment is a toxic stressor prevalent in the United States (US) (Shonkoff and Garner 2012) that often co-occurs with other adversities, including parental substance use, parental psychopathology, divorce, and other forms of violence exposure (Connell et al. 2007). However, these adverse experiences, commonly known as adverse child experiences or ACEs, are not consistently assessed in clinical settings, including emergency room departments or child advocacy centers (CAC) were children who are victims of maltreatment might be presenting (Campbell et al. 2019;Bethell et al. 2016). During child abuse investigations the focus is generally on the evaluation of maltreatment and often other adversities that families may be facing are not addressed (Campbell et al. 2019). Families who are facing multiple adversities are the most vulnerable, often having low economic, social and emotional resources and thus children may be most at risk for repeat victimization (Connell et al. 2007), identifying and addressing these factors when children are first involved with clinical settings, particularly for suspicion of abuse, may prevent repeat victimization and facilitate prompt referrals to trauma-informed mental health care. We examined the prevalence of adversities among children seen at a CAC for suspicion of child abuse and their relation to prior involvement with Child Protective Services (CPS). --- Methods We extracted medical record data from children seen at the Manhattan Child Advocacy Center (MCAC) from February 2009 to November 2014 for suspicion of exposure to sexual and/or physical abuse. The MCAC brings together professionals and agencies as a multidisciplinary team to investigate physical and sexual abuse cases and coordinate services to children and their families (Cross et al. 2007). Specifically, representatives from CPS, law enforcement, district attorney's office, Safe Horizon (a national victim assistance organization) and a medical team are involved. Children and their caretakers are referred for further investigation and medical assessment after a child abuse report is made to law enforcement and/or CPS. Certain criteria for evaluation by the multidisciplinary team at the MCAC must be met: familial or non-familial sexual offenses of children 12 years and under, physical abuse of children 10 years and under, the family resides in New York County and /or the alleged criminal activity occurred in New York County. Children are first interviewed forensically by Safe Horizon trained professionals. The purpose of every forensic interview conducted at the MCAC is to obtain a statement from a child, in a developmentally, age appropriate and culturally sensitive, unbiased and fact-finding manner that will support informed and fair decision making by the Manhattan multidisciplinary team. A medical examination by a board certified child abuse pediatrician is also conducted in about half of the children interviewed. Lastly, the caretaker, usually the non-offending parent is also interviewed by the child abuse pediatrician. Mandated reporting laws suggest that a report is made based on suspicion of abuse, not on definitive proof of abuse. It is then possible that there was no evidence of abuse or neglect after an investigation and therefore that there may not be any abuse. Of 1069 children who presented at MCAC between 2009 and 2014 and were referred for medical evaluation, 727 were interviewed forensically by Safe Horizon trained professionals and the caretaker, usually the nonoffending parent, was also interviewed by the child abuse pediatrician. During the medical assessment, the mother was interviewed alone and asked about past history of mental illness, her own history of incarceration or arrest, drug or alcohol use and history of intimate partner violence (IPV). To assess IPV, mothers were asked whether someone in the past year kicked, hit or punched them and whether in a past relationship they felt afraid or were harmed by their partner (Basile et al. 2007). Presence of an ongoing custody battle was also assessed to define parental discord. Caseworkers obtained access to prior CPS reports. The study was approved by the Institutional Review Board at Columbia University. --- Data analyses Bivariate analyses were conducted to assess the relationship between child and maternal characteristics and adversities with prior CPS history. Given the high prevalence of CPS involvement, binomial regression analyses were conducted to estimate the association between adversities and CPS involvement. Unadjusted analyses were first conducted followed by a regression model adjusting for child characteristics (race/ethnicity, gender, age, and type of abuse), mother characteristics (age, primary language and education), and receipt of public assistance. All analyses were conducted in SAS 9.3. --- Results The adversities' prevalence was high; 32% of mothers reported one adversity and 30% reported two or more. A higher prevalence of adversities was associated with prior CPS report (Table 1). In binomial regression analyses, the greater the number of adversities, the more likely a history of prior CPS report (experiencing one adversity [Prevalence Ratio (PR) 1.25 95%CI 1.04, 1.50 or 2 or more adversities PR 1.67 95%CI 1.41, 1.98], even after adjusting for sociodemographic factors. (Table 2). --- Discussion It has been suggested that pediatricians could support CPS-involved families with close follow-up and referrals to appropriate services in the community (Campbell et al. 2012). Child abuse pediatricians can do just that within their CACs' role: assessing adverse conditions for each family seen, connecting families to community based services in collaboration with the multidisciplinary team, and when possible involve the child's pediatrician in the overall treatment plan of the family. Coordinated and integrated collaboration between primary care providers and investigative teams will ensure the delivery of needed services at the community level for families for whom adversities are known (Campbell et al. 2019;Bair-Merritt and Zuckerman 2016). We acknowledge adversities were self-reported by the mother in the setting of a child abuse investigation and some were not assessed with validated scales. While the CAC population does not reflect the entire CPS population, our study findings provide further evidence that maltreated children are exposed to a host of other family dysfunction factors, addressing adversities at the first encounter of suspicion for child abuse may prevent further victimization of children. In addition, our study further supports the need to support a family in the face of an investigation by assessing and addressing other adversities; encouraging collection of data with more accurate measures of adversities, by using for example, documented domestic violence reports or prior child abuse reports and presenting an opportunity to study new models that integrate multiple social factors to build safe, stable and nurturing relations for children (Sege et al. 2017). --- Availability of data and materials Please contact author for data requests. --- Authors' contributions SFS conceptualized the study, supervised data analyses and wrote initial draft of the manuscript. EK conducted statistical analyses, contributed to the initial manuscript draft. JB conceptualized study and contributed to initial manuscript draft. All authors read and approved the final manuscript. --- Ethics approval and consent to participate The study was approved by the Institutional Review Board at Columbia University. --- Consent for publication Not applicable. --- Competing interests The authors declare that they have no competing interests. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Objectives: We aimed to determine the relation between childhood adversities and prior involvement with Child Protective Services (CPS) history among children presenting for evaluation at a Child Advocacy Center.The study evaluated children presenting to a Child Advocacy Center (CAC) from 2009 to 2014. A five-item child adversity measure, based on mother's report, was characterized into a scale of none, one, or two or more adversities. Caseworkers at the CAC assessed whether families had a prior history of involvement with CPS. Results: Among the 727 children included in the analyses, 43% had a prior history of involvement with CPS. Twenty-six percent of the children experienced one childhood adversity while 29% experienced two or more. In regression analyses adjusting for socio-demographics, experiencing one (Prevalence Ratio (PR) 1.25 95%CI 1.0-1.5) or two or more adversities (PR1.67 95%CI 1.4, 2.0) was associated with higher prevalence of CPS history compared to those who reported none. Conclusions: Childhood adversities are associated with prior contact with CPS, suggesting there are missed opportunities to provide services to high-risk families. CACs may be in a unique position to advocate for families and prevent further victimization of children.

More than ever-and contrary to what we are seeing happen around the globe-we need to focus on public health policy that protects women's rights to sexual and reproductive health. This is especially important for women with disabilities who have been largely neglected in this area. I work in Nigeria, a region with one of the lowest rates of contraception use in the world and some of the highest rates of maternal death and morbidity. 2 3 In Nigeria, as in many countries, women with disabilities face multiple and intersecting forms of discrimination. This includes harmful misconceptions about disability and sex which can lead to denial of their reproductive rights. Some people believe that women with disabilities do not have emotions, or sexual sensation or desire, and that they don't give birth. 4 In extreme cases women with disabilities are sterilised or given contraception against their will. 5 In my work I have seen women with disabilities being taken advantage of. Women with intellectual or physical disabilities are at greater risk of sexual abuse because of the stigma that some cultures associate with disability, or the vulnerability of their position. 6 7 Discrimination leads to barriers in accessing appropriate healthcare, accurate information, and the autonomy to make healthcare decisions. Stigma and negative attitudes around disability can also be held by healthcare workers. In northern Nigeria, where education for girls is often sidelined, women may lack the knowledge to speak up for themselves or defend their right to reproductive health. This means that for many women and adolescent girls with disabilities, accessing family planning and other services can be intimidating, dangerous, or simply non-existent. One in five women globally has a disability. They are not a homogenous group. As a result, there are a range of ways in which poorly designed and managed sexual and reproductive health services can be inaccessible. For example, information and services are often not adapted for people with visual and hearing impairments and intellectual disabilities. Health workers are not usually trained on disability inclusion, and infrastructure may be lacking or inaccessible for people with physical impairments or those who use wheelchairs. I have heard stories of women having miscarriages or being injured when falling from wheelchairs as they try to navigate inaccessible buildings. Inaccessibility-of both health centres and information-may lead to women and girls to be unable to access family planning methods or being coerced into agreeing to the uptake of certain methods without fully informed consent. The key to making sexual and reproductive health services inclusive is empowering women and girls with disabilities with information and promoting agency to advocate for their rights. They and their representative organisations must be listened to and involved in the design of policies and programmes around sexual and reproductive health. Their experiences and voices provide deeper insights that can help shape sexual healthcare that is disability inclusive. Disability should be considered in all areas of sexual and reproductive health policy and services, all staff must be trained on disability inclusion, and budgets provided to support this. Sexual health services can work towards being disability inclusive by confronting and raising awareness of stigma and discrimination, conducting outreach work that educates about misconceptions related to disability, and providing inclusive strategies and training for health workers. Cultural stigma must be challenged, not just in healthcare but in the wider community. We need to change the narrative around who sexual and reproductive healthcare is for and challenge ideas of disabled women's sexuality. There is a need for social behaviour change communication through the use of the media and interpersonal communication methods and messaging. People with disabilities should be empowered to advocate for their rights as well as active involvement in decision making regarding sexual and reproductive health services and rights. Promoting access to health equity for people with disabilities is a shared responsibility. Wherever you are on your professional journey, there is always something you can do to make health services more inclusive and accessible. From allocating budget to inclusion, to training staff and engaging local disability groups, we can all ensure that health for all becomes a reality. Sexual and reproductive rights are human rights. That's why sexual and reproductive health services need to be inclusive and accessible for everyone. The sustainable development goals have outlined the need for inclusive healthcare and reducing inequalities. 6 If we continue to neglect the needs of people with disabilities, then achieving these goals will almost be impossible. --- Competing interests: JS currently manages the Inclusive Futures, Inclusive Family Planning project in Nigeria. This project is funded by the UK Foreign, Commonwealth, and Development Office and is led by Sightsavers and BBC Media Action, in partnership with the Joint National Association of Persons with Disabilities and the Network of Women with Disabilities. It works with the Nigerian Primary Healthcare Development Agency. The project further collaborates with the Lafiya programme led by Palladium, and will feature an impact assessment led by PENDA, a consortium managed by the International Centre for Evidence in Disability. Provenance: not commissioned, not externally peer reviewed

With women's rights being rolled back across the world, it is more important than ever for sexual health and family planning services to be disability inclusive, says Joy Shu'aibu Joy Shu'aibu director of programme operations in Nigeria In May this year, G7 leaders made an unusually political statement denouncing the "well coordinated and funded rollback on gender and rights movements at country and multilateral levels." 1 OPINION Sightsavers Follow Sightsavers on Twitter and

Introduction Over the past 15 years [1], there have been significant advances expanding HIV treatment access in sub-Saharan Africa. Recent studies focused on the timing of antiretroviral therapy (ART) initiation have found that early diagnosis and treatment improves outcomes for people living with HIV (PLWH) [2••, 3••] and prevents HIV transmission to their sexual partners [4]. Based upon these results, the World Health Organization (WHO) has now stated it supports a "test and treat" model of care for all PLWH [5], supported by the Vancouver Statement [6]. If this strategy is ultimately adopted across nations in sub-Saharan Africa, it will lead to an expansive effort to include early-stage individuals in care, many of whom will be asymptomatic. While there has been a substantial focus on the entire care continuum, the pre-ART periodspecifically the time between HIV acquisition, testing, and treatment initiation-deserves special attention. This is a time where barriers to treatment initiation are not yet balanced by the motivation to recover from a debilitating and immediately life-threatening illness. The challenge of expanding treatment to people with earlier disease is supported by the observation that CD4 + cell counts at linkage to care and at ART initiation have not appreciably increased during the past decade in sub-Saharan Africa, despite multinational efforts to expand ART availability [7]. In this article, we will discuss factors driving pre-ART loss and present a framework for understanding the impact of pre-ART decision-making on early losses in the care cascade, with a focus on ART refusal. Our goal is to provide further understanding of why treatmenteligible adults may choose to present for HIV testing, yet may not initiate ART when indicated. By defining the stages of pre-ART decision-making, we hope to guide future empirical study of the factors related to refusal and corresponding interventions to increase treatment acceptance. --- Identifying the Scope of Loss in the Pre-ART Care Continuum As of 2014, there were an estimated 36.9 million PLWH. The vast majority of these individuals live in sub-Saharan Africa. Unfortunately, fewer than half (15 million) are currently receiving ART [8], despite widespread voluntary testing and free treatment. This is largely due to losses of PLWH whose CD4+ counts are too high to render them able to start treatment [9][10][11][12][13] and failure to initiate treatment promptly among those who are already ART eligible at HIV diagnosis [7,14]. There is a growing body of literature focused on pre-ART losses and the need to understand both structural and socio-behavioral barriers to ART initiation, in order to inform effective combination interventions [15•, 16-18]. Structural barriers to ART initiation exist at every level of the pre-ART care cascade, with continual losses through all stages, from the period prior to testing through entry into care and ART initiation [19][20][21][22]. Such barriers can include distance to the testing and treatment center [23-25], costs involved in transport and time lost from work [26,27], and perceived poor quality of care [28•]. Evidence indicates that decreasing structural barriers to testing through programs such as home-based counseling and testing [29][30][31][32][33][34][35][36][37] and point-of-care diagnostics [38] may be highly effective in improving rates of treatment initiation. In addition, shifting models of care from centralized top-down programs to more decentralized treatment structures [39,40], including community-based adherence clubs [41,42], may decrease barriers to initiating treatment and staying in care [43]. Social factors may also impact the pre-ART care continuum. A particular area of focus has been on the impact of psychological consequences of an HIV diagnosis (e.g., depression [44] and internalized stigma [45][46][47][48][49]) and how it may delay ART initiation [50, 51•, 52]. Other forces, including challenges associated with disclosure [53], fatalistic beliefs [54], and a lack of social support [46] may influence the decision to avoid testing, or treatment initiation. In addition, concerns about medication side effects [55] or a belief that ART is only reserved for the "sick" may also result in treatment avoidance [51•]. Interventions focused on addressing stigma through alternate means of testing [56,57] and optimizing disclosure (e.g., through couple's based counseling) [58] may mitigate some of the challenges associated with test and treat strategies and lead to improved uptake of services in pre-ART care cascade. --- Four Stages of ART Decision-Making-Developing a Framework for --- Understanding Its Impact on Early Losses in Care Pre-ART losses can occur at any point prior to testing, between testing and the receipt of CD4 + results, and between the receipt of CD4+ results and ART initiation. As outlined above, social and structural forces may derail PLWH at any of these steps along the continuum. Prior work has focused on losses prior to testing, and between testing and the receipt of CD4 + results; therefore, we have developed a framework to more clearly define components of treatment initiation. We have previously explained how ART-related decision-making at the point of testing can be framed in the context of risk aversion and that the pros of known health benefits need to be weighed against the feared risks of medication-associated disclosure and potentially disfiguring side effects of treatment [59]. Based on our research and a growing body of literature focused on developing interventions to reduce pre-ART losses [60], we have refined our understanding of the pre-ART care continuum to encompass four distinct patterns of decision-making among individuals who present for voluntary counseling and testing (VCT) (Fig. 1). While described as four distinct groups, individuals may initially be part of one group and move into another over time. Individuals may choose to initiate or refuse ART upon learning their eligibility. If they initially refuse and continue to refuse for at least 6 months, they can be classified as "Sustained Refusers." This group readily acknowledges they are unwilling to start treatment from the time of testing, and then continues to be unwavering in this belief, often despite multiple attempts by clinic providers to help engage them in care, including phone calls, text messages, and home visits. While this population presents considerable challenges for care providers, they are often forthright in their desire to forgo treatment from an early stage in the pre-ART care cascade and likely present unique intervention opportunities at the time of testing. Conversely, those who refuse to initiate upon learning their CD4 + but change their mind within 6 months are labeled "Initial Refusers." Initial and sustained refusal may be influenced by different factors. Specifically, concerns about treatment initiation at the point of testing may be related to a sense of wellness and a feeling that they are not yet "sick enough" to start treatment [61]. Whereas those who refuse treatment over a prolonged period tend to express concerns about unwanted disclosure, having a fatalistic worldview, low social support, and fears that medication-associated side effects may render them unable to adhere to a prescribed regimen [50, 51•, 62 Unfortunately, exaggerated beliefs related to ART side effects may have unwittingly been fueled by governmental policies designed to restrict treatment (e.g., the use of CD4 + cutoffs to guide treatment availability), the usage of medications with severe toxicities early in the HIV epidemic due to cost constraints, and ongoing mandatory pre-adherence counseling sessions [64]. Motivational interviewing may be effective in this population as a way to provide goal-directed, client-centered counseling to elicit behavior change [59,[65][66][67][68][69]. Conversely, individuals may convey a willingness to start treatment at the point of learning of their eligibility. They may then go on to initiate treatment ("True Acceptors") or fail to start within 6 months ("False Acceptors"). Research on the latter group has shown that structural barriers, including distance from clinic and economic constraints [70], may play a larger role in impeding ART initiation than with "sustained refusers." Psychosocial factors likely exist, however, including stigma, or poor emotional health, as well as a social desirability bias in reporting intended behavior [28•, [70][71][72]. Rates of "False Acceptors" may be well over 20 % in certain key populations [13,73,74] and will likely benefit from combination interventions targeting both structural and psychosocial factors through peer navigation and peer support. A new long-term strategy for marketing ART should promote more tolerable regimens, and the importance of preventing both long-term complications of HIV inflammation, as well as the benefits of avoiding HIV transmission. Interventions will need to be developed at several levels from public information campaigns to restructuring counseling messages for HIV testing and treatment, to programs that provide direct support for those considering treatment initiation. --- Conclusion The time between HIV acquisition and ART initiation is a critical period in the treatment continuum. To date, few studies have focused on this vulnerable period [75]. Issues of recruitment and retention remain challenging in this population, and measurement of ART initiation may lack clarity and rigor that has now been well developed and applied in ART adherence research [21,76,77]. Yet, it is clear that the cascade of refusal in the pre-ART period remains a critical concern, particularly as treatment is expanded to PLWH earlier in the course of their infection. If a "test and treat" strategy of care is to be adopted in sub-Saharan Africa, there will not only be economic and structural barriers to manage but also deeply held beliefs that ART is associated with illness and even death [51•]. Research in this area, which focuses on socio-behavioral intervention design and development, will be critical to the success of treatment as prevention in the time ahead.

Recent recommendations by the World Health Organization support treatment for all people living with HIV (PLWH) globally to be initiated at the point of testing. While there has been marked success in efforts to identify and expand treatment for PLWH throughout sub-Saharan Africa, the goal of universal treatment may prove challenging to achieve. The pre-ART phase of the care cascade from HIV testing to HIV treatment initiation includes several social and structural barriers. One such barrier is antiretroviral therapy (ART) treatment refusal, a phenomenon in which HIV-infected individuals choose not to start treatment upon learning their ART eligibility. Our goal is to provide further understanding of why treatment-eligible adults may choose to present for HIV testing but not initiate ART when indicated. In this article, we will discuss factors driving pre-ART loss and present a framework for understanding the impact of decision-making on early losses in the care cascade, with a focus on ART refusal.

estimated open defecation rate is 14%. Some counties, such as Turkana, Wajir, and Samburu, have open defecation rates exceeding 70% (MoH, 2017). Out of the 3643 villages in Makueni County, 860, or 23.6%, are open-defecation-free. Most of the open-defecation-free villages (488) are located in Kibwezi East Sub-County. The sanitation data from a records review indicates that 48% of certified villages (235 out of 488) had reverted to an open defecation state. Despite these concerning trends, it is noteworthy that no published study has documented them or attempted to describe the factors associated with this state in Makueni County. Therefore this study sought to determine the infrastructural factors influencing the resurgence and sustainability of open defecation free status among adult residents in Kibwezi East Sub County. --- METHODS The researcher used descriptive cross-sectional method for this investigation. This method works well for obtaining data to determine the relationship between independent and dependent variables. The participants in this study were adult residents of Kibwezi Eest Sub County, Makueni County, Kenya. The four wards that make up the Sub-County Mtito/Andei, Thange, Ivingoni/Nzambani and Masongaleni. Participants meeting the inclusion criteria were individuals aged 18 and above, residents in the area for over two years, and community health volunteers (CHVs) with a completed Form IV. Exclusion criteria comprised individuals under 18, non-residents, those residing in the area for less than two years, participants with mental illness, and household heads or participants who did not provide consent to the study. --- RESULTS --- Background characteristics of the respondents A total of 423 household heads were surveyed with a response rate of 100%. The socio-demographic profile of the participants is shown in the (Table 1). --- Infrastructural factors influencing the resurgence and sustainability of open defecation free status The (Table 3) summarizes key infrastructural factors related to facility accessibility, privacy, and management. Most sanitary facilities (59.5%) were located within 10-50 meters, with a median walking time of 3.0 minutes. A majority of 91.7% (N=388) were accessible to people of all ages. Most respondents, 67.1% (N=275), reported no open defecation sites in their community. Concerning lavatory wall materials, mud bricks were the predominant choice at 42.3%, while sand and cement screed dominated lavatory floors at 59.9%. A significant majority, 88.6% (N=373), had a roof in their lavatory, and 93.8% (N=390) were considered to have adequate privacy. However, 40.4% (N=169) encountered unpleasant odors from the toilet, and 42.4% (N=176) frequently encountered insects in the lavatory. --- Association between infrastructural factors and the resurgence and sustainability of open defecation free status In the (Table 4) below, ODF sustainability was less likely in households without user-friendly sanitary facilities (uOR=2.47, p<0.001) and roofless toilets (uOR=0.355, p<0.001). Longer walking times (>3 minutes) were associated with reduced ODF sustainability (uOR=0.341, p<0.001). Conversely, the absence of designated open defecation sites increased the odds of ODF sustainability by 1.669 times (uOR=1.669, p<0.001), and households with toilets emitting no unpleasant odors were more likely to sustain ODF (uOR=1.287, p=0.030). --- DISCUSSION Most of the respondents (98.8%, N=418) were Christians. This reveals the dominance of Christianity in the study area. In regards to education, most of the participants (52.9%, N=226) reported to have completed primary education. Studies have consistently shown that educational attainment has a strong effect on health behaviors and attitudes towards sanitation adoption and use. In the study, females (68.6%, N=269) dominated the sample. It is a clear indication that women and young girls may suffer a lot when a household lacks a decent sanitary facility for use by the members. This is in line with a study in Kenya by Njuguna, whose findings revealed that women and young girls in school are particularly at risk of violence and rape when searching open defecation sites, especially during late hours. 6 The study further revealed that individuals with education levels at or below primary education had higher odds of not sustaining ODF practices. The findings concur with the studies by Delaire et al where they reported a significant relationship between the mother's level of education, the presence of secondary school students, the frequency of latrine construction, latrine sanitation, and the use of latrines. 7 The study further revealed that most of the sanitary facilities (59.5%) were located within 10-50 meters, with a median walking time of 3.0 minutes, and the longer walking times (>3 minutes) were associated with reduced ODF sustainability. The results are in line with WHO's recommendations that the pits be built at a reasonable distance from the house, ideally balancing easy access against smell. 3 Additionally, the findings concur with those of Tessama et al who reported a significant relationship between the distance from the household to the toilet and ODF sustainability. 8 In this study, ODF sustainability was less likely in households without userfriendly sanitary facilities. This result agrees with Delaire et al report that, in order to maintain the status of ODF, all sanitary facilities, including school toilets, should be suitable for the elderly and children of all ages and sizes. 7 Further analysis from qualitative data revealed that, userfriendliness of sanitary facilities especially for the elderly population in the study area was a public health concern if we were to sustain ODF. Additionally, reports from qualitative analysis indicated that, common challenge was the lack of water in areas where SATO-PAN toilets were in use. The reasons why households return to open defecation are likely to vary among contexts, according to Odagiri's report, which supports these conclusions. 9 Many people who practice the open defecation method in some places may own toilets, but they may not use them because of poor construction, a lack of privacy, the availability of designated OD sites, or an offensive odour from the toilets. --- Limitations Challenges included long distances between sampled villages and households, compounded by limited resources. To address this, researcher used own savings. In quantitative data collection, biases were acknowledged and mitigated by employing an observation checklist. Monetary demands from study subjects were addressed by clarifying the study's educational nature, emphasizing voluntary participation. --- CONCLUSION This study achieved a high response rate. The findings indicate that socio-demographic factors, such as education levels and infrastructural factors such as time taken to access sanitary facility, absence of designated open defecation sites in the community and having a toilet that did not emit unpleasant odors are crucial for sustaining ODF status. Since education has been linked to better sustainability of ODF, the study recommends that the ministry of education continue with the efforts of 100% transition of pupils to secondary and higher education levels. Also, the community members should enhance infrastructural factors such as the provision of vent pipes, toilet roofing, construction of permanent toilets, latrine aperture covers, and hand washing facilities with running water and soap through subsidized government intervention. Further, the study recommends additional research to uncover more influencers to ODF sustainability. --- Funding: No funding sources Conflict of interest: None declared Ethical approval: The study was approved by the Institutional Ethics Committee

Reduced soil worms, cholera, diarrhea, trachoma, and malnutrition are some public health advantages associated with increased sanitation access. 1 Despite its well-known advantages, effective excreta disposal remains a challenge, particularly in attaining universal coverage of the dispersed rural populations that characterize most people in middle-and low-income countries. 2 Worldwide, 2.4 billion inhabitants have limited access to better sanitation, thus posing a challenge to sustaining open defecation-free status in villages. 3 Eliminating open defecation and providing safe, affordable, and accessible sanitation for everyone everywhere are central tenets of Sustainable Development goal 6 (SDG 6). 4 Research shows that adding latrines is not sufficient to reduce fecal-oral disease. Paramount indicators of ODF, such as toilet privacy, aperture covers, availability of facilities for handwashing with soap and water, and the absence of defecation sites, are non-negotiable in the effort to lowering the burden of these diseases. In Kenya, the

INTRODUCTION Nowadays, a severe acute respiratory syndrome (SARS), known as Coronavirus disease 2019 (COVID-19) quarantined the majority of countries. SARS-COVID-19 was first identified in December 2019 in the city of Wuhan, located in central China, and had spread worldwide 1 . Because of its widespread transmission, recognized as a pandemic disease by World Health Organization (WHO), measures to limit viral transmission and minimize contact with people infected by COVID-19, such as social distancing, have been recommended worldwide and imposed in some countries. Based on the negative effect of quarantine, as reported elsewhere 2,3 and its uncertain ending date, the scientific community has published valuable recommendations and strategies regarding the possible effect of quarantine and social isolation on mental health 4,5 and psychological impact 6 . Moreover, recent studies demonstrated psychological responses to the COVID-19 outbreak in Chinese 7 , Italian 8,9 and students from South India 10 , Bangladeshi 11 and so one 12 . The academic environment per se has already demonstrated to be stressful for professors and both graduate and undergraduate students, demonstrating a negative relationship with wellbeing and mental health [13][14][15] . Consequently, considering the quarantine and social isolation condition plus a new challenge of online learning, the psychological responses could be exacerbated in the University community. The main aim of this study was to evaluate the psychological responses to the COVID-19 outbreak in students, professors, and staff from a Brazilian University. --- METHODS --- Participants A total of 526 respondents participated in the survey, and 518 were part of the final sample. Inclusion criteria were: being a member of the University selected (student, professor, or staff), being home-quarantined, and 18 years older. The local ethics committee approved the study (protocol number 4,002,656). Informed consent was acquired online, in the first part of the survey. --- Procedures An online survey platform with a designated link was sent to the University community after one month of quarantine. We used social media and institutional email to reach a large number of university members. The survey was completed from 1 st to May 30th, 2020. This study is a part of a more comprehensive research project intituled "COVID-19: Psychological and behavioral impacts of social isolation in the university community in a Midwest State of Paraná -Brazil". --- Measures Descript data from sociodemographic questions were obtained through open and close-ended questions regarding the participants' age, biological sex, position (student, professor, or staff), number of members living together during quarantine, and contact with someone diagnosed with COVID-19. Moreover, behavioral responses as food consumption, sedentary behavior, and physical activities also were asked. Psychological responses were measured using some items from the SELF-Reporting Questionnaire (SRQ-20) described in Table 1. The SQR-20 is a reliable tool in Portuguese 16 that assess mental disorder such as depression and anxiety, include the questions Q1, Q2, Q3, Q4, Q7, and Q9. Also, questions regarding preventive measures were asked (Q5 and Q8). Participants should answer "frequently," "sometimes," or "never" for each question. --- Statistical analysis We used absolute and relative frequencies to describe demographic characteristics, psychological responses, and preventive measures. Chi-square and z-test tested the association between psychological responses and demographic characteristics. All the statistical analyses were performed using SPSS version 25.0, adopting p<0.05. --- RESULTS The majority of the respondents were female (71,2%), aged between 18 and 35 years (82,6%), students (76,1%), living in a family with 1 to 3 members during quarantine (55,4%). 37% left the city at the beginning of the quarantine, and only 10 (all students) had a family or friend diagnosed with COVID-19. The behavioral and preventive responses overall are displayed in Figure 1. At least 5% of the sample were quarantined alone; 52% of the women were eating more than normal, and 9-11% of the participants increased alcohol consumption. Women reported 2h more in front of the TV and cell phone compared to men. The majority of respondents answered "sometimes" for the presence of psychological parameters in all questions. Questions about feeling nervous, tense, or worried (Q1) and feeling tired more than usual (Q9) had the highest frequencies of "frequently" amongst the psychological questions. For preventive measures, almost all respondents are using preventive measures such as wearing masks, using hand sanitizer, and washing hands "frequently" (Q5), and the majority are going outside "sometimes" (Q8). Table 2 shows the association between psychological responses and preventive measures with sex, age, education, and quarantine living environment. Considering the biological sex, females demonstrated a significantly higher frequency of negative feelings for all psychological questions than men. Similar responses were shown by the youngest (18-35 years old) compared to the oldest (more than 35 years old), and graduate and undergraduate students compared to professors and staff. No significant association was found regarding living quarantine conditions for the number of family members and psychological responses. --- DISCUSSION The main aim of the present study was to evaluate the psychological responses due to COVID-19 outbreak in students, professor, and staff from a Brazilian University and the main findings were: 1) Female, young age (18-35 years old) and students were most sensible to present frequently negative psychological responses compared to their counterparts; 2) Independently of spend quarantine alone or with more than 4 people, the psychological responses are similar; and 3) Majority of the academic population are using preventive measures (wearing mask, washing hands…) and going outside "sometimes". The results of the current study indicated that females, young age, and students were associated with "frequently" negative psychological responses. This finding has been presented in recent studies during the COVID-19 outbreak. Female and younger than 30 years appeared to be risk factors for negative psychological responses in Italy's population 8,9 . In China, data suggest that females and students suffered significant psychological impacts and a higher level of stress, anxiety, and depression 7 . Indeed, women tend to be more vulnerable to experiencing psychological distress as well as more change to developing post-traumatic symptoms, as evidenced in the literature 17 . Therefore, during the quarantine period, it seems that women suffer more distress than men, and this gender difference can be explained for several reasons, from behavioral to physiological factors, as discussed by Song et al. 18 . Regarding young people, participants who are 18 to 35 years old showed a higher frequency of "frequently" negative psychological responses than those with more than 35 years old. A similar response was found in the Chinese population, where younger participants (<35 years) were more likely to develop anxiety and depressive symptoms during the COVID-19 outbreak than older participants (≥35 years) (AOR=1.65, 95%CI 1.49-2.02) 7 . As discussed elsewhere 8 , the negative psychological responses and higher anxiety in younger people may be explained due to easy and great access to information through social media 19 . Literature demonstrated that in normal conditions, the communication load resulting from internet multitasking is significantly related to increasing perceived stress 20 ; therefore, these amounts of information can trigger negative psychological responses. Lastly, our results showed that graduates and undergraduates present "frequently" negative psychological responses compared to professors and staff. This finding corresponds with those students in Bangladesh (n=505 college and university) in which 69.3% of students reported mild to severe level of psychological impact due to the COVID-19 outbreak, and additionally, university students had higher psychological impacts than college students 11 . Among Indian pharmacy students, 18 % reported extremely severe depression, and about 27.5 % with severe anxiety, and about 12.5 % with severe stress 10 . This response can be explained by uncertainty of academic progression and postponement of examinations, leading to a stressor factor in students mind 21 , especially in graduating final year students due to uncertainty about the pandemic effect may have increased their worry about graduating, finding a job, or enrolling in further study 22 . Taken together, females and students have demonstrated a considerable risk of adverse psychological responses in normal conditions. Recently, a longitudinal study with Chinese college students reported that female students suered from significantly higher levels of anxiety than their male counterparts on average 23 . In Brazil, a recent study with university students (n=1,827) also demonstrated that 32% of students presented a major depressive episode. The major depressive episode was more frequent among females, aged between 21 and 23 years, showing a risk of 60% to present depressive episode 24 . Therefore, the need for intervention in this specific group is necessary to promote a possible understanding of the situation. Despite the present study be one of the first to evaluate the psychological effect of the COVID-19 outbreak in a Brazilian University community, it is not without limitations and caution regarding the generalization of our findings is recommended. We used an online convenience sampling strategy, which required participants' access to the internet. It limited the participation of those who do not have internet access. The sample does not represent all the University community, limiting the generalizability of our findings. Finally, this study does not use a specific tool to evaluate psychological distress or anxiety and depression; therefore, we cannot classify the severity of these domains during the quarantine period. However, the current data, together with recent studies, suggest that the recent quarantine due to COVID-19 outbreak affect the psychological responses in people, especially in female, young aged, and students. --- CONCLUSIONS During almost two months of quarantine and social isolation due to COVID-19, in Brazil, an academic community demonstrated to be affected by negative psychological responses. Female gender, young age, and student seem to be the group with the major psychological impact of the outbreak. The results present a general picture of the psychological impact of the COVID-19 outbreak on students, professors, and staff in Brazil. Attention is required from public health authorities and members of the academic community, to cope with this situation. --- AUTHORS' CONTRIBUTIONS --- ETHICAL ASPECTS The project was reviewed and approved by the Research Ethics Committee of the UNICENTRO -University (protocol number 4.002.656). --- DATA AVAILABILITY STATEMENT Data associated with this publication is archived in the Git hub Integration Platform by link: https://github.com/timcavazzotto/ Psycho_Response_Covid19_Unicentro.

The study evaluates psychological responses to the COVID-19 outbreak in the students, professors, and staff due to the social distancing and transition of the classroom activities through online learning. METHODS: 518 participants from a University community in Brazil answered an online survey with questions related to demographic data, psychological responses, and preventive measures. Absolute and relative frequencies described the sample, Chi-square and z-test tested associations between the variables, adopting p<0.05. RESULTS: Female (71.20%), young age -18 to 35 years (82.60%), students (76.10%), living in a family with 1 to 3 members during quarantine (55.40%) were more prevalent respondents. Women, young age, and students had a significantly higher rate of negative feelings in all psychological questions. Curiously, negative feelings during social distances affect the participants, independent of living quarantine alone or with family/friends during the COVID-19 outbreak.Our findings demonstrated that the COVID-19 outbreak affected the psychological responses in the Brazilian academic community, also, women, young age, and students appear to be a risk group to negative psychological responses. The long-term quarantine due to the COVID-19 pandemic may cause further worsening in the psychological responses, especially in those in the risk group.

variable was operating margin, moderator variable was staffing intensity, and independent variable was PDPM for model 2. Organizational, community level, and COVID-19 related variables were used as controls. Results suggest that PDPM was associated with an increase in RN and LPN staffing intensity, but a decrease in Physical Therapist, Physical Therapist Assistant, and Occupational Therapist Assistant staffing intensity (p< 0.05). PDPM had a positive impact on financial performance moderated by RN and PT staffing intensity (p< 0.05). Policy and managerial implications are discussed. The growing number of people living with dementia (PlwD) implies an increase in the demand for eldercare at different stages of the disease. This study aims to investigate the utilization of eldercare among people with and without dementia in Sweden during the last five years of life and what social-background factors influence the use of eldercare. Data were derived from four linked Swedish national registers comprising all decedents aged 70+ in Sweden as of November 2019 (n=6294). The primary outcome variable was the utilization of eldercare (no care, homecare, residential care). Following the study sample retrospective from death, data analysis was performed using multinomial and linear logistic regression models. Results showed that (1) nearly a quarter of all PlwD did not use any eldercare, primarily people who were newly diagnosed with dementia and living with partners; (2) three out of four PlwD used residential care in the last years of life; and (3) age, gender, and cohabitation status were important social-background factors determining utilization of eldercare for PlwD. This study provides unique insight that many Swedes with a dementia diagnosis do not receive any eldercare and that the utilization of eldercare increases with time since dementia diagnosis. We suggest more research to investigate why a substantial part of PlwD does not have any eldercare at all and what the policy implications of this might be. --- SESSION 4195 (PAPER) --- MINORITY AND DIVERSE POPULATIONS (PAPERS) II

improved clinical outcomes. In its first two years, the RTNH initiative has fostered partnerships between three SONs and four NHs in Pennsylvania, and is planning to expand. The program is implementing the Institute for HealthCare Improvement Age-Friendly Health System "4Ms" quality improvement framework through an online learning network. The 4M quality improvement framework focuses on four evidence-based elements: Mobility, Mentation, Medication, and What Matters. In addition, the participating SONs are incorporating the 4Ms into curricula and clinical rotations. The evaluation will examine both implementation and outcomes for SONs and NHs. Measures include student competency, staff satisfaction and burnout, clinical process of care and resident outcomes. While some resident level measures can be extracted from the Minimum Data Set (MDS), others (deprescribing, rehabilitation goals, preference sensitive care) require access to the electronic medical record (EMR). The goal of this presentation is to describe the methodology for measuring the wide range of outcomes and to examine the performance of a synthetic comparison group to study overall quality using CASPAR data. We selected 1,764 similarly sized, non-profit NHs and conducted bivariate, and propensity score analysis to determine if the participating NHs were different on any observable characteristics. The findings suggest that the participating NHs were not statistically significantly different in terms of overall quality rating, staffing, or inspections.

Introduction During the COVID-19 pandemic, use of digital technology has become more widespread for routine activities for children (eg, medical visits, remote learning), perpetuating concerns about the US socioeconomic "digital divide." 1 In 2021, 19.7% of parents reported using telemedicine for their child. 2 However, for health care to adequately address children's health needs, defining the quality, access, and use of digital technology among families is essential. We characterize the type and quality of digital access among racially and ethnically as well as socioeconomically diverse households in Chicago and the associations with child and household characteristics. --- Methods Data collection for this cross-sectional study occurred from May 24 to July 29, 2021, through a panel survey of parents in English and Spanish via web and telephone. Eligibility criteria included being 18 years or older, the parent of at least 1 child living in the household, and a Chicago resident. Respondents were recruited from probability samples (1134 of 2280 eligible responses [49.7%]) (eMethods in the Supplement). The institutional review board at Lurie Children's Hospital approved the study, and participants provided electronic consent. This study followed the STROBE reporting guideline. Survey questions addressed type of device, perceived internet speed, internet costs, and concerns about affordability (eTable in the Supplement). Demographic characteristics and child health status were collected. Self-reported parent race and ethnicity were categorized as Asian and other race or ethnicity (which were combined owing to small sample size), Hispanic or Latinx, non-Hispanic Black (hereinafter Black), and non-Hispanic White (hereinafter White). All percentages and analyses were population weighted; a 2-sided P < .05 was considered significant. Differences in digital access by child health status and demographic characteristics were examined using χ 2 tests. Analyses were performed in SAS software, version 9.4 (SAS Institute, Inc). Multivariable logistic regression examined the likelihood of having high-speed internet with race and ethnicity and household income as covariates. [95% CI, 85.3%-92.3%]; P < .001) (Table 2). Child health status was not associated with having highspeed internet. In the multivariable model, Hispanic or Latinx parents were less likely to have highspeed internet vs White parents (odds ratio, 0.45 [95% CI, 0.28-0.73]) after controlling for --- Discussion The findings of this population-weighted cross-sectional survey of Chicago families suggest that disparities in digital access were associated with race and ethnicity as well as income but were not associated with child health status. After adjusting for income, the disparity in access to high-speed internet persisted for Hispanic or Latinx but not Black participants. This may be attributed to racial and ethnic residential segregation, because Chicago ranks high nationally on segregation indices, suggesting that broadband services may be limited in neighborhoods with residents who are members of racial or ethnic minority groups. 3 Previous studies have found that Hispanic or Latinx adults are more likely than Black or White adults to report having smartphone internet only. 4 Barriers to access might include affordability and real or perceived low demand, discouraging internet carriers to invest in broadband infrastructure where Hispanic/Latinx families live. 5 Study limitations include the generalizability to a national population, participants' representativeness by income of Chicago families, and possible underrepresentation of participants with limited internet access. These findings are important for the design and implementation of digital health services and policies in childrens' health care, ensuring that specific populations are not overlooked. 6 --- ARTICLE INFORMATION Author Contributions: Dr Heffernan had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Kan, Heard-Garris, Morales, Davis, Heffernan. Acquisition, analysis, or interpretation of data: Kan, Bendelow, Lewis-Thames, Heffernan. Drafting of the manuscript: Kan, Heard-Garris, Bendelow, Heffernan. Critical revision of the manuscript for important intellectual content: Kan, Bendelow, Morales, Lewis-Thames, Davis, Heffernan. Statistical analysis: Bendelow. Administrative, technical, or material support: Kan, Morales, Lewis-Thames, Davis, Heffernan. Supervision: Kan, Heffernan. Conflict of Interest Disclosures: Dr Kan reported receiving grants from the Agency for Healthcare Research and Quality (AHRQ) during the conduct of the study. No other disclosures were reported.

Data from 1620 Chicago parents (58.5% [95% CI, 55.0%-62.1%] women and 41.5% [95% CI, 37.9%-45.0%] men; 71.5% [95% CI, 68.2%-74.8%] aged 26-45 years) were collected. In terms of race and ethnicity, 9.5% (95% CI, 7.5%-11.6%) were Asian or other, 38.1% (95% CI, 34.7%-41.4%) were Hispanic or Latinx, 21.4% (95% CI, 18.5%-24.3%) were Black, and 31.0% (95% CI, 28.0%-34.0%) were White. Most parents (90.5% [95% CI, 88.6%-92.4%]) reported having a desktop or laptop at home, and 76.7% (95% CI, 73.7%-79.7%) reported having reliable high-speed internet (Table 1). Black and Hispanic or Latinx parents were less likely to have reliable, high-speed internet (76.0% [95% CI, 69.5%-82.6%] and 64.5% [95% CI, 58.8%-70.2%], respectively) vs White parents (88.8%

INTRODUCTION Marriage at a young age is common in many rural areas of the world, as reported by Bhattarai et al. (2022a). Millions of girls, especially in low-income nations, are still badly impacted by early marriage each year, despite efforts to limit its occurrence. When females are married at a young age, they often have to give up their education and their chances of succeeding in life (Bhattarai et al., 2022b). Additionally, girls who are married at a young age are more likely to have preterm births and other health problems. Therefore, effective strategies to reduce the prevalence of early marriage and boost girls' access to quality education and healthcare are required in rural areas (Deane, 2021). Socializing education on the risks of early marriage is one viable strategy, say Ninsiima et al. (2018). The term "socialization" is used to describe how a society's culture and norms are passed down from one generation to the next. As stated by Tremblay et al. (2015), the prevalence of early marriage can be lowered by the dissemination of information about the negative effects of this practice. This research discusses the importance of early marriage education in rural areas and offers suggestions for how to implement this strategy. The goal of this report is to provide light on successful methods of disseminating early marriage education in rural areas. This paper intends to socialize education about early marriage by doing a literature analysis and original research to determine the most significant difficulties associated with early marriage in rural communities, examining prior efforts to address the issue, and proposing actions that could be undertaken to do so. This research aims to provide a meaningful contribution to the current literature on child marriage by offering concrete advice to Girls who have already completed their education can mentor and advise younger girls in peer education programs about the value of postponing marriage and continuing their education. Group discussions, mentoring, and skill-building workshops are just some of the activities that can be a part of these programs, which can be held anywhere from a classroom to a community center. Education for Parents: Parents can be educated on the importance of their daughters' education and the drawbacks of getting them married too young. Trained educators can either host workshops for the community or make house calls. Parents might be encouraged to take an active role in their daughters' educational and marital planning. The media can be used to spread information about the harms of child marriage and the benefits of educating and empowering young women. Billboards, billboard displays, television, radio, and social media can all play a role in these efforts. A focus on girls' education and empowerment can counter cultural beliefs that favor marriage at a young age. Girls can be empowered to delay marriage and continue their education through the establishment of initiatives that take place within the classroom. Life skills training, mentoring, and extracurricular activities are just some of the things that can be a part of these programs. The provision of necessities like sanitary pads and school materials can also be used to keep girls in school. Working Together with Municipal Officials: Promoting girls' education and empowerment while also challenging cultural norms and attitudes that favour early marriage requires establishing partnerships with local leaders like community elders, religious leaders, and traditional authorities. The goal of these partnerships is to keep females in school and postpone their marriage. Educating rural populations about the dangers of early marriage can be accomplished using any one of these measures. The community's needs and circumstances should guide the selection of activities. Collaboration between community people, educators, legislators, and local leaders is essential for the successful implementation of these initiatives. Puffer (2018) claims that Leaders at the community level, such as elders, religious and traditional leaders, can be crucial in encouraging girls to stay in school and delaying marriage. Involving the community in the planning and execution of socialization activities can go a long way toward earning their trust and support. They can assist change minds about girls' education and empowerment by shedding light on local customs and traditions. Integration of Health and Education: Important settings for enacting socialization activities include educational institutions and medical facilities. School-based initiatives can be made available to girls and can be implemented in schools. Postponing marriage is possible with the help of health centers' resources on reproductive health and family planning. Working in tandem with these organizations can make socialization initiatives more long-lasting and productive. Culturally relevant and effective socialization exercises can be enhanced by making use of culturally suitable materials. Posters, pamphlets, and videos should all be created in local languages and adapted to fit local cultural norms. To ensure that they are culturally appropriate and effective, community members should be involved in their creation. Educators and facilitators on the ground need to be given the tools they need to carry out socialization programs successfully. The capacity of local educators and facilitators to deliver socializing activities can be strengthened through training. They need to learn about issues related to gender, how to communicate well, and how to rally the community. The success of socialization activities can be judged and improvement points pinpointed through careful monitoring and evaluation. To make sure that socialization activities are carried out as intended and to evaluate their effect on girls' education and postponing marriage, continuous monitoring and evaluation should be carried out. Monitoring and evaluation should include community members to make sure programs are meeting their needs. Long-Term Sustainability: Planning for sustainability is essential to ensuring that socializing activities have a lasting impact. Sustainable socialization activities are those that are planned and implemented with the goal of continuing their work after the project's completion. To do so, it may be necessary to strengthen local institutions and form alliances with government and non-governmental organizations (Berkes, 2017). Collaboration between community members, teachers, legislators, and local leaders is essential for successful implementation of these measures. Community needs and circumstances should inform strategy selection. --- Potential challenges and ways to address them The findings of Frumence et al. Community members' traditional ideas and attitudes concerning early marriage provide a significant barrier to the successful implementation of socialization programs. To combat this, trust and support-building initiatives should be developed alongside local leaders and community people. Education and awareness about the risks of child marriage and the upsides of continuing a girl's education are equally crucial. Shortage of Materials: Financial and material constraints can make it difficult to carry out socialization initiatives. To combat this, it's possible to form alliances with regional and global groups, tap into government funding, and ask for in-kind contributions (Horan, 2019). To make the most of limited resources, it is essential to set priorities for projects in light of community needs and circumstances. Baldacchino (2015) claims that The effectiveness of socialization activities may be diminished due to a lack of access to educational and medical resources. To combat this, institutions of higher learning and healthcare providers should work together to expand patients' access to a full range of medical care options, including those related to sexual and reproductive health. It could also involve lobbying government officials and community members for more funding for health and education. Communication and comprehension in group activities might be hampered by a lack of a common language or an unfamiliar culture. This issue can be fixed by using local translators and interpreters and using content that is tailored to the target culture. Educators and facilitators in the area may need to have their communication skills honed as well (Horan, 2019). Maintaining socializing efforts after the project's completion can be difficult. To combat this, it is necessary to strengthen local institutions, create alliances with government and NGO entities, and involve community members in the planning and execution of programs. Making activities sustainable may also entail coming up with ways to fund them in the long run. Collaboration between community members, teachers, legislators, and local leaders is essential for successful implementation of these measures. Constantly evaluating the success of programs and making any necessary changes is essential for adaptability and responsiveness to the community's needs and circumstances. But it's crucial to recognize that promoting early marriage education in rural communities is a complex and multifaceted issue that calls for steadfast effort and dedication from all parties involved. Poverty, gender inequality, and inadequate access to health care, education, and economic opportunities are all contributors to the widespread practice of marrying young. Improvements for girls, their families, and their communities can be achieved by concerted, longterm efforts to increase girls' access to education and postpone marriage.

The socialization of education concerning early marriage in rural areas is the subject of this report. In many rural areas, girls are still getting married off at young ages, which has devastating effects on their futures as learners and on their health and safety. Community workshops, peer education programs, parental education, and media campaigns are all included in the report as viable socializing activities to encourage girls to continue their education and postpone marriage. Effective tactics, such as incorporating local leaders, partnering with schools and health centers, employing culturally relevant materials, monitoring and evaluation, are needed to put these efforts into action. To guarantee the success of these endeavors, however, it will be necessary to overcome obstacles including community opposition, scarce resources, and language and cultural divides. In order to enhance results for girls, families, and communities, the report emphasizes the necessity of a long-term commitment to supporting girls' education and delaying marriage.

Objective: DISTINCT is a Marie Sklodowska-Curie Innovative Training Network. Supported by the INTERDEM network and European Association of Geriatric Psychiatry, DISTINCT aimed to establish a multi-disciplinary, multi-professional and intersectorial European research framework, for assistive technologies to support social health in dementia. In this symposium, we present research associated with the maturity lifecycle (development to evaluation) of four technologies: the ROADMAP online self-management intervention; online peer support for people with young onset dementia; online acceptance and commitment therapy for caregivers (ACT); and the FindMyApps tablet-based intervention for people with dementia and their caregiver. --- Method: In 2019, 15 ESRs were recruited to 13 research organizations across 8 European countries. Research projects were launched in collaboration with people living with dementia and caregivers, and industry partners. Projects were adapted to meet challenges and opportunities due to the COVID-19 pandemic. The projects presented in this symposium employed a variety of research paradigms (user-centred design, feasibility and implementation studies, randomized controlled trials). Key insights from each project were combined into best practice guidance for developers, researchers, healthcare professionals and people living with dementia, covering the full innovation lifecycle. Results: All DISTINCT research projects are now in the final stages, having so far resulted in more than 35 peer reviewed publications and many contributions to international conferences. Insights were incorporated into the Best Practice Guidance for Human Interaction with Technology in Dementia, published in December 2022, which will be updated by the end of 2023 with further insights from completed projects. Key findings presented in this symposium concern: development of ROAD MAP online; best practices for, and barriers to, online peer support; acceptability and preliminary effectiveness of online ACT; effectiveness and cost effectiveness of FindMyApps. 2 2023 IPA International Congress international commitment to planning for humanitarian emergencies that include individual and community psychosocial support for older adults with mental health conditions. The current lack of inclusion for these older adults in humanitarian response is dramatic and constitute a clear violation of their Human Rights. Governments and humanitarian actors need to do more during crisis to ensure that individual's specific needs are addressed. A humanitarian response includes the collective actions of actors responding to the global needs. Each state has the responsibility first to take care of the victims of these emergencies occurring on its territory. Humanitarian actors must provide assistance in accordance with the principles of humanity, neutrality and impartiality. Promoting and ensuring compliance with these principles are essential elements of effective humanitarian coordination, in respect of the Human Rights principles, in particular when vulnerable people such older adults with mental health conditions are involved. The symposium intends to describe the consequences on older adults' mental health during humanitarian emergencies and discuss potential solutions to improve the humanitarian response for all in need.

The LuBAIR™ Paradigm is a novel approach to ascribe meaning to behavioral expressions in advanced neurocognitive disorders when the reliability of a clinical assessment is limited. The meaning ascribed to each behavioral category was used to identify those who are likely to respond to the use of atypical antipsychotics in their management. De-prescribing was attempted on patients who qualified to enter this retrospective study. De-prescribing was defined as successful if individuals were completely withdrawn from AAP and remained off them for 60 days without the reemergence of behaviors.The LuBAIR™ Inventory was filled on two occasions. The data collected on the second occasion, in the successful and failed de-prescribed groups, were compared in this retrospective study. MANOVA, Chi-Square paired t-test statistical analyses were used to detect the differences in the behavioral categories between the two cohorts. Cohen d was used to measure effect size. Results: Patients who did not have Mis-Identification and Goal-Directed Expressions were more likely to successfully deprescribe: X2 (1, N = 40) = 29.119 p < 0.0001 and X2 (1, N = 40) = 32.374, p < 0.0001, respectively. Alternatively, the same behavioral categories were more likely to be present in patients who failed de-prescribing: MANOVA and paired t-test (p < 0.0001).Atypical antipsychotics, in their role as an antipsychotic and mood stabilizer, may be used to manage Mis-Identification and Goal-Directed Expressions, respectively.

To the Editor Balingue proposes in earlier correspondence the Confucian concept of ren as a cultural parallel to the notion of solidarity which is argued by the author as a powerful counter-response to the emerging social and racial discrimination against the Chinese people and those of Asian descent specifically during the height of the Covid-19 pandemic. 1 He believes that embedding the social response within the cultural framework of a Confucian ideal can easily facilitate communal solidarity among everyone, especially among the Chinese people. While Chinese individuals have reported more hate incidents compared to other Asian Americans in the USA, Filipinos have also been a target of assault and harassment. In a national report by the organization Stop AAPI Hate, about 65.2% of the reported incidents between March 2020 and March 2021 are of verbal harassment or name-calling and most of these take place in public streets and parks. 2 There were reports of a Filipino journalist who was verbally harassed in a New York subway 3 ; a physical assault involving a 61-year old Filipino in a Manhattan subway; and a 65-year old Filipina who was repeatedly kicked and stomped on her face. 4 The rise of Asian Hate-related assaults has already been tagged as a "secondary contagion." 5 Within Filipino (indigenous) psychology is a concept called, "kapwa," which is roughly translated as the "other." However, its more nuanced translation is a "shared self " where the very essence of self is tied up with others in an inclusive way. "By default, the dispositional intention of kapwa is to connect, relate, and share." 6 It tends to see the person beyond his/her social roles and status; whether or not the kapwa is an Asian or an American, or rich or poor, but fundamentally as a human person. To see the other not as different but as an essential extension or reflection of oneself allows a more communaloriented disposition that values more the spirit of oneness and connectedness rather than differences and social/racial hierarchy. As researches have shown a significant link between anti-Asian discrimination to increased levels of anxiety, depression and sleep problems, 7 it is important to create an ambiance of social connectedness not only within the Asian community but also even across all races and ethnicities. One of the identified strategies to address this problem is to invest in community-based efforts that will create, develop and increase awareness on the stigma of hate crimes to its victims, particularly on their mental health and wellness. 8 By infusing a strong kapwa paradigm in any community-based approaches, Filipinos and other ethnicities may look at one another not by hate or through it but by care, compassion, and solidarity with and among them. Any attempt to nurture social connectedness by treating the other not as entirely different from the self but as an extended self or a shared self allows an ambiance of communion which is essential towards communal recovery and healing. --- Conflict of interest The author declares no conflict of interest in this paper.

In a letter to the editor, the author has expressed how a Chinese notion of ren is a powerful tool to negate the stigma of racial discrimination among Asian people. I would argue that within the Filipino psyche, the notion of kapwa or "shared self" can be an equivalent socio-normative ideal that can be utilized towards not just countering the ill effects of social discrimination but also fostering deep communal and group solidarity among people, regardless of race, color and ethnicity.

Box 1: PHE's key recommendations • Make comprehensive ethnicity data collection and recording mandatory as part of routine NHS and social care data collection, including ethnicity data at death certification • Support community research in which researchers and community stakeholders engage as equal partners to understand the social, cultural, structural, economic, religious, and commercial determinants of covid-19's effects in ethnic minorities • Improve access, experiences, and outcomes of services for ethnic minorities through measures such as regular equality audits, health impact assessments, integration of equality into quality monitoring, and better representation at all staff levels • Accelerate the development of culturally competent occupational risk assessment tools to reduce the risk of employees' exposure to and acquisition of covid-19, especially for key workers The report concluded: "The unequal impact of covid-19 on BAME communities may be explained by a number of factors ranging from social and economic inequalities, racism, discrimination and stigma, occupational risk, inequalities in the prevalence of conditions that increase the severity of disease including obesity, diabetes, CVD [cardiovascular disease] and asthma." It said that further consideration needed to be given to factors such as diet, vitamin D levels, and housing. Hina Shahid, a GP in London and chair of the Muslim Doctors Association, said that the report and its recommendations were welcome but that it "raised questions on the lack of transparency and mixed messages received surrounding its publication." She added, "Trust within the BAME community is at an all time low, and the government has significant work to do to rebuild this. We are pleased to see several of our recommendations included. The government needs to urgently engage with community organisations and leaders to implement the recommendations in ways that are robust and sustainable." Andrew Goddard, president of the Royal College of Physicians, said it remained unclear why this second report did not accompany the earlier PHE review. He said the recommendations "must be placed at the core of both the NHS and the government's plans to restart services, as well as plans for further covid-19 outbreaks." He added, "There is no time for complacency, and leaders at all levels should be made accountable for delivering these recommendations and regularly reporting on progress." Goddard said that two weeks ago only 24% of college members said that they had undergone a formal risk assessment despite the NHS having known for weeks about the increased risk among ethnic minority staff, which he called "disappointing."

Racism, discrimination, and social inequality may have contributed to the increased risk of death from covid-19 among ethnic minority groups, a review commissioned by the government has acknowledged. The report from Public Health England, 1 published on 16 June, follows a separate PHE report on 2 June that found that people from ethnic minorities were more likely to contract and die from covid-19 but that received heavy criticism for its lack of recommendations on how to reduce the disparities. 2 The second report makes some recommendations (box 1), some of which were disclosed to The BMJ last week by disgruntled stakeholders who had expected them to be published with the first report. 3

INTRODUCTION The Krishi Vignan Kendras are composite training institutions that deal with all agricultural subjects including home science. With the help of subject matter specialists /scientists in the KVKs, training is provided to the farmers, rural youth and farm women on various activities according to their needs and interests. Both for quality as well as quantity services, it has been emphasized to link each discipline of the KVK to its respective department of host institution either SAUs or the ICAR research institutes.To bridge the gap between modern agricultural techniques and rural practices, KVKs are dedicated for transfer of technology (TOT) knowledge through methodologies such as on-farm testing (OFT), front-line demonstration (FLD), and comprehensive training programs aimed at enhancing the skills of farmers, farm women and rural youth. Nazir et al. [1] emphasized that KVKs play an important role in providing both shortand long-term vocational training courses that are tailored to the specific needs of the community, fostering skill-oriented development. Venkatasubramanian et al. [2] in their study listed out various trainings such as training for rural youth (both on and off campus), vocational training programmes, sponsored training programs at KVKs which are aimed at improving skills of farmers, rural youth, and extension personnel. He also categorized trainings as short-duration trainings (1-7 days), mediumduration trainings (8-14 days), and long-duration trainings (3-4 weeks). Modern agricultural technologies and relevant skills are crucial components in driving agricultural advancements and empowering rural youth to become successful entrepreneurs. The acquisition of knowledge and the mastery of contemporary agricultural practices have a profound impact on rural development. There is need to shed light on the profound impact of KVKs trainings on rural youth by investigating the status of knowledge retention and skill application following vocational training. By understanding the intricacies of this relationship, we can discern the pivotal role played by KVKs in shaping the agricultural landscape and driving the transformation of rural communities. Based on the above views an attempt was made in assessing the profile of KVK rural youth trainees in Western part of Uttar Pradesh with the following specific objective: 1) To assess the socio-economic profile of the rural youth trainees. 2) Types of training received by the rural youth trainees from KVKs. --- METHODOLOGY The --- RESULTS AND DISCUSSION --- Socio-Economic Profile of the Trainees Age: The data from the Table 1 indicates that majority (45.56%) of the rural youth trainees belonged to middle age group of 25 to 30 years, followed by old age group (28.89%) of above 30 years. One quarter (25.56%) of the rural youth trainees were in the young age group up to 24 years. In general, middle-aged people are more capable, passionate and responsible than younger and older age groups. In comparison, they appear to be more interested in development and want more money. This could be the cause for the bulk of rural youth trainees being in the medium age group who took training from the KVKs. The results were in line with the findings of Biswas et al. [3] and Sunil and Manjula [4]. Gender: By analyzing the data presented in the Table 1, it is evident that a majority (83.90%) of the rural youth trainees were male, while a smaller proportion (16.10%) were female. The participation of women was low as it is difficult for them to spare time to attend and stay in the campus. The results were in line with the findings of Mishra and Kumar [5] and Radhakrishnan [6]. --- Caste: The data from the Table 1 represents that majority (53.33%) of the rural youth trainees belonged to other backward caste, followed by general caste (32.22%), schedule caste (14.45%). The probable reason for the result was more number of backward class people participated in the trainings in order to improve their socio economic status. These findings align with the research of Balu [7] and Kailash et al. [8]. Educational Status: By analyzing the data presented in the Table 1 it becomes evident that the majority (93.10%) of the rural youth trainees were literate, whereas only a small percentage (06.90%) was identified as illiterates. Among literate rural youth trainees, the highest percentage (45.56%) had completed high school, followed by intermediate (29.40%), graduation (13.30%) and postgraduate (05.60%). As education is important for an individual to improve the intellectual capabilities most of them had basic education and were unable to go for higher studies as there were no higher education institutions in the villages and nearby towns. These results correspond with the findings of Biswas et al. [3] and Patel et al. [9]. --- Land Holding: The results presented in the Table 1 indicates that majority (49.40%) of the rural youth trainees were having marginal land holding, followed by small land holding (36.70%), medium land holding (11.10%), and large land holding (02.80%). The probable reason for having small holding was fragmentation of the land between the family members. Similar results have been reported by Prashad et al. [10] and Medhi et al. [11]. Social Participation: An analysis of the Table 1 shows that majority (76.10%) of the rural youth trainees were affiliated with one or more organizations, whereas the remaining (23.90%) were not members of any organization. These findings demonstrate the general interest of participation in social organizations among rural youth trainees. It can be because of Krishi Vigyan Kendra's initiatives or awareness most of the rural youths may have participated in social activities because of their willingness to volunteer their time to gain knowledge about various income-generating enterprises, technologies, and self-confidence through KVK training programmes. The results were in line with Sharma et al. [12]. Occupation: As depicted in Table 2, majority (52.78%) of the rural youth trainees were engaged in mushroom production, followed by farming + mushroom production (27.22%), and lastly, farming + services (20.00%) respectively. The probable reason was most of the rural youth trainees had taken trainings related to mushroom and took it as their career. The results were in line with Awasthi et al. [13] and Acharya et al. [14]. --- Annual Family Income: The results from Table 2 shows that maximum (43.30%) of the rural youth trainees had medium family income of 1 to 4 lakhs, followed by 35.60% and 21.10% with low family income of less than 1 lakh and high family income of above 4 lakhs, respectively. The results were in line with Kumar and Aski [15]. Information Source Utilization: The data from the Table 2 reveals that maximum (51.11%) of the rural youth trainees reported medium level of information source utilization, followed by high (28.33%) and low (20.56%) level of information source utilization, respectively. The probable reason was the rural youth trainees were in regular contact with the information sources to get latest information related to various activities. The findings align with the observations of Rosaiah yeluri [16]. --- Mushroom Cultivation Experience: The results from Table 2 indicates that majority (66.67%) of the rural youth trainees had low mushroom cultivation experience of up to five years, followed by medium (24.44%) cultivation experience between 5 to 10 years, while a smaller percentage (08.89%) possessed high experience exceeding 10 years. The probable reason for the result was most of them took trainings related to mushroom cultivation recently which leads to have a low experience. Achievement Motivation: Table 2 data reports that majority (54.44%) of the rural youth trainees exhibited medium level of achievement motivation, followed by (27.23%) with high level of achievement motivation, while a smaller segment (18.33%) indicated low level of achievement motivation. The probable reason was the rural youth trainees were highly motivated towards achieving higher positions. The results were in parallel with the findings of Kumar [17] and Bortamuly [18]. Economic Motivation: Table 2 results indicates that majority (52.78%) of the rural youth trainees exhibited high level of economic motivation whereas 32.78% and 14.44% indicated medium and low level of economic motivation, respectively. The reason for having high economic motivation was the rural youth trainees were oriented towards gaining more profits and improve their economic status. The results were in parallel with the findings of Priyanka and Ghadei [20]. --- CONCLUSION The study on the socio economic profile of the rural youth trainees reports that majority of rural youth trainees were in the middle age category of 25 to 35 years were male belonging to other backward classes. Maximum rural youth trainees were educated up to high school, engaged in mushroom production and possessed marginal land holding, had membership in organizations with medium annual family income of 1 to 4 lakhs. The study underscored the pivotal role of information sources in influencing decisionmaking, with a considerable proportion of respondents exhibiting medium utilization levels. They had an experience of up to five years in mushroom cultivation, and achievement motivation was reported at medium levels, indicating a balanced pursuit of excellence. Economic motivation was medium with a substantial number of rural youth trainees exhibiting high levels of desire for financial success. Most of the rural youth trainees preferred on-campus training programme and found three days of training method helped in improving their knowledge. A look into the study of the KVK training programmes, it is heartening to note that the trainees had shown an overall satisfaction and high regard for the KVK training, the subject matter specialists and the facilities. --- SUGGESTIONS FOR FUTURE LINE OF WORK The present study was conducted at only three KVKs of the university. It should be done on larger scales to make generalizations. Kind of trainings need by the rural youth trainees and their perception towards the training programmes can also be studied. --- COMPETING INTERESTS Authors have declared that no competing interests exist.

The present research study was carried out during 2022-23 to known the Socio-economic profile of the Krishi Vignan Kendra rural youth trainees in Western part of Uttar Pradesh. Out of 20 Krishi Vignan Kendras (KVKs) under Sardar Vallabhbhai Patel University of Agriculture and Technology, meerut, three KVKs were selected purposively for the study. From each KVK, 60 rural youth trainees were selected randomly constituting a sample of 180 respondents. Structured interview schedule was used to collect data through personal interview method. The study reported that

Energy and energy policy: chemistry's role --- Steve Berry This supplement to the Chemistry Central Journal (CCJ) is meant to serve at least two functions. One, consistent with the long-term goal of this journal, is to bring to its audience the full span of topics and areas in which chemistry plays a key role, even if it is not the only key contributing subject. Obviously energy is very much such a subject; chemistry plays an integral role in the acquisition, generation, distribution and efficient use of energy. But its role is only fully meaningful when chemistry's contributions are integrated with those of other sciences such as climatology, and, every bit as important, with economics, sociology and political decisionmaking. This brings us to the second function of this supplement. It consists of a set of six papers developed in a course at the University of Chicago in the Fall term of 2010, and then later revised a bit for CCJ. Each paper was the work of an interdisciplinary team, consisting of three to five students; each team had to include at least one student in a natural science and at least one in a social science such as economics or public policy. A primary goal of the course was educating the students, all fourth-year undergraduates or graduate students, in working together across interdisciplinary lines, learning to convey the relevant concepts of their own field to others in very different fields and to integrate the concepts from very different areas to come to a coherent analysis of their chosen topic. Each team made a progress report to the class midway through the term, and then made a final presentation in one of the last sessions. Students were encouraged to ask questions and make critical comments about papers prepared by other teams. Each team could choose a topic from a list of suggestions or request approval of a topic of their own invention. The papers selected for this supplement were ones deemed particularly relevant by the two people giving the course, Professor George Tolley, an economist, and myself. Both of us have worked for many years in various aspects of energy, and a good fraction of that work was done together. It might be relevant here, to give a sense of the environment in which the papers were written, to point out that Professor Tolley and I agreed on some things and openly disagreed and argued in class about some other things. So these papers were written in a context in which questioning, challenging and testing ideas was pervasive. And the course continues! --- Competing interests The author has no competing interests in this material.

Open access provides opportunities to our colleagues in other parts of the globe, by allowing anyone to view the content free of charge.

Background It is difficult to understand how a relatively educated population like the German people followed the hateful and perverse social ideas of the Nazi government, or how the Soviet people supported Stalin's anti-science delusion of Lysenkoism, or how the American population agreed to eugenic sterilization (Allen et al. 2001). All these should have remained in the dark past, and we should have learned from these mistakes that generated only suffering-but the COVID-19 pandemic shows us that these demons are not exorcised. --- Main text It seems unbelievable, but today's Brazil gives an example of how far radicalism and ignorance can go and how threatening are those who preach and follow scientific denialism, which has found an ideal means of propagation, through social media (McKee and Diethelm 2010). The arrival of a vaccine should have been widely celebrated, especially in a country that has the second largest number of cases of COVID-19. But instead, the first shipment of vaccines to Brazil had to be hidden, not to be within reach of the threat of Brazilian groups that are against vaccination, partly because of fears of its foreign (Chinese) source, and favor supposed alternative remedies of unproven efficacy. How could this happen? The Brazilian government is complicit. Brazil's president Jair Bolsonaro recently questioned the need for a rush for a vaccine against COVID-19 (Bello 2020). Lost in daydream, he also stated categorically that he will not take any vaccine, for he mistakenly claims not to need it on the grounds that he would already have been infected by now. Such an attitude could be just a subject for jokes: The government is notorious for its ignorance about many subjects. But its horde of followers is large and noisy, impeding the dissemination of a vaccine that can avert thousands of deaths. And the government's dismissive attitude toward the COVID-19 vaccine bolsters anti-vaccine movements in general, at a time when vaccination rates for various diseases (such as measles and polio) are decreasing and vaccine rejection rates are increasing around the world (Silva 2020). Brazil is conspicuous for the virulence of its government-led COVID-19 denialism. But anyone who supposes that this phenomenon is restricted to developing countries would do well to reflect on the death threats received by the American immunologist Anthony Fauci over his role in combating the pandemic there (Ioannidis 2020). --- Conclusions Scientific denialism is serious and pervasive, and it shows no signs of abatement. Information through the press and the field of education seem to have no effect, becoming instantly discredited by propaganda and populist leaders. The world needs to react to this kind of disturbance, seeking effective ways of confrontation-and the academic field needs to be more active in this difficult battle. --- Authors' contributions Heslley Machado Silva participated in all stages of the text's elaboration and approved the final manuscript. --- Funding There is no funding. --- Availability of data and materials No. --- Declarations --- Ethics approval and consent to participate There is no need. --- Consent for publication Not applicable. --- Competing interests No competing interest. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Scientific denialism has always had harmful consequences for humanity, but with the advent of the pandemic these effects seem to have been accentuated.Unwillingness to accept the facts about the COVID-19 pandemic ascertained by scientists and public health authorities has led to widespread scientific denialism, including the emergence of conspiracy theories of all sorts. Examples are diverse, reaching both developed and developing countries, arriving through populist leaders and the spread of conspiracy theories through social media.It is important to pay attention to the risk of the extremes of this denialism and the possible repercussions, especially in countries that have leaders who agree with these conceptions, such as Brazil and the USA.

Introduction/Background: An ongoing realist evaluation of the implementation of the program [Amsterdam Customization method] in social welfare in Amsterdam (NL), focussing on multiproblem families, revealed among others, that participating organisations within the program tend to focus on their own tasks, without shared decision making. This becomes extremely clear in the context of safety for the children: parents are not seen as partners to guarantee this safety but as causer of the problem. And this view from the perspective of one organisation seems to diminish all efforts to offer the parents help in finding ways to create a safe environment for their children. Instead parents are more or less threatened by the risk that the children will be taken away from them. The mechanism is a lack of interdisciplinary adjustment of observations and a lack of shared decision making, the outcome for the parents is fear and withdrawal from involved professionals. This is in contrast with the principles of the implemented program. --- Why a workshop? A 90 minutes workshop is a good way to share experiences with the delegates and find ways to handle a well-known problem within the implementation of integrated care programs. Who is it for? Participants from the area of social work as well as participants in implemented integrated care programs as such are a welcome audience to share ideas and experiences. --- What we are going to do? •A 15 minute ointroduction on the context of the implemented program and the findings of one part of the research: client interviews [first researcher] oFocus on one finding: the missing collaboration between all stakeholders in the context of safety for the children in multi-problem families [first researcher] •Depending on the number of participants: 60 minutes discussion in one or more groups around two questions (1. do you recognise the situation [examples]; 2. What did you do / are you planning to do/ could be done to stimulate shared decision making that involves all stakeholders) •15 minutes report and (an attempt to) conclusions •10 minutes wrap up and eventually exchange of contact addresses

Van Eck: The lived experiences of complex care of families with complex problems: A realist evaluation of Integrated Social Care How are you going to engage with the audience? Fitting to the concept of a workshop the meeting will be interactive, participants in the subgroups are asked to appoint a speaker to present the core of the group discussion, results of the plenary will be written down and per email shared with interested participants. How are you going to summarize the take home messages? We end up with lessons learned and sum these up in take home messages. Attendees are invited to write these down and take these with them.

Introduction Globally, the pandemic of HIV/AIDS has continued to pose serious health and socio-economic challenges. 1 By the end of 2010, about 33.3 million persons were estimated to be infected with HIV globally. Of these, 22.5 million were in sub-Saharan Africa, and about 2.98 million in Nigeria. 2,3 Thus, Nigeria has the second highest number of people living with HIV/AIDS (PLWHA) in Africa after South Africa. 1,2 The World Health Organization characterized the family as the primary social agent in the promotion of health and well being 4. The family is the natural and fundamental unit of society. Most people are born into a family, live much of their lives within a family, and consider it to be a high priority in their value system. A healthy lifestyle is usually developed, maintained, or changed within the family context. 5,6 Multi-drug resistance usually arises from suboptimal HIV treatment adherence. 7,8 Hence PLWHA on highly active antiretroviral therapy (HAART) should have at least 95% adherence rate to prevent drug resistance. 8,9 HIV/AIDS is a highly stigmatizing disease with PLWHA experiencing rejection even by their families; however with availability of treatment, HIV/AIDS is now a chronic manageable illness in our society. [10][11][12] A study on medication adherence to antiretroviral therapy among PLWHA in Nepal reported that people living in extended families were more likely to be non-adherent to therapy compared to people in nuclear families. 13 Also, money and the need to attend social functions such as marriage, funerals or festivals had been reported by patients for missing an appointment partially or completely. Therefore financial and socio-cultural barriers emerged as themes for missing hospital appointment. Also, patients had shared that they did not want to take their tablets in front of anyone including family members because of fear of stigmatization, indicating that socio-cultural barriers affected ART adherence 13,14 . Hitherto, there have been very few studies on family influence on adherence to antiretroviral drugs at the study site since inception of the antiretroviral programme. Hence the need for this study which determined the influence of family dynamics on adherence to antiretroviral therapy among adult PLWHA in Osogbo, Nigeria. --- Methods --- Study site --- Sample size calculation The required sample size of 327 was calculated using a formula for estimating the minimum sample size in descriptive health studies [n=Z 2 pq/d 2 ] 13 and finding from a previous study 14 where 54% were reported. The minimum sample size was increased by 10% to take care of incomplete/non response and refusals. --- Sampling method Participants were serially recruited into the study over a 6 month period. Inclusion criteria were consenting PLWHA on antiretroviral therapy for at least three months while very ill PLWHA and those who were unable to provide information were excluded. --- Data collection and analysis Data were collected using a pre-tested, semistructured, interviewer-administered questionnaire that has socio-demographic data, family characteristics, perception of family support using Perceived Social Support Family Scale and perception of family functioning using Family APGAR Scales. The Perceived Social Support-Family Scale (PSS-Fa) PSS-Fa is a 20-item validated measure of family support. Subject answered "yes", "no" or "don't know" to questions on their feelings and experiences with their family. Each response that leads to family support was scored 1 while response indicating lack of family support was scored 0. Summated scores were used to arrive at a family support score for each subject, with a possible score range of 0 to 20 points. Higher scores indicated higher level of perceived family support with scores equal to or greater than 11 taken as strong family support, scores 7 to 10 taken as weak family support while scores equal or less than 6 taken as no family support). The Perceived Social Support -Family Scale has been found to have good reliability and validity. The original Perceived Social Support Scale has an alpha coefficient of 0.90 indicating that the scale has excellent internal consistency. The alpha for the PSS-Fa ranged from 0.88 to 0.91. 15 Family APGAR is acronyms for adaptability, partnership, growth, affection and resolve. It is a 5 item validated measure of family functioning with subject answered "hardly ever", "sometimes" or "almost always" based on their frequency of feeling satisfied. "Hardly ever" received a score of 0, "sometimes" a score of 1 and "almost always" a score of 2. The total score range from 0 to 10 with higher scores indicated higher degree of satisfaction with family functioning. Score of less than 6 was taken as family dysfunction while 6 to 10 was normal family function. The Family APGAR has good reliability and validity. The Cronbach's alpha values reported across studies using Family APGAR have ranged from .80 to .85, and item-to-total correlations ranged from .50 to .65 16,17 . The survey instrument was available in English but translated to Yoruba to accommodate for non English speaking respondents and was completed either before or after the physicians visit, in a separate consulting room, on individual basis, in respect of patients' privacy. Measure of adherence used was self report and pharmacy pill counting. Information obtained included duration of commencement of antiretroviral drugs, attendance at follow up clinic, numbers of drugs being taken, drug régime, cost and source of drugs. The level of adherence of the PLWHA to antiretroviral was calculated from the formula: % adherence over 7 days = (No of pills taken -No of pills missed) x 100 No of pills taken A score of 95% and above represented good adherence and less than 95% was rated poor adherence. 7,8 Quantitative data were analyzed using SPSS for Windows software version 14. Descriptive and chisquare statistical tests were employed. A probability value less than 0.05 was accepted as being statistically significant. --- Ethical Clearance Ethical clearance was obtained from the Research and Ethics Committee of Ladoke Akintola University Teaching hospital, Osogbo. Informed written consent was obtained from each participant before the interview. --- Results A total of 379 PLWHA were interviewed. Their mean age was 40.8 years (SD=9.9, range 20-70). There were 149 (39.3%) males and 230 (60.7%) females. Majority were married (55.7%) while 22.1% were divorced. Most completed secondary education (72.1%) and were Yoruba (86.3%). Most respondents (95.5%) were adherent to HAART. Table 1 showed the relationship between sociodemographic characteristics and HAART adherence of respondents. There was no significant relationship between sociodemographic characteristics and adherence to HAART (p>0.05). Mean score for the family APGAR was 7.82(SD=2.31) while for the PSS-Fa was 10.37(SD=2.42). Most respondents were cared for by their spouse (53.3%) and parents (29.6%) (figure 1). About 93% were satisfied with care received from their family while 82.3% were treated like other family members (table 2). Majority (99%) of adherent PLWHA had normal family APGAR score compared with 1% non adherent PLWHA (p=0.023) while 97% of adherent PLWHA had strong perceived social support compared with 3% non-adherent PLWHA (p=0.001) (table 3). This present study showed that family support contributed to the respondent's high drug adherence. This emphasized the importance of involving the family in the care of these patients. Family caregivers are major stakeholders in patient management especially in chronic diseases such as HIV/AIDS and when carried along by the patients and health care workers will enhance patient adherence to drug therapy as reported in this study. Several studies had shown the importance of the family in providing support for patient's care. [20][21][22] The good adherence rate may also be explained by the following factors. Firstly, the clients on antiretroviral therapy at Lautech Teaching Hospital, Osogbo in partnership with Institute of Human Virology, Nigeria access their drugs and laboratory investigations free. Another factor that might have contributed to the relatively high adherence rate among respondents is the nature and quality of support received from the care institution. On-going adherence and psycho-social counseling services were offered to PLWHA on antiretroviral therapy. This study showed that the relatively high adherence rate could be attributed to high moral and psychological support received from family care givers. Infact, most patients were satisfied with care received from their family members. However, some patients reported lack of care and neglect from their family caregivers. This they cited was responsible for their poor drug adherence which resulted from stigma and discrimination they suffered from their family caregivers. Globally, stigma and discrimination are major obstacles leading to reduced treatmentseeking behavior and effective HIV/AIDS prevention and care, especially in sub-Saharan Africa. 9,[23][24][25][26] Studies showed that patients often missed their doses as a result of fear of being identified as HIV-positive and being on antiretroviral medications for the rest of their lives. 24,25 As a result, strategies to address the problem of stigma should be important and necessary components of all adherence 22,26 This further emphasized the need to educate family caregivers about mode of transmission of HIV/AIDS and how to care for their relatives who live with HIV/AIDS instead of stigmatizing and neglecting them. 23,24 PLWHA need love and care from their family members, not stigma and neglect. 26 This paper highlights the importance of family caregivers in improving their HIV positive relative's adherence to antiretroviral therapy while providing necessary HIV/AIDS care to them. The family caregiver while serving as a nonpaid treatment partner could motivate these PLWHA to live positively and enhance their adherence rates. A well informed family caregiver on HIV/AIDS care will not stigmatize or discriminate against their HIV positive relatives. Therefore, findings in this study could be used by policy makers to encourage PLWHA to have treatment partners who could be targeted for HIV care and support training including drug adherence training which will improve their quality of life and adherence rates. Major limitations of this study included that being a cross-sectional study it is difficult to establish cause-effect relationship while self report as a measurement of adherence relied on patient remembering having taken the drug though pharmacy pickup was equally used to cross-check. Despite assurances on purpose of the study, some respondents may have given socially accepted answers to some sensitive questions. --- Conclusion PLWHA with good social support were adherent to HAART. There is need to educate and train family caregivers on stigma reduction and how to care and support their HIV positive relatives. Competing interest: None declared

Background: Adherence to highly active antiretroviral therapy (HAART) has been proven to be the only effective treatment for HIV/AIDS worldwide. Good adherence to HAART might require good family support. Objective: To determine the family dynamics and social support of people living with HIV/AIDS (PLWHA) and its roles on HAART adherence at an ARV treatment clinic in Osogbo, Nigeria Method: Descriptive cross-sectional study. Consenting PLWHA on HAART were interviewed using pre-tested semistructured questionnaire incorporating Perceived Social Support-Family Scale and Family APGAR. HAART adherence was measured using patient self report. Results: A total of 379 PLWHA were interviewed. Their mean age was 40.8 (SD=9.9) years. Most (60.7%) were females. More than half (55.7%) were currently married and the majority (72.1%) had secondary education and were Yoruba (86.3%). Most respondents (95.5%) were adherent to HAART. Over 90% were satisfied with support received from their family while 82.3% were treated like other family members. Most attributed their HAART adherence to the care and support received from their family. Conclusion: Most PLWHA had good social support and were adherent to HAART.

Introduction: Increased life expectancy has resulted in population aging and subsequently entails addressing the needs of older adults. Shifting family structures from multigenerational to nuclear have had a significant effect on the older adults' livelihood and their ways of interaction with community members. This research aims to comprehend the relationship between neighborhood context and older adults' quality of life (QoL) in Nepal. Methods: A total of 847 non-institutionalized older adults (≥60 years) from eastern Nepal were interviewed in 2021. The QoL was measured by13-item version of the Older People's Quality of Life questionnaire (OPQOL-brief), and each item was measured on a 5-point Likert scale. The OPQoL mean score < 3 was recoded as low, and ≥3 was high QoL. Ethnic diversity, monthly income, connection with family, friends, and neighbors, cultural connection, residential instability, and accessibility were measured to see the effect of neighborhood context. Perceptions of successful aging may be impacted by unique lived experiences such as migration, adaptation, and traumatic life experiences. While there exist studies on successful aging among immigrant communities, research studies on successful aging among older refugees, who flee due to life threatening situations, are sparse. The present qualitative study aimed to shed light on the match or mismatch that may exist between older refugees' perceptions of successful aging and their perceptions of their lived experiences, as well as sex variations in those perceptions. Twenty-one Burundian refugees, aged 50+, were recruited from an upper Midwest community to participate in in-depth interviews. The qualitative interviews were analyzed using thematic content analysis. Themes denoting a match in aging refugees' perceptions of success aging and lived experience included: wisdom/ability to give advice (i.e., guidance especially to younger individuals), experiencing peace and security, and fostering family relationships. A mismatch was highlighted in themes related to work experiences (i.e., the challenge of engaging in jobs not related to their prior skills), lack of social connections, and communication difficulties. Gender differences were apparent in that women emphasized shifts in work-related gender roles while men emphasized shifts in dependency-related gender roles. In many ways, aging refugees' unique backgrounds and experiences seemed influential for their match/mismatch in successful aging perceptions and experiences. These findings highlight the importance for host communities to better understanding how refugees perceive and experience successful aging to best inform the implementation of effective interventions for aging refugees. --- SESSION 3385 (SYMPOSIUM) Abstract citation ID: igad104.1162 --- ESPO AND ACADEMY FOR GERONTOLOGY IN HIGHER EDUCATION SECTION SYMPOSIUM: UTILIZING TECHNOLOGY IN THE ADVANCEMENT OF OLDER ADULT EDUCATION Chair: Yan-Jhu Su Co-Chair: Janelle Fassi Discussant: Christine Fruhauf TThis symposium intends to echo one of the core values of the GSA 2023 Annual Scientific Meeting -empowering all ages. Online lifelong learning has become more common in the 21st century. The speed of technological development far exceeds people's imagination. The speed at which technology develops is shown to create a widening gap between older and younger populations, known as the digital divide. Introducing technologies into intergenerational learning environments remains an important step to bridging the generational digital divide. In accordance with the AGHE gerontological education competencies, these authors will describe how older adults utilize technology. The first speaker will discuss the effectiveness of a virtual intergenerational program that addressed experiences of ageism for older and younger participants. The second speaker will introduce user-centered design principles and innovative tools that facilitate virtual Information Communications Technology (ICT) support and training for older people with limited abilities in using technology. The third speaker will illustrate concrete practice through international cases from different intergenerational technology integration projects. The fourth speaker will present key elements from the University of Rhode Island (URI) Engaging Generations Cyber-Seniors Program internship and describe student experiences enrolled in the program. The last speaker will discuss the benefits and challenges of technology use among older learners and state the experience of leading older learners using technology in Taiwan. This is a Geriatric Education Interest Group Sponsored Symposium. Abstract citation ID: igad104.1163 --- LIFELONG LEARNING FOR THE OLDER POPULATION-TECHNOLOGY WITH THE OLDER LEARNERS Yan-Jhu Su, and Andrew Alberth, University of Massachusetts Boston, Boston, Massachusetts, United States Advances in digital information technology and population aging are two hallmarks of the 21st century. Modern students are increasingly dependent on digital technology in their education. However, how to make digital technology less exclusive to young students remains an important issue. The COVID-19 pandemic has also popularized remote learning and the use of communication software among all ages. Teaching remotely has broadened access to education for all ages. Therefore, how to use technology to help older people achieve the goal of lifelong learning remains critical. This presentation will review the literature to explore the relationship between technology and older adults, as well as share the author's experience leading older adults to use technology for online learning in Taiwan. The key takeaways from this presentation will help educators understand the benefits and challenges of technology use among older adults, and highlight ways to bridge the digital divide between older and younger learners in the classroom. Abstract citation ID: igad104.1164 --- THE EFFECTIVENESS OF A VIRTUAL INTERGENERATIONAL ACTIVITY FOR REDUCING YOUNGER AND OLDER ADULTS' AGEISM Janelle Fassi, University of Massachusetts Boston, Boston, Massachusetts, United States This presentation will discuss results from a study that examined whether a virtual intergenerational activity was feasible and effective for reducing ageism among older

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

Institutes of Health (NIH) funded study designed to improve the understandability of labels for pediatric liquid medications. As part of the study, the mother received a medication label with the instructions "Take 2.5mL (½tsp)." She carefully measured out 2.5 teaspoons of the study medication into a cup -5 times the indicated dose. At the end of the study, the mother reported that she found the medication label confusing and very unlike medication labels she had received in her native Mexico, from which she had emigrated 8 years prior. In her experience, the mother explained, Mexican medication labels and doses are not "individualized," as they are in the United States (US), to the child's age, weight and provider's indications. Over the past decade, the Latino population in the US has increased by more than 40%, and in many states, the proportion of the total child population born to Latino parents has surpassed or will soon surpass half of the population. 1,2 This demographic shift comes alongside two public-policy decisions that broaden healthcare access for Latino families: the Affordable Care Act (ACA), which has disproportionately increased Medicaid coverage for Latino families, and new immigration regulations, which provide greater public-services access for Latino immigrant families with children. 3 While there have been improvements in ensuring pharmacists are prepared to communicate with Spanish speaking families through the inclusion of Spanish language education in pharmacy programs, the limited availability of partially or fully bilingual pharmacists or interpreter access continues to be minimal across pharmacies studied. 4,5 To meet the health needs of this growing immigrant population with increased access to healthcare services, it is critical to ensure that we design systems of care that are sensitive to the cultural norms and experiences of families who have recently arrived from other countries. 6,7 In Latin American nations and other nations of origin for immigrants to the US, the pharmacist often has a much larger role in healthcare decisions than in the United States. Due to limited access to clinicians, customers often rely on pharmacists and pharmacy clerks to provide advice and recommendations regarding medications for their ailments. 8,9 If an individual is able to seek a prescription from a doctor, the doctor will give either verbal or written instructions, and when the prescription is filled, individuals are given the medicine in the original manufacturer's container without any personalized labeling or instructions. These generic instructions on a medication label may or may not coincide with the instructions the doctor provided in the exam room. Furthermore, simply translating text on a medication label may introduce hazards. Prior pharmacy-based efforts to to translate medication labeling from English to Spanish have been found to be inconsistent and, in some cases, potentially unsafe. 10 Taken together, these cross-national differences in prescribing, labeling, and delivery of medications may explain some of the ethnic disparities in medication use and misuse, particularly for medications that require additional patient effort to dose or administer, such as pediatric liquid medication. In Latin America, pharmacists often function as de-facto primary-care providers. Selfprescription and self-diagnosis are standard practices, substituting the pharmacist for a health care provider. 7,9 Once arriving in the US, they may even refer to employees, from specialty markets selling Latin American products, for health and medication advice. 7 Recent Latin American immigrants arrive in the United States with pre-set ideas about prescription medications and complementary alternative medicines from their home country. 7,11 As a result, in many Hispanic communities in the US, some pharmacists continue to function in that capacity. In Hispanic communities in the US where pharmacists do not act as primary-care providers, families may suffer from confusion about medications, including indications and dosing. 7,12 Due to limited Spanish speaking pharmacists, and translation services many new Latin American immigrants may face barriers to building similar relationships with their pharmacists. 13 Research has shown that the language barrier is only one component in prescription labeling understanding. Having bilingual and also bicultural pharmacists may lead to improved understanding and concordance with medication. 14 In a study done among 6 Latin American countries the results were that nearly two-thirds of prescription-only medications were obtained without a doctor's prescription, and nearly a third of these medications were dispensed for children. 12,15 Once in the US, limited English proficiency and unfamiliarity with US medication practices may lead to self-prescription, medication misuse and overuse. 7 Additionally, low acculturation and out-group perceptions are likely to contribute to low adherence. 11 This confusion may result in additional risks for medication misuse and safety issues, particularly among the most vulnerable populations: children and those with chronic illness. To date, research and regulatory requirements for medication safety in the US have attended insufficiently to the patient-safety risk inherent in providing complex, English-language labels to non-English-speaking families, many of whom have limited literacy in their native language. Some states have passed legislation enacting the universal medication schedule, but enforcement is challenging without sufficient resources. 16 As families move, this patient-safety risk is increased by shifts in pharmacies, which often have different medication-labeling standards. 13 It is important to examine how recent immigrant parents are addressing the medication needs for their children based on their cultural norms and how those cultural practices and acculturation into the US health care system may impact their risk for injury. New research and policy efforts may help address these barriers to safe medication use, among them: --- 1. Further research to understand how immigrant families access, use and misuse medications through pharmacies in their newly adopted communities in the US. --- 2. Systems-level action, including root-cause analyses of actual medication safety problems, that include specific attention to the role of language, acculturation and health literacy. 6 --- 3. Policy action to help guide introduction and use of non-English-language labels 17 for prescription and non-prescription medication. 18 --- Key Points --- Background • The Latino population has increased by 40% in the United States over the past 10 years --- • Immigrant children, especially Latino immigrant, face increased health disparities, including the inappropriate use of over-the-counter (OTC) and prescription (Rx) medication. --- • These child-health disparities may be exacerbated by the medication-related beliefs and behaviors of their parents, which are informed by different policies and prescribing practices in their home country. --- Findings • Current policies that require multi-language prescription labels are not implemented uniformly and accurately. --- • Addressing health disparities may require adjustments to existing medication prescribing and delivery systems that account for parent language and acculturation.

Objective-To identify the patient-safety hazards of current medication labeling standards for immigrant and language-minority families. Summary-The Latino population in the United States (US) has increased by more than 40% over the last decade and the total child population born to Latino parents will surpass half the population in many states. This demographic shift has a disproportional effect on the Latino families with recent health care and immigration policies. Research shows that recent Latin American immigrants face disparities when encountering the US pharmacy system. A review of these disparities shows how new policies should be informed when considering new pharmacy regulations in order to better address the cultural needs of recent Latin American families to improve medication understanding and adherence.States have attended insufficiently to the patient-safety risk inherent in providing complex, English-language labels to non-English-speaking families, many of whom have limited literacy in their native language. As families move, this patient-safety risk is increased by shifts in pharmacies, which often have different medication-labeling standards. It is important to examine how recent immigrant parents are addressing the medication needs for their children based on their cultural norms and how those cultural practices and acculturation into the US health care system may impact their risk for injury. New research and policy efforts may help address these barriers to safe medication use.

survey was conducted among 453 older adults belonging to REPRINTS, a volunteer picture book reading organization from October 2021 to January 2022. 404 respondents were obtained, and 277 respondents (mean age: 73.4, SD: 6.1, female: 91.2%) with no missing responses were included in the analysis. Analysis items were Revised Japanese Version of Generativity Scale (JGS-R) composed of 3 factors (generational interest, behavior and achievement), satisfaction and burden of activities, frequency of activities in the last month, Child Image Scale for Older Adults composed of 5 factors (protection, purity, self-centeredness, creativity and self-reliance), a shortened version of the Help Seeking Scale, physical and mental health (subjective health, TMIG-13, J-WHO-5), living conditions, gender, and age. Multiple regression analysis was used with each subscale score in JGS-R as the dependent variable and others as independent variables. The results showed there was a significant association between generational interest and image of creativity, desire for help, mental health, and social roles; between generational behavior and image of purity (-), creativity image, desire for help, resistance to help (-), and social roles; between generational achievement and desire for help, social roles, and gender (male), respectively. In conclusion, physical and mental health, image of the child, and desire for help were associated with older volunteers' generativity even during the COVID-19 pandemic even during the COVID-19 Pandemic. The large number of deaths due to COVID-19 has resulted in a similarly high number of people experiencing grief. Attending to the needs of grieving individuals will be a critical public health issue for years to come. Moreover, the circumstances surrounding many COVID-19 deaths may contribute to more severe and protracted grief. The aim of this qualitative study was to learn about the social and psychological experiences of pandemic-related grief. Semi-structured interviews were conducted with individuals who had lost someone close to them to COVID-19 (N = 25). Interview questions addressed circumstances surrounding the death, rituals and memorializations undertaken, and subsequent emotional consequences. Thematic analysis was used to identify themes and patterns. Participants described their grief as being highly personal and unique and only understood by others who had experienced a similar loss from COVID-19. They expressed significant distress at the circumstances surrounding the death, with many not having an opportunity to say goodbye. Their distress was amplified by a lack of closure due to limited rituals allowed during the pandemic. Participants also reported feeling invisible in their experience of loss and grief as they reflected on the overwhelmed healthcare systems during the height of the pandemic, comparison to the type of experience they would have had were it not for the pandemic, as well as feeling the world had moved on once pandemic restrictions were lifted. Taken together, these findings suggest unique grief experiences with COVID-19 and the need for targeted interventions from mental health practitioners. Abstract citation ID: igad104.2666 --- HEALTH-RELATED QUALITY OF LIFE IN OLDER ADULTS AFTER A FLOOD Piper Bordes 1 , Katie Cherry 1 , Matthew Calamia 1 , Emily Elliott 1 , Laura Sampson 2 , and Sandro Galea 3 , 1. Louisiana State University, Baton Rouge, Louisiana, United States, 2. Harvard University, Boston, Massachusetts, United States, 3. Boston University, Boston, Massachusetts, United States Exposure to multiple back-to-back disasters may threaten physical and mental health for people who live in geographic areas that are prone to severe weather events. In 2005, coastal residents from south Louisiana lost homes in Hurricane Katrina and many moved inland to presumably higher and safer ground. In August of 2016, historic flooding brought widespread destruction, creating a second round of catastrophic losses for those who had permanently relocated to Baton Rouge, Louisiana after Katrina. The present research is part of a larger longitudinal study on health and well-being after multiple disaster exposures. In this study, we examined associations among current and prior flood experience and health-related quality indexed by the SF-36 Health Survey (Ware & Sherbourne, 1992). Three flood exposure groups were compared across two waves of testing: non-flooded (controls), single disaster (flooded in 2016) and double disaster (flooded in 2005 and again in 2016). Results indicated that the flood exposure groups did not differ in physical health, although mental health was poorer for those whose homes flooded relative to the non-flooded controls at both waves of testing. Correlation analyses revealed that age was negatively associated with intolerance of uncertainty and physical health, but positively correlated with mental health at both waves of testing, consistent with the inoculation view of post-disaster psychological reactions. Implications of these data for understanding health-related quality of life after multiple disaster exposures are discussed. Abstract citation ID: igad104.2667 In 2005, Hurricane Katrina devastated the U.S. Gulf Coast with catastrophic damage and substantial loss of life. In this study, we examined associations among psychosocial variables and mental health indicators in younger and older adults who lived in south Louisiana in August of 2005 when Katrina made landfall (M age = 51.7 years, SD = 13.03 years, age range: 32 to 78 years). All self-identified as African American / Black women. They were recruited through social media, flyers sent to churches and schools, and word of mouth referrals. On the first day of testing, participants completed sociodemographic, religiosity, and post-traumatic growth surveys and an adapted structured storm questionnaire (Cherry et al., 2011). On the second day of testing one week later, participants responded to open-ended questions on their Katrina experience, and they completed measures of post-traumatic stress disorder (PTSD) and depression. Correlation analyses revealed that age was inversely related to PTSD symptoms, which is compatible with an inoculation perspective on post-disaster psychological reactions. In addition, post-traumatic growth was positively correlated with religious beliefs and practices and religious coping, and negatively correlated with symptoms of PTSD and depression. Religious beliefs and practices were inversely correlated with PTSD symptoms and depression. Qualitative analyses of participants' narrative responses indicated that some reflected on scripture and utilized prayer as a way to navigate their new lives in the years after Katrina. Implications of these data for understanding individual and community-level challenges in the years after exposure to devastating severe weather events are considered. Covid-19 hit Adult Day Services (ADS) hard with sites across the country forced to close. As part of the ADS-Plus study, two focus groups were conducted to understand the impact of Covid-19 on ADS sites, their participants, and staff. Six sites across the country, represented by nine staff and administration (females=n, males=1) participated in focus groups. Focus groups were recorded, transcribed verbatim, and coded by the authors. Four themes emerged, (1) Ways to stay in touch with families; (2) Issues reopening; (3) Family concerns; and (4) Future of the ADS Industry. Sites stayed in touch with families through a variety of measures, including virtual daycare or activities via zoom, house calls, and help obtaining food. Upon reopening, there were multiple issues with getting the census back for both participants and staff. Families were reluctant to return due to fear of Covid-19, placing their family member in LTC due to decline in functioning or due to work, and using more home services. Staff were reluctant to return due to fear of Covid-19 and salary, some reporting they made more on unemployment. There was a decline in both physical and cognitive health of ADS participants, attributed to the lack of socialization. In looking towards the future, focus group participants felt that the old approach of doing ADS is not sustainable and that the industry needs to expand to include more home options. Also, funding of ADS needs to be addressed as many facilities are not able to keep up with increasing salaries. --- HURRICANE KATRINA'S LASTING IMPACT ON YOUNGER AND OLDER ADULTS: THE ROLE OF RELIGIOSITY AND POSTTRAUMATIC GROWTH

secondary control predicted corresponding shifts in mental health and well-being outcomes (bs = |.10-.25|, p < .005) except life satisfaction (b = .10, p = .061). In other words, participants reported increased mental health and well-being on occasions during the pandemic when they experienced increased secondary control. Findings advance the literature by documenting that secondary control exhibits dynamic shifts during a major life stressor. Additionally, these findings point to the adaptive role of such shifts (within-person increases) in supporting well-being during the pandemic.

Conclusions: This retrospective study highlights important trends that warrant further research. It identifies health inequalities in OG cancer, particularly in terms of age at diagnosis, incidence rates in deprived areas, and gender disparities. The study underscores the urgency for targeted interventions, public awareness campaigns, and resource allocation to address these disparities, alleviate the burden of advanced-stage OG cancer, and improve access to early diagnosis and effective treatment in an equitable manner. The findings contribute to the growing body of evidence on health inequality in cancer, however further research is required.

Background: This abstract presents the findings of a study investigating health inequality in oesophago-gastric (OG) cancer throughout Greater Manchester (GM). The study aimed to assess the impact of socio-economic deprivation on cancer incidence, clinical stage at diagnosis and treatment intent. Methods: The study reviewed MDT minutes from 2022 for patients newly diagnosed with oesophageal or gastric cancer. Treatment intent at diagnosis, patient age, and deprivation scores based on national data were examined. Patients were categorised into quintile (Groups 1 to 5) based on their Index of Multiple Deprivation (IMD) score from their postcode. Results: 674 patients were included from a population of 3.5 million. Stages 1-2 accounted for only 21% of cases and stage 4 accounted for 57% of cases. 31.6% of all cases occurred in the MD (p=.565). Among all cancers, 9% more patients who had palliative disease resided in the MD (12% vs 21%, p=.565). There were 7.2% more stage 4 cancer in the MD (10.2% vs 17.4%, p=.865). Men were proportionally more represented in stage 4 disease compared to stage 1 (65.5% vs. 72.7%, p=.155). Patients in the MD had earlier onset of disease (median 70 years vs. 75 years, p=.

Introduction Coronavirus 2 (SARS-COV-2) is responsible for acute respiratory syndrome; in March 2020, the World Health Organization (WHO) declared it a pandemic [1]. To avoid the diffusion of the virus and an increase in cases in Italy, the Government has approved the Decree-Law "I stay at home" [2]; it declared every type of public gathering is forbidden and thus closed many public and workplaces. Going out is allowed only for reasons of necessity. Consequently, digital platforms have offered a strategic opportunity for communicating with the outside world. Even before the lockdown, social media had been fundamental in our everyday lives (for example, Facebook, Instagram, Twitter, and YouTube) [3,4]. They are sources of information but also sharing tools [5] that have grown in importance due to the rarefaction of social interactions following the emergency. This is true also for the people affected by eating disorders (ED) who could have experienced a worsening of symptoms related to living alone. On the contrary, they could become very close to their families or, again, develop a change in their food habits [6,7]. Anorexia, bulimia, and binge eating are the three principal disorders, all connected to each other; the subject can migrate from one disorder to another [8]. The web can be also used as a tool for sharing different experiences in regards to different types of ED. Social networks can, in fact, amplify Body shaming [9]. More generally, during the lockdown, social networks have represented a tool through which people could shield themselves from a weight gain induced by their excessive sedentary lifestyle [6]. The aim of this study is that of evidencing the increase, during the lockdown, in the use of the Internet, in the time spent on social networks, and in the Google searches regarding ED in Italy during the Covid-19 pandemic. Our aim is also to verify its possible impact on these disorders, using as an indicator the increase of new patients treated by Public services for ED. In addition to the increased sedentary lifestyle, the contents of much of the online communication may have had a negative impact on the people who are most fragile and sensitive to this issue. Together with the general data on Internet users, the data on Google searches related to food disorders in the same period have served to understand the trend of online searches on such issues. Finally, the data relating to patients with ED analyzed in a study of the National Center for Disease Prevention and Control (CCM) of the Italian Ministry of Health, concerning new patients treated by Public services for ED, confirm a relevant increase of them during the first months of lockdown [10]. --- Methods This research used data from Wearesocial (results of GlobalWebIndex international surveys in different years among 1,010 Italian Internet users aged 16-64) on the increase in the number of Internets and social media users over the last years and particularly in the first 6 months of 2020 [5]. It added other data from a survey from the same source (GlobalWebIndex survey among samples of about 1,000 responses per country of Internet users aged 16-64 years), concerning the time spent on social networks by the Internet users of the principal European countries in the first months of 2020 due to the Covid-19 emergency. Moreover, it considered the frequency of some keywords related to food disorders in the Google searches in Italy between 4 August, 2019, and 26 July, 2020. Finally, we have analyzed the data of the CCM national study, by the Italian Ministry of Health, "Platform for fighting malnutrition in all its forms (triple burden: malnutrition by defect, by excess and by micro-nutrients)." The first part of the project concerning patients of public services for ED was coordinated by the Umbria region (scientific coordinator of the project Dr. Dalla Ragione) [10]. The observational study concerning patients obtained the approval of the ethics committee of Umbria Region (protocol CER (Comitato Etico Regionale) Umbria N.20032/20/ ON of 19/11/2020). More specifically, among the objectives of the project, there was the realization of a national "survey" which collected activity data of all the services/ districts/SIAN (food and nutrition hygiene services)/hospitals of the national territory dealing with malnutrition, as well as SDO (hospital discharge form) data relating to hospital admissions of such patients. The data were collected in an ad hoc platform and those reported are some first results, related to the first 6 months of 2020. --- Results All the analyses on web usage trends in Italy, in the last years, agree in highlighting its increase. Wearesocial data underline a 19% increase in net users between 16 and 64 years old among the total population from 01 January, 2016, to 01 January, 2020. In absolute value, we have switched from 37.63 million to 43.48 million people (82% of the total). Social media users have greatly increased from 47 to 58% (35 million). The average time of net usage per day has increased from a little more than 4 h to the current 6 h (Table 1). Furthermore, there has been an increase in Internet usage during the Covid-19 emergency [5]. The data on social network users of July 2020 have raised to 60% of the total population considered. A survey on Internet users in the first months of 2020 has shown that Italian Internet users who have affirmed to spend more time on social media due to the emergency are 43%, similar to Spain, compared to 31% in France and the UK and 19% in Greece (GlobalWebIndex survey among samples of about 1,000 responses per country of Internet users aged 16-64 years) [5]. The frequency of Google search queries on "ED" between 4 August, 2019, and 26 July, 2020, was hence assessed to verify the quantitative dimension and the variations in the interest of web users on the topic in the first months of 2020 (Figure 1). Figure 1 highlights a quite fluctuating frequency that tends to stabilize, starting from February 2020, with peaks during the first months of 2020 until the end of July. The analysis of the search frequency of the query "body shaming" on Google has a much more clear-cut trend. Starting right from February, there are strong peaks in its searches on the net. Some increase in frequency is also present in the most recent of weeks, and the data are generally slightly on the rise (Figure 2). Moreover, a general impact of the first lockdown period can be reflected in the 40.9% increase of new patients treated by public services for ED in the first 6 months of 2020 compared to the same period of 2019 (from 163.547 new patients in the first semester of 2019 to 230.458 in the first semester of 2020). --- Discussion This historical time is pervaded with anxiety, fear, and loss of control. The fear of contracting the illness can be associated with a loss of control, which people suffering from anorexia or bulimia try to compensate for by further increasing food restrictions. On the contrary, the same loss of control could trigger more frequent episodes of binge eating for those who suffer from such a disorder [6]. During the lockdown period, people being treated for ED, who may have taken months to find the courage to ask for help and embark on a path or may have waited months for hospitalization, have found themselves having to stop treatment or not being able to start it, increasing the risk of aggravation, chronicity, or relapse of the disorder [11]. Nevertheless, a significant increase in new patients has occurred, and this may be linked to the worsening of problems and/or emergencies. The tedious household routine forces adolescents to spend the great majority of their time closed in their rooms while surfing the Internet. Wearesocial data from July 2020 underline that social media users have reached 60% of the total population. Furthermore, the Italian net users declared that they keep spending more and more time on social media during this period due to the emergency (43%). Our results have also shown that the Google search frequency of the query "ED" by Italian users is increasing despite fluctuations. Moreover, the search frequency of the query "body shaming" has shown an increase starting right from February with a first peak in the same month (100 in the chart of Google trends) and the second one in May. Some increase in frequency is also present in the last weeks, and data are generally slightly on the rise. While in the first case "ED," there is a great number of searches directed to the gathering of information on this phenomenon (with some references also to local news), in the second, the search for information and the increase in communication are referred essentially to celebrity VIPs and their latest news. Adolescents have shown the tendency to use the Web not only as a leisure platform but also, more and more frequently, as an information tool [12]. Digital platforms are the fertile ground upon which to cultivate the myth of a slender and ideally perfect physique through the sharing of images, photos, and videos. This has led, directly or indirectly, to the spread of common stereotypes according to which overweight people are deemed lazy and lack self-control. At the same time, they help promote unrealistic physical appearances and extreme methods of weight control typical of nervous anorexia [13]. There are many examples of this tendency: Instagram and Facebook profiles with pictures of skinny bodies and phrases that praise resisting hunger. In this virtual reality where "thin is beautiful," younger people who do not mirror this perspective are bound to be isolated from the masses and often bullied. There is a high risk of losing self-confidence and of interiorizing the idea that it is necessary to appear always as one's perfect version. Adding up to this, virtual reality grows in importance over real life. As a consequence, physical appearance becomes the first thing to consider when relating with others [14]. In the most vulnerable subjects, adolescents, it can lead to the onset of ED. Food becomes a means for handling emotions, especially during a global pandemic, when anxiety, stress, sadness, and loneliness have become constants in their everyday life [7]. On one hand, this means that social networks can serve as a tool to avoid complete isolation; on the other hand, if not utilized correctly, they can work as risk factors in the development of dysfunctional eating habits or pathologies with dire consequences on health. It has never been as important as it is today, now that the Web has grown to be the principal instrument to feel close, despite being far, to watch over those who make the greatest use of these tools, the adolescents. In fact, the new spread habits regarding web accessibility represent one of the key aspects relating to lifestyles that can impact health conditions, up to the point of becoming risk factors. Families and schools must promote healthy and conscious use of the Internet, especially when dealing with the crucial theme of one's physical perception. --- Data availability statement: The datasets analyzed during the current study related to the CCM national study, by the Italian Ministry of Health, "Platform for fighting malnutrition in all its forms (triple burden: malnutrition by defect, by excess and by micro-nutrients)" are available in the "Unità sanitaria locale 1 dell'Umbria" repository laura.dallaragione@uslumbria1.it. All data analyzed during this study related to Internet use are included in this published article. --- Conflict of interest: The authors declare that they have no known conflict of interest or personal relationships that could have appeared to influence the work reported in this paper.

Objective -The purpose of this study is to assess the increase both in the use of the Internet and social media and in Google searches regarding eating disorders (ED) in Italy during the Covid-19 pandemic. Our aim is also to verify the possible impact of such an increase on ED, since patients treated for ED by the National Health Service (NHS) have increased in the first 6 months of 2020 as well. Method -We used data from Wearesocial surveys on Internet users in the first 6 months of 2020 and the Google searches related to the query of "food disorders" and "body shaming." The first results of a project of the Italian Ministry of Health on ED have been considered too. Results -The social media users in July 2020 increased to 60% of the Italian population; a tendential increase in Google searches on these issues has emerged. Finally, new patients of NHS with ED showed a high increase in the first 6 months of 2020 (+40.9%). Conclusion -Considering the contents diffused on the Internet, it is fundamental to watch over net usage in the adolescent population and those with ED, because massive access to social media can be considered almost as a risk factor.

Caption Denial of children's basic needs and human rights is a product of poverty, racism, sexism, and violence. Clinicians cannot properly care for patients experiencing homelessness without understanding homelessness as a risk factor for diminished life quality and decreased life span. Public discussion of homelessness often neglects its impact on children and the growing number of children experiencing homelessness in the United States. My aim in creating this comic was to represent children's faces among those who experience homelessness and to illustrate how children become homeless and experience its negative social and health consequences. Without taking into account how homelessness influences all stages of a person's life, attempts to respond with care to the needs and vulnerabilities of people experiencing homelessness will fall short. Lilly Taing is a third-year medical student at the Icahn School of Medicine at Mount Sinai in New York City and an illustrator-comics artist. She likes to draw quiet, comforting things and tries to use art to help marginalized communities have their voices heard. --- Conflict of Interest Disclosure The author(s) had no conflicts of interest to disclose. --- The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA. Copyright 2021 American Medical Association. All rights reserved. ISSN 2376-6980

Homelessness has enduring consequences for children throughout their lifespan. One role of clinicians as sources of social and cultural power in US society is to promote equitable health care for all as a right from birth to death. This graphic considers clinical and ethical dimensions of community-and health professions-based obligations to children experiencing homelessness.

Methods --- Survey Development The University of Colorado Family Medicine Residency is a large opposed academic program with university, urban-underserved, and rural tracks. In 2017, faculty and residents established a working group committed to promoting social justice. The group developed a climate survey that was first administered in 2018, drawing on similar surveys from other institutions. [12][13][14][15] Based on feedback, the survey was substantially revised in 2019, with only minor subsequent changes. Because the survey was administered for internal quality improvement purposes, the Colorado Multiple Institutional Review Board determined it did not require review. --- Questionnaire The 2019-2021 survey included 81 questions across six areas: general climate, climate for specific groups, discrimination experiences, BACKGROUND AND OBJECTIVES: Recruitment of underrepresented minorities (URM) in medicine has risen to the forefront as a strategy to address health inequities, but the experiences of URM residents within their own programs are poorly understood. We describe the development and implementation of a diversity, equity, and inclusion (DEI) climate survey at our residency program, the results of which have informed our DEI efforts. --- METHODS: A resident-faculty work group collaboratively developed an 81item questionnaire, informed by other institutional climate surveys. We administered the survey annually from 2018 through 2021 to all residents and faculty at our large academic family medicine residency program. The anonymous survey covered six key areas: general climate, climate for specific group, personal experience with discrimination and harassment, recruitment, burnout, and curriculum. RESULTS: Average response rates were 84% and 50% for residents and faculty, respectively. Survey results show low satisfaction with resident and faculty diversity; higher rates of burnout for respondents who self-identify as URM, persons of color (POC), and/or LGBTQ; and racial and gender differences in experiences of workplace discrimination and sexual harassment. --- CONCLUSIONS: Instituting an annual internal climate survey at our residency has provided invaluable information regarding the perspectives and experiences of our residents and faculty that has informed our DEI initiatives. We envision that our survey will inform continual improvement and serve as a model for similar introspection leading to meaningful action at other programs. Demographic questions included residency position, race, gender, and sexual orientation. General climate questions asked about the program's supportiveness and responsiveness. In the "climate for specific groups" section, respondents were asked if residents and faculty are "treated with the same level of respect and given the same opportunities" as others based on gender identity, race, religion, sexual orientation, disability status, and family status. The "experiences" section asked whether respondents felt "unsupported, disrespected, or discriminated against" due to gender or race, and/or if they had experienced sexual harassment. "Recruitment" assessed satisfaction with program diversity and recruitment efforts. We assessed burnout with a validated single-item question. 16 Curriculum questions are not presented here due to their specificity to our program. Most questions used a 5-point agree/disagree Likert scale. Each section included a free-response space. --- Analysis We aggregated and analyzed results from 2019-2021. 17,18 We calculated and compared descriptive statistics by race and gender using χ 2 tests. --- Results Each year, all residents (mean n=39) and faculty (mean n=67) were invited to participate. Mean pooled response rates were 84% and 50% for residents and faculty, respectively (Table 1). --- General Climate Most respondents agreed the climate is supportive and the residency values diversity. This result did not vary substantially between respondents or over time. --- Climate for Specific Groups and Experiences With Discrimination and Harassment Women were more likely to ever experience discrimination due to gender, most commonly outside of the residency (women: 62%, n=84; men: 6%, n=3; P<.001; Figure 1). People of color (POC) and URM respondents were less likely to agree that "residents who are racial minorities are treated with the same level of respect and given the same opportunities as White people in this residency," (POC/URM: 79% agree, n=34; a For race/ethnicity, participants could self-identify from "White non-Hispanic," "underrepresented minority (URM; Black or African American, Hispanic or Latino, or Native American or Alaskan Native)," "person of color (POC)," and/or "race not otherwise listed." Due to sample size and for anonymity purposes, URM and POC responses were combined for data analysis when comparing to White respondents. b Transgender men and men were combined for data analysis. c Asked separately on survey, combined for data analysis. Note: The survey population was largely consistent each year. Approximately one-third of the resident population was different, representing graduating residents and new interns. The faculty population was largely unchanged. White: 93% agree, n=117; P=.02). Regarding personal experiences with disrespect and discrimination, racial differences were most pronounced for instances that occurred outside the residency but within the workplace, with 52% of POC/URM respondents reporting this (n=23; Figure 2). In 2021, when a question was added to clarify who perpetrated discrimination and/or harassment outside of the residency, the most common responses were "patients," "patient family members," and "offservice attendings." --- Recruitment Respondents agreed that the program is making a genuine effort to recruit URM residents (92%, n=179) and residents of "other diverse identities (LGBTQ, socioeconomically diverse, etc)" (85%, n=163). Satisfaction regarding recruitment of URM faculty was lower but increased from 39% in 2019 (n=24) to 53% in 2021 (n=34). Only 20% of respondents were satisfied with the number of URM residents (n=38), and 10% were satisfied with the number of URM faculty (n=19). --- Burnout While 44% of respondents overall reported burnout (n=85), POC/URM respondents reported higher rates than White respondents (POC/URM: 61%, n=27; White: 37%, n=50; P<.01). Sixty-five percent of LGBTQ respondents reported burnout (n=15) compared to 40% (n=63) of heterosexual/ cisgender respondents (P=.02). Women (44%, n=59) and men (41%, n=21) reported similar rates (P=.75, Figure 3). --- Discussion The climate survey provided us with invaluable data regarding resident and faculty experiences. Significant findings include higher burnout rates for URM/POC and LGBTQ respondents, low satisfaction with program diversity, and significant racial and gender differences with discrimination and harassment. These findings reflect existing literature on disparate experiences of URM and women trainees. [4][5][6][7] We have used these results to affect significant changes in our DEI efforts (Table 2). Further research should explore burnout amongst URM/POC and LGBTQ residents and investigate interventions to reduce discrimination and harassment, particularly perpetrated by patients. 19 Limitations of this analysis include evaluation of a single residency, which lessens generalizability, lack of survey validation, and the unmeasured impacts of the COVID-19 pandemic, which profoundly affected residency experiences. The large number of women respondents and lower number of URM, POC, and LGBTQ respondents, while reflective of our program's demographics, also likely impacted findings. Additionally, DEI interventions implemented during the 3 survey years likely affected findings, and we hope Nevertheless, this continuous selfassessment has been instrumental in identifying areas of concern and enacting meaningful change within our residency. Furthermore, conducting the survey demonstrates a culture of open inquiry and dialogue around DEI issues that can improve resident/faculty experience and promote inclusivity. It is critical that the medical community not only recruit a diverse workforce, but also use self-examination to create a truly inclusive environment for all. The pursuit of social justice at our program began by gathering information through the climate survey, but it cannot end there. By supporting minority voices, we envision informing continual improvements and inspiring similar introspection and meaningful action at other programs. --- ACKNOWLEDGMENTS: The authors thank Jodi Holtrop and Elizabeth Stanton for their manuscript review, the numerous members of the Social Justice Working Group who contributed to survey development and revisions, and our residency program leadership for their continued support of social justice and DEI initiatives. --- PRESENTATIONS: This study was presented at the STFM Annual Meeting (virtual), August, 24-27, 2020. CORRESPONDING AUTHOR: Address correspondence to Dr Elizabeth Kvach, 1001 Yosemite St, Denver, CO 80230. 303-602-4545. Elizabeth.Kvach@dhha.org.

s the medical community grapples with the effects of structural racism on health outcomes, recruitment of underrepresented minorities (URM) has become a prominent strategy to combat inequity. [1][2][3] However, upon starting residency, URM physicians continue to face barriers throughout training. [4][5][6] Research shows that many medical trainees experience harassment or discrimination, with women and URMs experiencing more discrimination than their peers. [7][8][9] Existing surveys assessing resident experience generally do not address diversity, equity, or inclusion (DEI), and little data exists on experiences of diverse residents and faculty within their own programs. 10 Inclusion, in particular, is often overlooked. 11 This report describes our experiences developing and instituting a climate survey in our residency program to assess resident and faculty experiences and improve inclusivity, and provides a summary of findings and resulting DEI initiatives.

There are several reasons for this. Physicians and hospitals understand that health is shaped by these broader conditions and are genuinely motivated to improve them as part of their responsibility to community health. With the enactment of the Affordable Care Act, hospitals have clear incentives to monitor and address community needs. Mitigating the social determinants of health may help Accountable Care Organizations reduce costs and meet value-based-care goals, such as mitigating risk of re-admission or medication non-adherence. At its core, for many health care organizations, addressing social determinants is born of frustration with the often-demoralizing alternative: treating people only to send them back to the conditions that contributed to their health problems. Efforts to address these issues are also reflected in the literature. In a recent series of articles physicians were encouraged to interpret health issues from a social determinants perspective. 6 The suggestion underpinning such initiatives, however, is often that once social determinants are "diagnosed", these powerful influences can be attended to by practitioners and clinical service organizations. This is, however, far easier said than done. Many fundamental determinants of health are far upstream of healthcare and are deeply rooted in the distribution of money and power, at local and national levels. This growing medical engagement with social determinants then raises two important questions. Does physician engagement with these factors risk distracting from the broader responsibility government and society must assume if meaningful progress is to be made for the health of all? What is the most relevant focus with which physicians can engage the social determinants to make a difference? Starting with the first question, physician engagement with the social determinants is different than physicians' core role: providing healthcare to those who need it. Through necessity, healthcare practitioners must focus on the immediate illness or health problem, and are not well positioned to coordinate longer term population-level health improvement strategies. For example, emergency physicians and surgeons treat patients with gunshot wounds, but their focus on this critical task means they are not best placed to be responsible for the longer-term, strategic goal of preventing gun violence, and incentivizing them to do so may distract them from their vital role. Even more worrisome, the medicalization of the social determinants of health also absolves policy-makers in non-health sectors such as justice, transportation, housing, employment, environment, benefits, education, sanitation, and a host of other vital contributors to health from any responsibility in the generation of health, despite the widely accepted acknowledgement of these very same factors as crucial in determining health. In parallel, the notion of addressing social determinants in the context of clinical practice devalues and medicalizes the complex burden and barriers encountered by those affected by discrimination or poverty. Conditions such as poverty or racism are not medical ailments that can be alleviated. Such conditions have individual, community, and societal influences on this and future generations that extend far beyond health. The societal responsibility to these determinants clearly extends beyond the medical focus of eliminating the health harms that reflect acute and expressions of much larger and complex disadvantages. Therefore, healthcare professionals cannot and should not bear primary responsibility for changing these determinants, particularly if they truly want them to change. Caught in this dilemma, what can physicians and other clinicians along with healthcare organizations do to maximize their influence on the social determinants of health, particularly when these are so fundamental to improving health, and when no physician wants to send a patient back to healthharming conditions? A core role of the medical profession is preparing the next generation. That it took over-long decades for doctors and organized medicine to embrace a social determinants agenda suggests that a rethinking of medical training is warranted, and essential. Medical education for physicians could be revised from first principles, and be founded upon the generation of health, not just the provision of healthcare. This would cast an understanding of the structural forces that shape health at the heart of medical training rather than relegating it to the sidelines as a course to which little attention is paid. This refocus will help equip physicians for what might be their most enduring impact: creating a healthier world. In parallel, ensuring adequate representation among physician ranks from all walks of life could go a long way towards putting social determinants thinking at the heart of the medical profession. Poverty and racism are an abstraction at best when one has not experience of either. It is not a far step to see how having a diverse physician body can, indeed, create doctors in future who are much more willing and able to speak and change the public conversation on the social determinants of health. This aligns the burgeoning diversity and inclusion efforts at nearly all medical schools in the country. Finally, their most enduring effect may be in changing the conversation around health and responsibility for it. Physicians are the most powerful and authoritative voices on health, and they can use this characteristic to champion health in all policies approaches. 7 They can point to the narratives of their patients and how much of health is determined by forces outside their control. 6 They can use their knowledge to counter the unsupported narratives in which individuals who have health conditions that are beyond their control are blamed and penalized for their poor health. Clinicians also can communicate their own stories as healthcare practitioners and the hopeless task they at times encounter in delivering effective care for patients, only to return them to the social and economic conditions of which their illness was a symptom. As those most acutely exposed to the consequences of inequality and the relationship with health, physicians and other clinicians are well-positioned to encourage state and federal agencies to focus on generating better health for all in the community. It seems incumbent on physicians to acknowledge that a concern with the social determinants is not just their responsibility, but also everyone else's.

To a large degree, health is shaped by the conditions in which people are born, grow, live, work, and age, collectively termed the social determinants of health. 1,2 The US public and health care professionals care about improving health outcomes. Compared to other high-income countries, the US spends significantly more per capita and in total on healthcare. 3 Yet through chronic underinvestment in some of the conditions that most influence health, such as social services, education, physical environments, and access to healthy food, progress has been undermined, with lower than average outcomes across a range of health indicators, including life-expectancy. While perhaps slow to respond to this challenge to the health of populations, in the last decade, hospitals and physicians in the US have taken up a role in addressing social determinants of health. According to a 2017 survey of 284 hospitals by Delloite, 80 percent of respondents, including clinical and administrative staff across leadership levels, indicated that "…leadership was committed to establishing and developing processes to systematically address social needs as part of clinical care." 4 This often includes partnering in some way with community organizations to improve access to housing, food, transportation, or social services to patients who may have difficulty with access to healthcare. The American Hospital Association has published a toolkit on "…how hospitals can address the social determinants of health in their communities" including helping to address food insecurity or transportation costs." 5

that students should get outside and encounter and/or experience nature and therefore learn experientially about our interconnection with natural phenomena. This educative step however, needs to be coupled with reflection, processing and synthesis, so that is it not merely stepping outside but an immersion in the place in which one lives. Immersing ourselves into place can raise awareness of both positive and/or negative elements, which in turn can foster democratic ideals of participation and civil engagement, as students may be moved to act upon what they see within their communities. The name of Hensley's book, Curriculum Studies Gone Wild, signifies the potential of curriculum as a medium to reestablish education as method in which students and nature coalesce to form a new sustainability paradigm. By calling for a "de-carbonized" curriculum, he advocates for a curriculum premised on the notion of students learning to live or tread lightly upon the Earth. In essence, Hensley is suggesting that education is a catalyst for change, bringing new ways of thinking, doing and acting as they relate to living on the planet-for example, trying to minimize a carbon footprint. As Hensley nears the end of the first chapter, he lays the groundwork for a more in-depth discussion of sustainability as it is tied to a bioregional context. Citing a reverence for life as the lens to which sustainability is to be enacted and understood, the reader is led to an understanding of Hensley's underlining message of an eco-curriculum. While the first chapter touches upon sustainability and education, the second engages the reader with an in-depth exploration of curriculum studies research as it intersects with ecology. An influential concept for Hensley is the idea of a curriculum of abundance (Jardine, Friesen and Clifford 2006), which describes an abundance of opportunities to explore in the places in which we live and to "live well within our place" (p. 34). The author utilizes this idea as a platform to imagine education to be one, which cultivates an ethics of sustainability. Furthermore, he sees education in a manner which views students as more than consumers, but as advocates for ecological-social change. Hensley also works with the concept of currere, stated by Pinar and Grumet (in Pinar et al., 2004), noting how reflecting autobiographically upon one's experiences can lead to eco-consciousness. The concept of currere is a vital aspect within this text and is used by the author to clarify and enrich the discourse surrounding a "complicated conversation" (Pinar, 2004) Thus far in the book, the author articulates his ideas in a cogent manner as they apply to curriculum studies and sustainability and his projected vision of education. Additionally, as a reader I see the significance of Hensley's use of the bioregional framework as this could be applied (as he does state only briefly) to any place not only to natural settings. It is relevant and important to highlight this point-in that not everyone has had the same outdoor educational experiences as Hensley, nor may they feel the pull or call of the wild. Even more so, depending on where schools are located, students and teachers may not have easy accessibility to untouched natural environments. Therefore, the author's arguments are convincing and could be applied to understanding the world's continuous push towards urbanization, and how to live sustainably within this movement (Benton-Short & Short, 2008). In Chapter 3, Hensley discusses the current material world as it relates to educational systems and environmental degradation. The current American educational system, as stated by Hensley, is stifling the implementation of an eco-curriculum. Educational systems premised on the industrial model of schooling coupled within a social efficiency paradigm create a carbon copy curriculum that emphasizes linear, compartmentalized thinking and relegates direct experiences to the periphery of learning. Further, the carbon copy curriculum as illustrated in its title produces copies of the same ways of thinking and acting amongst students, which "emphasizes training, uniformity, and conformity" (p. 50). Also, Hensley likens the concept of a carbon copy curriculum to a river not running its natural course. When a river, like a student is "controlled" or "channeled" to run a fabricated path, both the river and students are steered off their paths of natural inclination. Both, he argues results in heighten negative consequences-more flooding and erosion, and the hampering of genuine interests, intellectual curiosity and lived experiences of students. Education, with a mechanistic worldview tunnels our vision to see only fragmented, narrow pieces of our planet, thereby reinforcing perceptions that disenfranchise notions of community, sense of place and sustainable living. Although I am in agreeance with the author, I feel that changing the pervasive ideologies in education is a lofty goal. Nevertheless, change can occur and to implement Hensley's vision will require dedicated practitioners and, I would argue people genuinely concerned about the welfare of the planet. His aims are imperative and will require a coalition of like-minded educators, students and advocates to act in the pursuit of social justice for a healthy planet and population. As a suggestion Hensley proposes to reinvest in intellectual exploration via the arts. The arts, for instance can connect us back to nature, and to ourselves by exploring our autobiographical narratives. Seeking a more authentic self reconnects us to "our personal river" (p. 63), one in which we can work towards "greening [our] imagination" (Doll, 2000as cited in Hensley, 2011, p. 59), and work towards regenerating our identity as ecological stewards of the Earth. I feel that the implementation of autobiographical narrative adds to the richness of the text, as it highlights Hensley's experiences as an outdoor educator. While I read through the chapter the autobiographical narratives pushed me to reflect upon my own experiences in the places in which I have dwelled and currently dwell. Therefore, the author's desire to have education infused with self-reflection for the purpose of self-realization is insightful. It is also effective because it allows us to reflect upon our behaviour and who we are in comparison to others and our place in the world. Hensley puts forth the notion that "to live sustainably, the human vote must be considered as just one of the many votes cast from the millions of species that compose this planet. Thus, living sustainability involves looking at the world ecologically" (p. 97). This quote exemplifies the aim of his fourth chapter, which is to outline the history of sustainability as it intersects with education. In addition, Hensley discusses his view of curriculum as an ecological text. This notion is premised on the blending of sustainability and curriculum studies as a tool to foster a transformative educative potential. For Hensley, perceiving education through the lens of an ecological worldview rather than a mechanistic one deepens our thinking about human-Earth relationships and their inherent connectivity. As a reader, I am intrigued by Hensley's belief in sustainability as a conduit for the advancement of healing and vitality. When we think about education serving as a basis for ecological healing of the planet, the more-than-human, and ourselves we can see the impact of learning that "valorizes the importance of being connected to our bioregion" (p. Bioregional poiesis is a concept that utilizes the uniqueness of each place with its surrounding ecological and social contexts as a springboard for educational experiences. Some of the desired outcomes of focusing on place are the development of authentic interest for one's community, to make meaning with place, and the re-engagement of youth in placespecific work such as restorative ecology. In addition to bioregional poiesis, Hensley proposes a unique watershed approach to education that forms part of the larger ecocurriculum of place framework. This approach builds upon place-based education by adding a component of educational experiences tied to learning about the watershed that resides in one's bioregion (or place). A watershed is defined in the text as "an area of land that drains to a common body of water" (p.158). The purpose of incorporating such a framework for Hensley is to unify action amongst all people worldwide, yet to provide an education that is "contextualized to fit our place, the place we inhabit" (p. 158). Examining education through the watershed perspective is to expand the idea of interconnectivity as it links to sustainability. For instance, polluting one area of a watershed will ultimately pollute the common body of water. Hence, learning to live in harmony with our bioregion requires that people are "fully implicated" in our current and future solutions to environmental emergencies (p. --- 159). Turning to the last chapter, Trudging Towards Sustainability, Hensley continues to demonstrate his passionate voice in his mission to share the power and significance of thinking and acting sustainably. Particularly interesting in this final chapter, is his attention toward sustainability by finding our way back to a human tempo, one which calls for us to slow down and pay acute attention to the patterns that we see out in nature, and to tap into a "human rhythm-a cadence of inquisitive proportions" (p.182). By tapping into this human tempo, we can start to re-listen and find our "human speed not machine speed" (p. 182). Leading from this thought, as one amongst many, Hensley eloquently connects sustainability to a prayerful act. Theorizing about sustainability is a prayerful act because its focus is on a "way of being-it is an ethics" (p. Hensley posits that the fields of curriculum and sustainability have the potential to transform the future of this planet. Curriculum theorists are a "community of healers…charged with the task of restoring the balance", offset by contemporary educational forces based in biophobic views of the planet (p.218). Embracing humanization is a "step towards sustainability", one couched in the creation of self and eco-literacy as a way to "read the world and the word" (Freire & Macedo, 1987). Lastly, when humanity realizes that we inhabit this planet as partners with the more-than-human, we can then advance towards a more holistic, unified ecological community. The strength of utilizing a place-based method has merit as a transformative movement, and as one reads Hensley's text one is convinced of the potentialities of investigating the boundaries within space and place, and of education's continued capabilities for long-lasting alterations for the planet. As an educative text, Curriculum Studies Gone Wild provides the reader with clear explanations of the intersections between the fields of curriculum and sustainability studies. The possibilities of Hensley's arguments are far-reaching for education. For instance, due to the nonprescriptive nature of Hensley's eco-curriculum for sustainability, it is transdisciplinary and approachable, and thereby applicable to all levels of education. Hensley reviews complex topics but presents them in a manner that is easily assimilated by the reader, thereby making his text a valuable addition to curriculum, and education. Even for a novice reader new to the concepts he puts forth, one can take away a deeper understanding of the importance of place, as well as how to cultivate an ethics of caring and become stewards of the Earth. Lastly, Hensley illustrates with passion the potential of education to be the vehicle of change in today's uncertain environmental future. Further, his educational perspectives provide hope to live better, and more attuned to nature, others and society-as the conditions of Earth affect all aspects of how we live and where we live (economic, political, cultural), regardless if we choose to see them or not.

leads the reader on a journey in which his life experiences become the basis for a curriculum that fosters a sense of place, community and ecological revitalization. Hensley pushes the boundaries of what it means to learn in place and space and joins curriculum and sustainability studies together into what he calls "eco-curriculum". Underscoring from the start the importance of nature immersion and exploration, one of Hensley's many goals is "to forge an education that will enable students to…ecologize everything" (p. 7). He invokes a passion, deep interest and moral responsibility for all citizens to "realize the social, ecological, and interconnectedness between all phenomena" (p.7). Hensley begins by calling attention to the overconsumption patterns of our current state of being on the planet. Further, he points to the disconnection that exists between students and nature, a pattern that he understands is a result of the lack of experiential opportunities presented within the classroom. To remedy this disengagement, Hensley argues Book Review: Curriculum Studies Gone Wild VALERI

Introduction The pandemic is continuing as the world health organization day to day work throughout the day due to its fast transmission and kills many million peoples around the world [1]. In Africa, more than nearly one million cases, 20,000 death, and in Ethiopia 17, 530, and 274 death were reported until this time [2]. The virus is too contagious and transmits to humans through contact of humans and surface, and symptoms were cough, fever, fatigue, breathing difficulty [3]. The Ethiopian ministry of health is working on the prevention of the virus at the country level by transmitting the media about the method of prevention, distributing face masks, sanitizers, and soaps [4]. During the severe acute respiratory syndrome, almost half of the non-infected communities were suffering from a mental and psychological disturbance related to the unpredictable outbreaks that happened in the world [5]. The current pandemic causes hopelessness, depression, anxiety, and suicide in all communities, infected, infected, health professionals following a few days of the outbreak [6]. The study done in china was the highest magnitude (53%) of them suffered from moderate to severe levels of the psychological problem [7]. Mental health services have been working to address the crisis through online, outpatient, and inpatient mental health services for all of the communities in need [8]. Despite this fact, there is no sufficient study done on these issues in low and middle-level countries. Therefore, the purpose of this study was to determine the magnitude of mental health crisis and associated factors related to the pandemic. This study result might be vital for generating appropriate mental health crisis management policies and plan for responding to the impact of the infection. --- Methods and Materials --- Study Area, Study Period and Study Design The study was a community-based cross-sectional design conducted at the Gedeo zone from March-April 2020. It has a total population of 847,434, of whom 424,742 are men and 422,692 women, and 359 km far from Addis Ababa (the capital city of Ethiopia, the main road from Addis Ababa to Kenya crosses. --- Eligibility Criteria The inclusion criteria of this study were respondent's age 18? and able to listen and respond with either of the local languages, Amharic, or Gedeoffa local languages. The exclusion criteria of this study were those who weren't able to listen to the questions asked and not present during the data collection period due to different reasons (not in the house during the data collection period, acutely or severely ill). --- Sample Size Calculation The sample size was calculated using a single proportion formula population. We used the p value of the previous study done in China 53.8% [7]. P ¼ 0:54%; Where; n ¼ required sample size n ¼ Z a=2 ð Þ2 pq=d2; p ¼ 0:54 ¼ 1:96 ð Þ 1:96 ð Þ 0:54 ð Þ 0:46 ð Þ= 0:05 ð Þ 0:05 ð Þ ¼382 where z is the reliability coefficient at a 95% confidence interval (1.96) W (margin of error) = 0.05 and N = non-response rate 10% = 38. The final total sample size was, 382 ? 38 = 420. --- Sampling Technique and Procedure The sampling technique of this study was a multi-stage random sampling. Gedeo zone has seven woredas, Namely, Bule, Dilla town, Dilla zuria, Gedeb, kochere, Wenago, and Yirgacheffe. It has 179,677 households. At first, we selected all woredas in the zone. Then, we proportionally allocate to each kebeles of the hose holds found in the woredas. To select each household of the kebeles, we used simple random sampling and lottery method. --- Data Collection Tools The first part of the questioner is about the sociodemographic characteristics of respondents. The second part of the questioner was about the mental health crisis and assessed using the Depression, Anxiety and Stress Scale (DASS-21) a 21-item Likert scale and sored \ 30 (Normal), 30-43 (mild) and 43-59 (moderate) [ 60 (severe) [9]. The third part of the questioner was about knowledge, attitude, and practice regarding the coronavirus, which has 12-items and scored as a continuous variable. The higher score is good knowledge [10]. --- Variables Dependent variable-mental health crisis Independent variables-Age, sex, educational status, occupational status, family size, and monthly income, and KAP about COVID-19. --- Data Collection Procedures First we carefully designed the questioner then we trained data collectors, supervisors for about four days about the aims of the study by considering the value of privacy and confidentiality. Each day the supervisors were checked the data about its completeness. --- Data Quality Control The pretest was done on the 5% populations before two weeks of the actual data collection period. The questioner translated into the Amharic and Gedeoffa language and back-translated to English to check the consistency. The Amharic and Gedeoffa version questioner used for data collection. --- Data Processing and Analysis Data was entered into the Epi-Data 3.4 software package and exported to the Statistical Package for Social Science version 22. Descriptive statistics such as frequencies, percentages, graphs, and tables used to describe the data. Logistic regression analysis used to determine the predictor variable of outcome variable at (95 CI and p value \ 0.05). --- Result --- Sociodemographic Characteristics Result of the Respondents Nearly two-thirds of respondents had more than three family sizes and the average mean monthly income was 300 ETB (Table 1). --- Knowledge, Attitude and Practice About Corona Virus Nearly half of the respondents have no information about the signs and symptoms of the coronavirus. More than two-thirds of the respondents were not using a face mask when they leave their homes. Two-third of the respondents were frustrated about the control of the virus in Ethiopia. Mental Health Crisis 44.4% of the respondents were reported mild to moderate psychological problem. --- Factors Associated with Psychological Problem Variables associated with the outcome variable during bivariate and multi-variant logistic regression at 95% CI were female gender, less 300 ETB monthly incomes, and more than three family size. The odds of being a female's gender 2.32 times (95% CI, 1.32-4.56) more likely to develop mental health problems in response to the pandemic. Monthly income less than 300 ETB 4.56 times (95% CI, 2.13-6.76) more likely to experience psychological problems. The last variable contributing to the psychological problem was having more than three family size 2.34 (95% CI 1.23-4.09). --- Discussion This study found 44.4% of the respondents were reported mild to moderate psychological problems in response to COVID 19 pandemic. This study finding was lower than the study done in China in response to the COVID-19 epidemic which was 53.8% [7]. It might be due to the difference in culture, literacy, mental health service, resources for controlling the pandemic. This study found that being females increase 2.32 times (95% CI, 1.32-4.56) than males for developing psychological problems in response to the pandemic. This study was supported by the study done in Italy [11] and china [7]. It might be due to their natural lowlevel tolerance to stress and new situation. In-addition females in this study area are highly responsible for marketing and caring for the family. This study found that the odds of monthly income less than 300 ETB has 4.56 times (95% CI 2.13-6.76) more likely to experience psychological problems as compared to their counterparts. This finding was similar to the study done in Saudi-Arabia [12]. The economic crisis the pandemic is significant in low-income countries to the extent unable to buy preventive measures including soaps and facemask. This study investigates that having more than three family size increase the chance of experiencing psychological problems by 2.34 times (95% CI 1.23-4.09) than those who are alone. This study was consistent with the study of India [13]. The number of family sizes might contribute to an economic crisis to fulfill the daily needs of each family. Moreover, the family size increases the chance of contact with different people for contracting the virus from others. --- Limitation of the Study As the study used a cross-sectional study design, no conclusions can be drawn regarding causality and alternative explanations of the findings and cannot be ruled out. --- Conclusion This study found that as there is a mental health crisis in the community living in the Gedeo zone, SNNP, Ethiopia. The most affected populations were female, low-income, and family size. Therefore it is better to work on the psychological wellbeing of the community through teaching how to handle the crisis of the pandemic during limited resources. The government should supply soaps and face masks for those who weren't able to buy in the community. There should be a sustainable mental health task force for handling the psychological crisis of the pandemic in the community. --- Ethics approval and consent to participate Ethical clearance gained from the ethical review board of Dilla University and zonal health beauro. The written informed consent obtained from the respondents. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The current COVID-19 pandemic is not still controlled around the world and affects all humans' domains of day to day life. Peoples have killed themselves due to the fear of stigma by their community. This study aimed to assess the current mental health crisis of the COVID-19 pandemic among communities living in, Gedeo zone, Dilla, Ethiopia. The study was community based cross sectional design conducted from March 10-Apr 10, 2020, using a multi stage sampling techniques. Structured interview, Depression, Anxiety and Stress Scale (DASS-21), and logistic regression analysis (95% CI, p value \ 0.05) was used. This study included 420 respondents who were living in the Gedeo zone. In total, 44.4% of respondents had a psychological problem (21.4% mild and 23% moderate level of the mental crisis). Gender female, monthly income below 500 ETB, and more than three family size were variables associated with the outcome variable (p \ 0.05). Nearly half of the respondents had mild to the moderate mental crisis in response to the pandemic. It is better to give mental health support for the peoples living in the zone to enhance their mental resilience.

A fter a summer of sport, the London Olympics and Paralympics have ended and the city is now returning to normal. For London, normal means roads and public transport that are crammed, especially at peak times. It was all very different during the games, when many of the streets and shops in this dynamic city were eerily deserted. What made behaviours change so dramatically? And what lessons can be learned for behaviour change in other arenas? Congestion was a potential major headache for the organizers of the Olympics. The conventional way to prompt a change in behaviour such as driving is to use incentives, the price mechanism beloved of economists. There is already a congestion charge for vehicles entering the city centre, so this could have been ramped up. And a special levy could have been introduced for travel on public transport. But the increases in price would have had to be enormous to deter people, so London relied instead on socialnetwork effects. Before the games, a massive publicity campaign focused on how crowded the centre of the city would be. Bus and train passengers, for example, were bombarded at regular intervals with recorded announcements from mayor Boris Johnson that warned just how busy public transport would be, and urged people to avoid them if they could. The strategy worked -too well in factbecause of feedback effects. People do not receive such warnings as isolated individuals: they discuss them widely with friends and work colleagues. Employers reinforced the effect by promoting special arrangements for homeworking and flexible hours. As a result, commuting cyclists had many roads to themselves and visitor numbers at flagship London venues fell by one-third. Johnson gave us a glimpse of public policy as it could be applied in the twenty-first century, relying on network effects rather than on incentives. In the twentieth century, both social and economic policy in the West were dominated by the principles of conventional economic theory: individuals with fixed tastes and preferences took decisions in isolation, and reacted to changes in incentives. So to achieve a policy goal, politicians would change tax rates and offer subsidies. This model is not wrong. But it is incomplete picture of the way in which the world now operates. Network effects are not new. Throughout history, a crucial feature of human behaviour has been our propensity to copy or imitate the behaviours, choices and opinions of others. We can see it in the fashions in pottery in the Middle Eastern Hittite Empire of three-and-a-half millennia ago. But we are now much more aware of what other people are doing, or plan to do. For the first time in human history, more than half of us live in cities, in close, everyday proximity to large numbers of other people. And the Internet has revolutionized communication. Social networks are often thought of as a web-based phenomenon: Facebook, for example. Such forums can indeed influence behaviour. But real-life social networks -family, friends, colleagues -are even more important in helping to shape preferences and beliefs. Social problems such as obesity are driven by network effects. It is not that people decide to copy fat friends and eat huge amounts; here, the network effect is one of peer acceptance. If most of your friends are obese, then it is more acceptable for you to put on weight. The problem of worklessness is also driven by networks. My home town of Rochdale, UK, attracted notoriety a couple of years ago when 84% of working-age adults on one council estate were found to be on benefits. Yet estates with very similar socioeconomic backgrounds had much lower rates, although still high by national standards. The social values of some estates had evolved to make being on benefits the norm. A great deal of Europe's economic policy can be seen as an attempt by various players to use the social-network effect to get their narrative version of events to 'go viral' and dominate financial markets, almost without regard to objective reality. For example, although the United Kingdom has a higher public-sector debt relative to the size of its economy than, say, Spain, the United Kingdom is perceived as sound and Spain as risky. Thanks to advances in network theory, we now know much more about how behaviour is spread and contained across networks than we did even ten years ago. Something that is particularly disturbing for policy-makers is the inherent level of uncertainty: some network effects simply fail to spread, and it is impossible to predict accurately how much traction an idea will get, and how any one event will unfold. Tackling social, economic and global issues, such as climate change, will require real, fundamental changes to behaviour. To make this a reality, policy-makers, in both the public and the corporate sphere, will need to radically change their view of how the world operates. The inherent uncertainties of social networks make policies much harder to implement, so network theory must come up with effective, practical tools that help policy-makers to achieve their goals. For when they work, as we saw in London, social networks are a powerful and useful way to get things done. ■

The classic economic approach of using incentives is not always the best way to change human behaviour, argues Paul Ormerod.

BACKGROUND Language is main medium used in communicating. Through language, we can know the characteristics of language speaker because language is a feature of language behavior. As social beings, humans certainly carry out communication activities as one of their needs to interact with others according to (Julisah Izar, 2020) . Without language, communication among people will not run smoothly. In communicating, speech spoken by people is not same and has its own type or style of speech. In this case, speech activity happening in daily life pragmatically is named speech act. (Richards, 2002) argue that Pragmatics is the science of language use to see how it relates to other people or the science of language which sees its meaning and relationship with situations of speech or speech acts. A language can only function when the speaker and interlocutor can communicate well. Good communication will arise when the meaning in a communication can be interpreted properly or can be understood as it should be. This understanding arises when the speaker and the interlocutor understand the situation and context of the speech. Speech act is the embodiment of everything done and expressed through speech using language as a medium for conveying meaning. According to (Levinson, 1983) Levinson (1983:236) Pragmatically, speech act is divided into three kinds, they are locutionary, illocutionary, and perlocutionary. that determines the use of the language used when being angry. Bintang Emon having profession as comic has his own way in expressing his angry expression. Being angry is a form of speaker's expression containing of negative meaning. Form of being angry can be expressed using language. The language used is a anger expressed by speaker through the speech according t (Al Baqi S. , 2015) . Not only that, (Supratiknya., 1995)states that being angry can be expressed directly and indirectly or can be both in the same time. --- Speech act of angry expression conducted by Comic Bintang Emon can be customized with situation and condition. Bintang Emon, who has the status as a comic, certainly used language used when being angry has his own characteristics. The characteristics of uniqueness will emerge speech act of angry expressive of Comic Bintang Emon in his speech in his personal Instagram account regarding social distancing. --- METHODOLOGY This research used descriptive qualitative approach. Qualitative research according to (Ary, 2006) is the data that explain with the words rather that with pictures or numbers. This explained and described the result of data found by using theory that related to research purpose according to Creswell (2009:3). The method used in this research is is sociopragmatic, which is to see how the language spoken by speaker is adjusted to the sociolinguistic context then see how the relationship is. Collecting data in this research is using video form then listening repeatedly. After that, record the part that is considered as needed data. After collecting data, then data reduction or separation of necessary and unnecessary data is carried out. After the reduction stage, the data analysis was carried out based on the theory used and finally the conclusion stage, doing the conclusions succinctly and easily was understood, so the purpose of this research would be seen. --- Speech 4 " Ayo mari semua kita lawan korona. --- Nih korona kalau di diamin lamalama ngelunjak nih. Nih korona kalau bentukannya orang udah gue klepekin dari dulu ni" Means "Come on, let's all fight Corona. This is Corona, if it's guaranteed to take a long time. This is Corona, if it's form is like people, I've always clapped it" The speech is a non-literal direct speech act.

This research aims to describe speech act form of angry expressive spoken by Comic Bintang Emon in social media about social distanting. The method of this research is qualitative by describing the data. The data source of this research is Comic Bintang Emon's speech in social media about social distancing. Collecting data in this analysis used technique of listening, data reduction, and data analysis. The data were analysed to see how the form of speech act was spoken by Bintang Emon and relatedness of speaker's sociopragmatics. The result of this research is speech act of angry expressive spoken by Comic Bintang Emon used speech strateries: literal direct speech act and unliteral direct speech act. Literal direct speech act in the speech consisted of two speeches while non-literal direct speech act consisted of five speeches.

Mistry's novel "Family Matters" deals with the most important issues of Parsi community that is old age care. which is the serious matter for nation. In this novel Nariman Vakeel, in the age of seventy-nine-yearold, a Parsi widower and the protagonist lives in large apartment in chateau felicity which was once elegant. The apartment is now more or less, dilapidated condition. Nariman was dwelling there with his adult step children, Coomy and Jal. Roxana is one natural daughter of Nariman who is busy in her married life with husband Yezad and their two children Murad and Jahangir. No one able to take care of Nariman in his old age. There are very less young and able children in Parsi community to take care for their old and disable parents. Hence the burden caring the parents is falls on the younger generations or unmarried youngsters, who refused their duty and wants to live a free life. The exact condition is falls upon the Nariman where he becomes the burden of his step children who live with him. Coomy is very indignantly blame her stepsister Roxana run away from parents care duty and force her married sister to taking care of her father. The character of Jahangir a nine-year-old boy of Roxana and Yezad has a great concern about his grandfather Nariman. Jahangir is often seen with his attempt to set a jigsaw puzzle. Jahangir make the reader visible how he try to solve the baffling of his own family politics through his jigsaw puzzle which we see several time a boy tries to lift together in the novel and wanted to puzzle out the quarrels of his family and take care of his grandpa (Nariman) who passes through the tough period of his life his old age. With all drawbacks of an old age, wrapped by ill health, Nariman still willing to go for his daily walk. His stepchildren both discard this wish in order to his safety; as much for any nuisance it would bring them. "Even with my healthy legs, Papa, walking is a hazard." Said Jal, continuing the daily fun over his step father's outing. "And lawlessness is the one certainly in the streets of Bombay. Easier to find of gold nugget on the footpath than a told of courtesy. How can you take any pleasure in a walk?" (FM-3) Coomy and Jal sensed possible dangers come upon their stepfathers presented as reality with him. while returning home with a tiny hobble and scratches on his elbow. This clarify that he had stumble on some element and hurt his ankle while crossing the lane outside chateau felicity. Nariman's hang back for evening walk put him in real trouble. With the saints having let up after pouring relentlessly for the last fifteen days, Nariman had fallen in a trench dug up by the telephone company. The fall took him down up in the bed with broken ankle, encased in plaster of Paris cast right down from his thing to the ankle. He paid for the delight of walking on the road of Bombay. Without the help of his stepchildren Nariman did not carry out the smoother things of his life. He wishes to go for evening walks in spite of the several medical problems. He denied to be cowed down by Coomy's continuous instructions and Jal's extended fear of walking regarding dangers of the streets of Bombay. He retort's angrily: "In my youth, my parents controlled me and destroyed those days. Thanks to them, I married your mother and wrecked my middle years. Now, you want to torment my old age! I won't allow it" (FM-7) Nariman has to fed up with Coomy's dominated nature and restrictions over things. She has laid down rules for nearly everything in the house. He has to announces his intention to use the W.C. He is not allowed to lock door. On the occasions that he forgets the rules. He has to put up with a lot of ragging from Coomy. He is happy only when Roxana came to visits with her family. He therefore excitedly anticipates the happy meeting on his birthday, and is naturally sorry to see them go. The sad look of loneliness returned to Nariman's face, as Jal fetched the raincoats and umbrellas from the bathroom. Securing than front door against the night, Coomy said that each time the Chenoy family visited, she felt exhausted, as though a whirlwind or a van olio had passed through. Nariman besotted with old age problem matters by accidentally falling into a trench; He now has to completely depend on Coomy and Jal for everything. They try to make thing comfortable for him, yet Coomy cannot keep the resentment out of her voice and actions sometimes. The doctors had emphasized the point that Nariman was to be on complete bed rest, with no strain on his ankle. The first mistake Coomy makes is to buy a commode for him. Jal and Coomy have a tough time putting their stepfather on commode and taking him off. His ankle gets terribly hurt in the process. Nariman feels very helpless and cries quietly at night. His stepchildren also cannot bear the brunt of the labour any more. Coomy argues with Jal that since Nariman didn't have to change her diaper as a child, she too isn't obliged to clean his bum and that it should actually be done by Roxana, his own blood, not like Jal and me, second class." (FM-7) Jal as usual lets himself be convinced by Coomy and they prepare to literally dump Nariman into Roxana's house, without notice, unceremoniously. Roxana proceeds with the day's work and at this juncture the tranquillity of the morning is broken with the unheralded arrival of Nariman on a stretcher, brought in an ambulance by Coomy and Jal. Roxana tries her best to persuade Coomy that looking after their old father in his present condition in her small flat would be next to impossible. But, Coomy does not relent; sort of emotionally blackmails her and departs with Jal leaving Nariman with his suitcase, medicine and bedpan with Roxana. She tries to make the most of the situation, makes her father comfortable on the settee, changes his clothes and serves lunch to her son and father. Jahangir is overjoyed to see his grandfather and wants to feel him. They allow him to do so after he has finished his own plate. Watching the scene from the balcony, Roxana is overwhelmed. This is very touching portrayal of a scene immensely valuable in depicting human relationship. There are the moments Nariman longed for in the large flat at chateau felicity, where he silently wept at night feeling the rejection of his stepchildren. In the constrained space of the tiny flat at Roxana he gets all the love and attention he could have wish for. He gets the feeling of being loved, and wanted the scene of belonging to a family. Yezad is angry with Coomy and Jal for behaviour abominably, for thoughtlessly --- Volume 5, Issue 2, pushing Nariman out of his own flat and advice Nariman to put his foot down. To this Nariman replies as the mouthpiece of Mistry; "If I could put my foot down, everything would be fine". Said Nariman with a wry smile. "How can you force people? Can caring and concern be made compulsory? Either it resides in the heart or nowhere." (FM-121) Through the various problems faced by the Chenoy family in looking after ailing Nariman issue close to Mistry's heart are discussed in detail. Roxana is happy for the exposure for sons are getting in caring for the aged. The young Jahangir, sleeping besides his grandfather in their small flat, is quick to hold his hand and comfort him when the letter has nightmares. Yezad, too, with his initial revulsion in handling Nariman's bedpan, and forbidding his sons from doing it as well, display a massive shift in attitude. On an occasion when Roxana is not present in the house, Yezad surprise his sons by deciding to give the bedpan to Nariman who needs to do number two. Between father and sons, they have and left and somehow manage successfully. Roxana returns when they are on the verge of completion. She is as much astonished at touched by the sight, which meets her eyes. The canvas of the story is cantered the family of Nariman Vakeel. Through Nariman Mistry can exemplify his own reality suppressed feelings. The life of Nariman is clouded with the extreme pain, alienation, marginalized and sickness of the character. Death of his wife and his lover is the result of the ill treatment by his stepchildren Coomy and Jal who played negative role in his life. Both of them blame Nariman and consider him a sinner who never gives happiness to their mother. --- Conclusion: The whole novel is presented the suffering of an old man. He is fence by the Parkinson disease, osteoporosis and hypertension. The presentation of the novel is the mental, cultural, social, regional and physical sufferings of the old protagonist and the postmodern society basically Parsi society. --- Work Cited: Primary source: Mistry, Rohinton "Family Matters" London Faber ana Faber 2002.

Old age care is an emerging challenge in India. Old age responsibility is a grim reality and anxiety for minority community like Parsi. The excessive urban thoughts give rise to the problems of nation. They have their own mindset about their life. However, there is also a fact that due to high rate of properties in Bombay where most of the Parsi families live. Social atmosphere that remains most of the members unmarried. Adult unmarried children in Parsi community compel to live with their parents, and when they get married, they live away to make their separate home.

Introduction The social and economic environment influences the feasibility of starting a business, as well as the growth and sustainability of the enterprises run by women entrepreneurs [1]. Women face several unique obstacles in starting and growing their businesses, which can be attributed to a range of economic, social, and cultural factors. For example, women entrepreneurs may face financial constraints or difficulty accessing capital, which can hinder their ability to launch or expand a business [2]. Socio-cultural factors, such as gender stereotypes and discrimination, can also limit women's access to resources and opportunities. On the other hand, supportive business environments that provide access to financial and human resources, networks, and training can enhance women's entrepreneurial activities [3]. Governments, NGOs, and other organizations can promote women's entrepreneurship by creating policies and programs that address these factors. financial aid or credit accessibility is a crucial business environment factor that can significantly impact women's entrepreneurial success. Research has shown that women entrepreneurs often face challenges in accessing credit or loans to start or grow their businesses. This is because financial institutions and banks tend to favour low-risk ventures and may be hesitant to provide loans to women entrepreneurs, especially those without collateral or formal education. Moreover, women entrepreneurs may have limited access to other financial resources, such as venture capital or angel investors, who are more likely to invest in male-led ventures or those in traditionally male-dominated sectors. However, the emergence of micro-credit has been a positive development for women entrepreneurs, particularly in developing countries. Micro-credit provides small loans to low-income individuals, including women, who often lack access to traditional banking services. Micro-credit programs are designed to empower women and other marginalized groups to start or grow their businesses, improve their households' economic welfare, and generate employment opportunities. The success of micro-credit programs has led to a global movement toward making microloan accessible to people worldwide. Many advocacy groups, existing banks, NGOs, and alliances, such as the International Coalition on Women and Credit, RESULTS Education Fund (USA), Women's World Bank, Grameen Bank (Bangladesh), Accion International (USA), FINCA (USA), SEWA (India), VOICE (Africa), and many others have promoted and supported micro-credit and micro-enterprises in policy circles. [4]. These efforts have helped to raise awareness of the importance of women's entrepreneurship and the need for targeted support to address the challenges faced by women entrepreneurs worldwide, particularly in developing countries. As a result, more resources are being directed toward supporting women's entrepreneurship, including micro-credit programs, which can provide women with the financial resources they need to start and grow successful businesses. Overall, business environment factors play a crucial role in the success of women entrepreneurs. By addressing the challenges and barriers faced by women in the entrepreneurial process, a more inclusive and thriving business ecosystem can be created. Women's motivations toward entrepreneurship are strongly correlated with perceptions of success. --- Methodology The 'Ex-post facto' research design was followed for the present investigation. The district Vaishali of Bihar was selected purposely as the locale of the study. Out of sixteen blocks in the district, four blocks namely Hajipur, Biddupur, Mahua & Jandaha were selected randomly. Twenty five women entrepreneurs from each block were selected through snow ball technique and formed a sample size of hundred respondents. The data were collected through a well-designed questionnaire schedule and analyzed statistically --- Perception level Perception level has been operationalized in this study as the perception of women entrepreneurs about the business environment rather than looking at the perception of the researcher or professional personnel. A schedule was developed to measure it on five point continuum as below : CATEGORY SCORE Completely agreed +2 Partially agreed +1 No opinion 0 Partially disagreed -1 Completely disagreed -2 --- Results and Discussion Perception level of women entrepreneurs about the business environment In this section perception level of women entrepreneurs about the business environment was analyzed rather than looking at the perception of the researcher as professional personnel. It was measured on five points continuum and scores of +2, +1, 0, -1 and -2 were assigned to "completely agreed". "Partially agreed", "no opinion", "partially disagreed" and "completely disagreed" respectively. On the basis of the score obtained by the respondents in the category "completely agreed" ranking was being done to give a clear idea of the perception level of the respondents. The views of the respondents are presented in Table 1. The data revealed that the highest agreement of women entrepreneurs (72.1) was with the statement overall a positive environment for women to enter into business has been ensured and it ranked first. 64 per cent of the respondents had the perception that 'Social barriers are decreased' for women to start enterprises. Further, they feel that 'Access to information has increased' both statements ranked second. 60 per cent of the women entrepreneurs feel that 'Social and family responsibilities to promote women in business has increased', again they confirm that 'Credit facility has increased' and 'NGOs and women organizations are contributing to women's economic development'. The statement 'Help from the government has gradually increased' and 'Training facilities for women increased' attained the fourth rank with 52 per cent of the responses. Half of the respondents (50%) agreed with the fact that women-friendly environment has been created at the public institutions and ranked in fifth position. Again nearly half of the respondents (48%) showed their agreement with 'Women are getting a proper price for their product' and 'Women business network extended'. The statement 'Governments help for women to participate in trade fair increased' and 'Women are getting administrative and legal support' attained the seventh rank with 44 per cent responses of agreement. At last, only 40 per cent of the women, entrepreneurs agreed with the statement that 'quality of the assistance provided by the government is gradually increasing' and ranked at eighth position. This finding confirms other research findings supporting the statement that a positive environment for women to enter into business has been ensured. According to the Global Entrepreneurship Monitor Women's Entrepreneurship Report 2018/19 [5], a significant percentage of women entrepreneurs agreed that their governments have created an adequate environment for supporting women's entrepreneurship. The report found that in over 50% of the economies studied, women entrepreneurs were confident about their capabilities to start a new business due to a supportive environment created by the government, access to funding, and networking opportunities. Another report by the International Finance Corporation [6] also found that there have been significant efforts by governments worldwide to create an enabling environment for women entrepreneurs, such as providing access to training, technical assistance, and financial resources. --- Conclusion This study has investigated the perception of women entrepreneurs on the social and business environment in Bihar. The findings of the study suggest that women entrepreneurs have a generally positive perception of the social and business environment. However, there are still a number of areas where improvement is needed. These areas include increasing access to training facilities, creating a more women-friendly environment at public institutions, and improving the quality of assistance provided by the government. The findings of this study have implications for policymakers and other stakeholders who are interested in promoting women's entrepreneurship. These stakeholders can use the findings of this study to develop policies and programs that will help to create a more supportive environment for women entrepreneurs. --- Recommendation To overcome the lack of training and skill the interventions by stakeholders may include creating gendersensitive financial regulations, providing mentorship, training, and networks, and promoting gender equality and empowerment through education and advocacy. To improve access to credit and financial resources for women entrepreneurs, policymakers, financial institutions, and other organizations need to create targeted interventions that address the specific challenges faced by women. These may include providing gender-sensitive financial services, reducing collateral requirements, and increasing training and education opportunities for women in finance and entrepreneurship. Such interventions can enhance women entrepreneurs' access to credit and financial resources, promote their ability to start and grow businesses and contribute to more inclusive and thriving business ecosystems.

Women entrepreneurs have the power to overcome several challenges, including creating an environment of equity, finding equilibrium, and ensuring sustainable socio-economic development. Women's Entrepreneurship development is greatly influenced by factors such as economic, financial and sociocultural. To increase a better understanding of how women perceive their social and professional environments the present study was conducted in Vaishali district of Bihar. The study employed an ex post facto research design. A total of hundred women entrepreneurs were randomly selected for the purpose from four out of sixteen blocks in Vaishali district. A survey schedule was developed for the collection of data based on pre-testing. To know about the perception of women entrepreneurs about the social and business environment, they were asked to rate their responses on five-point rating scale. The collected data were then analyzed. The study found that the majority of women entrepreneurs felt that a positive environment for women to enter into business has been ensured. They also agreed that societal barriers had diminished as well.

This study was part of a qualitative rapid assessment of information and prevention needs among ethnic and racial minorities living in Antwerp during the first COVID-19 wave in 2020. We used an interpretative and participatory ethnographic approach, conducting semi-structured interviews to explore personal experiences and a focus group discussion to capture community perceptions and attitudes. Data were collected online or by phone between April and September 2020. A community advisory board was set-up to advised on recruitment of participants, data collection and interpretation of findings. Data were transcribed and analysed using a thematic analytical approach. A total of 27 participants were included. Results showed that study participants and people in their social networks received information mostly through social media, and struggled with misinformation about the new virus and prevention measures. The combination of intersecting social and economic disadvantages made coping with control measures difficult for those living in precarious circumstances. Structural disparities combined with a lack of information made it particularly challenging to adhere to COVID-19 prevention guidelines, leading to vicious cycles. Despite those COVID-19-related challenges, the pandemic also provided important lessons about social resilience and coping strategies of SSA communities in Antwerp. Communities developed a number of community-based initiatives. Community and religious leaders improvised ad hoc solutions to challenges, from filling-in knowledge and information gaps among their members to developing creative solutions to mitigate the multi-layered impact of the lockdown measures: Ddungu: Responding to the information and prevention needs of sub-Saharan African communities in Antwerp at the beginning of the COVID-19 pandemic translating prevention messages, fighting misinformation, providing food packages for those in need, helping with administration, etc. To better design support and control strategies targeted to specific groups, such as racialised and ethnic minorities, we need not only to involve communities in developing an adequate response by addressing their specific needs and concerns, but also build on their strengths and resilience. This will remain important in the context of widening disparities and future epidemics. This presentation targets people with prevention and care needs and healthcare policy makers. The lessons from our research will be discussed with the view on co-design of prevention strategies for future crises.

communities in Antwerp at the beginning of the COVID-19 pandemic.

The Exhibition Program, part of the History of Medicine Division of the National Library of Medicine (NLM), spotlights NLM collections by creating exhibitions and educational resources that explore the social and cultural history of medicine. The program's goal for showcasing NLM's collections in exhibitions is to stimulate people's enthusiasm for history and encourage visitors of all ages to learn more about themselves and their communities. We do what we do because we believe that health and well-being are fundamental human rights and are essential to our American way of life, and we believe exhibitions are a logical expression of that commitment. In the series of exhibitions that examine the relationship between medicine and the arts, NLM launched a new project: Graphic Medicine: Ill-Conceived and Well-Drawn! This exhibition explores graphic medicine, an emerging field of medical literature in which patients and their loved ones, caregivers, and health professionals tell stories about health and illness through the medium of comics. In graphic medicine, artists and authors use a combination of words and images to present powerful and informative narratives and understandable health information to their audiences. For patients, graphic medicine promotes health literacy and often provides a therapeutic artistic experience. For health professionals, the genre serves as a gateway to understanding the patient experience and fosters effective treatment strategies. Writing in 2012 for Medical Humanities, physician, educator, artist, and graphic medicine pioneer Ian C. M. Williams published a background and overview of the field. In his article "Graphic Medicine: Comics as Medical Narrative," Williams asserted: The comics medium, due to its unique and specific properties, is ideally suited to portraying the subjective experiences of the author with regard to illness and suffering and is furthermore ideally suited to the education of both the public and professionals and that published graphic memoirs of suffering may be of help to the similarly afflicted, or careers and family of the ill. [1] COLLECTION DEVELOPMENT NLM exhibitions often focus on underrepresented subjects or lesser-known types of literature, which helps to inform NLM's collection development activity. Collection development staff take a keen interest in viewing exhibitions, attending related History of Medicine Division lectures and special display tours, and performing bibliographic research on topics that are unlikely to be captured in conventional scientific and professional literature. This heightened awareness leads staff to discover niche publishers, significant authors, and unique titles, thereby enriching the collection for future generations. --- FIRST STEPS NLM collection development staff initially encountered comics as literature in the 1990ssomewhat by accident. The first modern graphic works that staff reviewed were manga-style comics produced for Japanese health professionals and medical students. Collection development staff, which included an East Asian specialist, received a few such publications. After a lively discussion, staff decided to collect five examples of these Japaneselanguage monographs because of their unique cultural and historical value. Although there were a few contemporary, break-out graphic novels developed for Western audiences (Will Eisner's A Contract with God and Other Tenement Stories, 1978; Art Spiegelman's Maus, 1986; Alan Moore and Dave Gibbons's Watchmen, 1987), it was not foreseeable that the publication of graphic nonfiction would expand to the medical arena and find acceptance by an American audience. Fast forward to 2014: the Exhibition Program staff began researching the possibility of developing a project that would become Graphic Medicine: Ill-Conceived and Well-Drawn! For this exhibition, we wanted to work with a guest curator who would be able to communicate the power of graphic medicine to diverse audiences in an exhibition format. Who better to collaborate with than an award-winning graphic medicine author and artist? We invited Ellen Forney-who published the highly regarded graphic medicine work about her struggles with bipolar disorder and creativity, Marbles: Mania, Depression, Michelangelo, and Me (2012) (Figure 1)-to collaborate with us, and she agreed! The curatorial and research team for this project asked, "If graphic medicine is important enough to be featured in a new exhibition, should NLM also consider collecting works of this type?" At the time, NLM's collection development staff took the opportunity to learn more about graphic medicine and, again, to consider collecting it. --- EXPLORATION OF THE GENRE Forney collaborated with the NLM collection development staff in its exploration. Forney is active in the comics field; she is an educator and advocate for the power of graphic medicine. She identified forty-eight titles for NLM to review. Library staff also examined bibliographic databases, publisher and vendor title lists, and graphic medicine websites to identify additional selections for the collection. Initially, collection activity focused on widely disseminated works, such as Roz Chast's Can't We Talk about Something More Pleasant? (2014), a renowned cartoonist's memoir of caring for her aging parents. Staff sought works-some humorous, some harrowing, but all engaging-by patients, caregivers, and health professionals from diverse backgrounds and with unique viewpoints. The intention was not to collect all graphic medicine titles, but to assemble a representative collection that would likely have long-term appeal. To round out the collection, staff also acquired scholarly monographs about the genre. While some graphic titles are available in print, many worthy titles exist only on the web. NLM has begun planning for the addition of graphic medicine to its web collecting and archiving program that utilizes the Archive-It web archiving service. It will join other NLM web collections, such as Global Health Events, Health and Medicine Blogs and Disorders of the Developing and Aging Brain: Autism and Alzheimer's on the Web. --- FRAMING OF A COLLECTING PHILOSOPHY The purpose of NLM, as outlined in the US Code, is "to assist the advancement of medical and related sciences and to aid the dissemination and exchange of scientific and other information important to the progress of medicine and to the public health" [2]. As new medical concepts, approaches, and disciplines proliferate, NLM assesses the worthiness of the associated literature within the framework of the Collection Development Policy of the NLM, fourth edition, which lists five criteria for selection. The materials must: • Record progress in research in biomedicine and the related areas of the life sciences, • Document the practice and teaching of medicine broadly defined, • Demonstrate how health services are organized, delivered and financed, • Chronicle the development and implementation of policy that affects research and the delivery of health services, and • Illustrate the public perception of medical practice and public health. [3] The team considering graphic medicine determined that this literature should be part of the NLM collection for the following reasons: 1. Graphic medicine records progress in research, especially from the perspective of the patient. 2. Increasingly, graphic medicine makes a dynamic contribution to the medical education of physicians, especially in medical humanities curricula. Through graphic novels, physicians explore the creation of graphic narratives and learn about how the health care system is experienced by patients. 3. Graphic medicine is well positioned to expose the development and implementation of policies that affect the delivery of health services. With their emphasis on the receivers of health service-specifically, the patients-graphic novels are exceptional, clear focused, and straightforward. 4. Similarly, graphic medicine presents a frank description of the public's perception of medical practice. If the objective is to collect works that capture a wide range of health-related behaviors, trends, and viewpoints and to chronicle experiences and perspectives not found in scientific, technical, and professional medical publications, then graphic medicine not only conforms to the objective, but also plays a unique role in the corpus of medical literature. --- FINAL NOTES The graphic medicine initiative is one example of the ways in which different program areas of NLM help to inform, strengthen, and expand the collection. Thus far, NLM has acquired some forty titles that are part of the graphic medicine genre and continues to seek additions to this fledgling collection. NLM hopes that medical literature patrons around the world will enjoy and learn from the many unique and fascinating graphic medicine works by patients, family members, and health professionals. These publications not only are of interest to contemporary readers, but also are likely to fascinate future historians, medical sociologists, and medical --- AUTHORS' AFFILIATIONS

The Exhibition Program, part of the History of Medicine Division of the National Library of Medicine, spotlights the collection of the library by creating exhibitions and educational resources that explore the social and cultural history of medicine. Our goal is to stimulate people's enthusiasm for history and encourage visitors of all ages to learn more about themselves and their communities. We do what we do because we believe that health and well-being are fundamental human rights and are essential to our American way of life. And we believe exhibitions are a logical expression of that commitment. Oftentimes, exhibitions focus on underrepresented subjects or lesser-known types of literature, which helps to inform the library's collection development activity. Collection development staff take a keen interest in viewing exhibitions, attending related lectures, and performing bibliographic research on topics that are unlikely to be captured in conventional scientific and professional literature. This heightened awareness leads staff to discover niche publishers, significant authors, and unique titles, thereby enriching the collection for future generations. Following the decision to embark on an exhibition about graphic medicine, collections staff more closely investigated this class of literature. This column explores how wider social and cultural influences can change the medical literature and inform and enrich the collections policies of an institution.

Introduction Introducing the LMD system in Algeria aims at developing competency and enhancing critical thinking among learners which is the challenge of modern education. Reaching a high level of thinking entails a successful learning process. Such thinking, when being achieved, is not useful only at university but lasts forever and will influence the socialization process of learners as well as their capacities in raising issues and defining the perspectives of their future life. In an era of communication where computers are used in all the domains and are found everywhere, the 'Y' generation is very 'connected' to the web. Teachers and students communicate through 'facebook' and all research goes through internet. It becomes obvious that introducing Information Communication Technologies (ICTs) in university studies is necessary. However, what should we teach in foreign language classrooms? It seems that this module goes beyond teaching computing to our students and focuses more on how using ICTs to support learning and developing thinking. --- Enhancing Critical Thinking Many conceptions of critical thinking find their definitional origins in Dewey's (1910) writings. He distinguishes between all that goes through the head and mind named as 'thinking' and how we think referred to as 'reflective thinking'. It is as (DEWEY. J, 1910:1) states "the ground or basis for a belief is deliberately sought and its adequacy to support the belief examined". For further clarifications, let's raise the following issue: what does the word 'whale' mean to the reader? --- Figure1. Critical Thinking Process The diagram above highlights the level of thinking of different individuals. Some define whales as big beautiful animals and others believe that they are determinant elements for the survival of life on earth. On the other hand, Paul (1995) views critical thinking, from a philosophical point of view and primarily approached, as the norm of thinking, the rational aspect of human thought and as the intellectual virtues needed to approach to the world in a reasonable way. The same concept is defined from a cognitive psychological approach in (STEMBERG. R, 1986: 3) as "the mental processes, strategies, whale mamals ocean disappear --- Lack of oxygene --- Plankton --- Suffocation --- Death of Man No more life on earth and representations people use to solve problems, make decisions, and learn new concepts" while (HALPEM. D, 1998:450) adds that it is "the use of those cognitive skills or strategies that increase the probability of a desirable outcome". Besides, critical thinking is identified as a purely cognitive and involves various mental capacities to process knowledge and "seeing both sides of an issue, being open to new evidence that disconfirms your ideas, reasoning dispassionately, demanding that claims be backed by evidence, deducing and inferring conclusions from available facts, solving problems, and so forth". (WILLINGHAM. D, 2007: 8) --- Bloom Taxonomy and Critical Thinking Among the educationalists who introduced critical thinking in learning are Bloom et al; (1956). When elaborating Bloom's taxonomy, the focus went on three main domains: Cognitive Domain, Affective Domain and Psychomotor Domain. The taxonomy in question, classifies 'knowledge' at the bottom and 'evaluation' at the top whereas 'comprehension, application, analysis and synthesis' are the cognitive and metacognitive elements that process data as shown in the figure bellow: In the light of this classification, it is clearly noticed that data goes through various steps before the learner reaches evaluation and determines whether he has really grasped it in order to able to use it when being in another learning situation. Acquiring knowledge is a natural process that starts at a very young age. It involves many parameters like language, family and peers, socio-cultural elements… It also needs a whole mental process that allows its internalization and use in solving other experiments. All these cognitive and metacognitive processes are achieved through 'Language of Thought', as named by (Pinker. S, 1996: 70-81), for "People do not think in English or Chinese or Apache; they think in language of thought.... probably looks a bit like all these languages; presumably it has symbols for concepts, and arrangements of symbols that correspond to who did what to whom". --- Social Function of Critical Thinking Promoting thinking is essential for development of the whole society. According to Facion (2011: 11), Critical thinkers include: In fact, reaching this high level in thinking can be achieved through a successful learning process shaped by an adequate methodology, a coherent syllabus and an evaluation system that focuses on comprehension and structuring data. Among the elements that may contribute in developing such thinking is the use of Information Communication Technology at all levels of the educational system including university. --- Information Communication Technology at University In an era of technology, computing is part of our everyday life. It is involved in all the domains including learning. In all the developed countries using Information Communication Technology (henceforth ICT) starts at the primary school. In the light of the works of Rathore (2011), the use of ICTs in the learning teaching process is very beneficial and useful. It makes the learner more involved in the process he is undertaking rather than being an external element who only memorizes data. Rathore (2011) has summarized the phenomenon in the following points: ---  The learner processes data easily (when using the audiovisual). ---  --- It develops communication among learners. ---  The pupil is in control of the lesson. Teaching through ICTs involves learners in their learning process since it contextualizes lectures. Using the audiovisual concretizes learning since it provides learners with supports that facilitate comprehension and newly introduced notions are clearer. --- ICTs in the LMD System In the Algerian university, with the LMD system, in the ancient canvas, teaching ICTs was introduced in the 'Transversal' unit. What was noticed is that computing engineers were in charge of this module. The syllabus taught was more devoted for students of computing than foreign language learners. Thus, students start to complain. In the year 2013-2014 a new canvas, proposed by the ministry of higher education concerned only the first two years S1, S2, S3, S4. In the year 2015-2016, a new canvas was given by the Ministry of Higher Education to teachers who were required to determine contents of modules where no ICTs were introduced except in the fourth semester. However, in all the canvas of master in the transversal unit ICTs are introduced. In the master we have opened, named 'Psycholinguistic Issues in English Learning' the time devoted for ICTs is two hours each week that makes 28 hours in the semester. It is taught by a teacher whose field of interest is didactics and masters the use of computers. It aims at: --- Learning ICTs' Outcomes In Algeria, teaching ICTs in the LMD system is evaluated through an exam and a TP mark. Yet, no computers are available in our department to support learning. The second year promotion of the year 2014-2015, is made of 231 students divided among of 14 groups. Lectures are given through TDs in small classes. What is noticed is that the syllabus focuses on teaching theory and not practice. For exams, they are given exercises of computing and the TP marks include the participation in the classroom, assiduity and presence. The outcomes of students are shown below: In the light of the results above, it is clearly noticed that the rate of failure is two times higher than that of success. We wonder why such phenomenon takes place with the 'y' generation whose main means of communication is social networks and smartphones. Moreover, if we fail in teaching ICTs how can we expect them to enhance critical thinking? --- Conclusion The heart of any successful learning is to construct a knowledge useful not only in the classroom but in the everyday life of learners. Motivation is higher and students are more involved when using ICTs. However, the content of the module of ICTs should correspond to the needs of EFL classrooms. It should more focus on learning through ICTs and how to use ICTs in making research and not computing. Using modern technology when teaching English makes learners more active since they are learning in concrete situations and all the topics are contextualized. Moreover, it also raises debates and develops critical thinking.

Starting from the assumption that learning is a mental process shaped by cognitive and metacognitive capacities and that the LMD promotes developing competency, this work unfolds the role of this newly introduced system in enhancing critical thinking. This paper highlights the way Information Communication Technologies are used in our university and exhibits their contribution in developing critical thinking. For this, we will primarily study different elements that enhance critical thinking and its social function, and then move to the role Information Communication Technologies play in its development. The final step analyses fourth semester's students' outcomes and drawbacks when dealing with this module in the department of English.

Introduction "Prevent alcoholism, save the life and society" Alcoholism refers to the use of alcoholic beverages to the point of causing damage to the individual, society or both. In India the alcohol addiction is more common and the disorders are also increasing. About 75% of the adults in India are regular drinkers. Most of the family problems and other violence are arising due to alcohol consumption [1] . The major physical disorders such as cardiac disease, Liver disorders, and nephritic disorders are common in alcoholic person. Long-time use of alcoholism may affects to social and occupational functioning, creating personal, professional, financial and legal problems. The alcoholic use in early adolescents may leads to the psychological problems such as emotional and behavioural problems, depression, schizophrenia, echolalia, mood disorders and sexual dysfunctions etc [2] . The various forms of violence such as gang behaviour and drug related violence are increasing day by day. The types most often described by the psychiatric patients are family violence, nonfamily rape and sexual assault. Family violence is a range of harmful behaviour as that occurs between family and other household members. It includes physical and emotional abuse of children, child neglect; abuse between adult estimate partners, marital rape and elder abuse violence may be a family secret and given conditions through generations and above may be caused by an interaction of personality, demographic, biological, and situational and socio cultural factors. The United States has a high level of violence compared with other nations [3] . Some of the biological factors are also affecting the person to take alcohol, more than half of the current drinker has a family history of alcoholism. Much evidences from adoption, twin and animal studies indicates hereditary is significant in the development of alcoholism. Many studies estimates that the alcoholism is a tendency towards anxiety, anger, low selfesteem, and negative feelings [4] . ~ 71 ~ Many psychological theories have attempted to explain the factors that predispose people to developing substance abuse. Psychoanalytic theories says that, alcoholics as being fixated at the oral stage of development thus seeing need satisfaction through oral behaviours such as drinking. Clinicians have observed a link between substance above and several psychological records such as depression, anxiety, antisocial personality and depended personality. Some substance abuse have psychological problems related to adverse childhood experiences and parental alcohol abuse. Most of them have low self -esteem and efficiently expressing emotions. These problems may have influenced the critical use of alcohol [5] . Socio cultural factors also influence the addiction of alcoholism. Some of the sociocultural factors such as attitudes, values, norms, religion, gender, family backgrounds, and social environment etc. Affects for the use of alcohol. Formal religion belief also affects drinking behaviour. Gender differences also have been noted in the prevalence of substance abuse [6] . --- Need for The Study According to WHO 2017, the statistical finding on consumption of alcohol in worldwide is 140 million, India 42.7%, Andhra Pradesh -37% and Nellore about 18% [7] . According to Department of Health (2015) estimates, in worldwide about 65% of adults, India about 75% and about 22% of adults are using alcohol daily and in this about 8% are women [8] . The onset of alcoholic use before age 20 years predicts more sustain use over time from 70%-90% of males and 50%-60% of females who abuse alcohol in the adolescence continue to do so in the adult life. The first use of alcohol at the age of 11 to 14 years greatly increases the risk of development of an alcohol disorder. Mostly this condition is due to the changes in life style and also due to poor family co-operation, stress, anxiety and superstitious believes and cultures. Some teenagers use alcohol to decrease their anxiety especially when socializing [9] . Studies estimates that new risk for developing Breast cancer and a link to mental illness are due to over usage of alcohol. The alcohol consumption affects women than men. Also most of the liver diseases about 14,406 peoples accidents and homicides about 23,199 peoples are due to the over usage of alcohol. Most of the psychosocial as well as family problems are due to the long-time use of alcohol [10] . A descriptive cross sectional study was conducted on assessment of prevalence and perceived health effects of alcohol use among male adolescents in Owerri, south east Nigeria. Questionnaire method is used for data collection. The sample size was 482 males. The result showed that the current use of alcohol was 348, with 128 of them being heavy drinkers, 225 of them had health problems. The study concluded that there was high prevalence of alcohol use established among study groups [11] . --- Statement of Problem A study to assess the prevalence of alcoholism and psychosocial problems among adults in Akkuthotta Village at Nellore, Andhra Pradesh. --- Objectives  To assess the prevalence of alcoholism among adults.  To identify the psychosocial problems related to alcoholism among adults.  To find the relationship between prevalence of alcoholism and psychosocial problems.  To find out the association between prevalence of alcoholism and psychosocial problems with selected socio-demographic variables. --- Delimitations  Adults living in Akkuthotta Village at Nellore.  Sample size of 100 children. --- Methodology Research Approach A quantitative approach was adopted to determine the research study. --- Research Design The present study was conducted by using descriptive research design --- Setting of The Study The study was conducted at Akkuthotta Village at Nellore. --- Population Target Population The target population for this present study includes all adults. --- Accessible Population The accessible population for the present study includes adults living in rural area, Akkuthotta at Nellore and who fulfilled the inclusion criteria. --- Sample The sample for the present study was adults. --- Sample Size The sample for the present selected from 100 adults. --- Sampling Technique Probability Stratified random technique was adapted for the study. --- Criteria for Sampling Selection Inclusion criteria  Adults with age group of 20-60 years.  Adults who are present in Akkuthotta at the time of data collection.  Adults who are suffering with psychosocial problems due to alcoholism. --- Exclusion criteria  Adults aged More than 60yrs of age.  Adults who were not available at the time of data collection. --- Variables of The Study Research variables: Prevalence of alcoholism and psychosocial problems. Demographic variables: Age, sex, education, occupation, income and religion and personal habits, marital status, place of residence and history of alcoholism. --- Description of The tool Part-I: It deals with socio demographic variables. --- Part-II: An observational checklist to assess the prevalence of alcoholism. --- Score interpretation --- S. No

Background: Alcoholism refers to the use of alcoholic beverages to the point of causing damage to the individual, society or both. In India the alcohol addiction is more common and the disorders are also increasing. About 75% of the adults in India are regular drinkers. Most of the family problems and other violence are arising due to alcohol consumption. Aim: The aim of the study was to assess the prevalence of alcoholism and psychosocial problems among adults. Objectives: 1. To assess the prevalence of alcoholism among adults. 2. To identify the psychosocial problems related to alcoholism among adults. 3. To find the relationship between prevalence of alcoholism and psychosocial problems. 4. To find out the association between prevalence of alcoholism and psychosocial problems with selected socio-demographic variables. Methodology: 100 adults from rural area, Akkuthotta, Nellore were selected by using stratified random sampling method.The study concluded that almost half of the adults 42(42%) were mild alcoholics and 44(44%) adults had psychological problems due to alcoholism. The co-relation between the prevalence of alcoholism and psychosocial problems was +0.89.

Perspectives on Politics

Perspectives seeks to nurture a political science public sphere, publicizing important scholarly topics, ideas, and innovations, linking scholarly authors and readers, and promoting broad refl exive discussion among political scientists about the work that we do and why this work matters. A full-length copy of the journal's editorial philosophy appears in Perspectives on Politics 8(1): 7-10 and also on the web at https://www.apsanet.org/perspectivessubmissions.For submission guidelines, please see https://www.apsanet.org/perspectivessubmissions. Our editorial team discusses all submissions. Those that seem promising are evaluated by several external reviewers-with full confi dentiality on both sides-and then accepted, returned for further revisions, or declined with suggestions of more appropriate venues for publication.

nants of health, or conditions in the environment in which people live and work, including poverty, unemployment, and lack of health insurance. [9][10][11][12][13] Results of the Community Partners in Care (CPIC) study (http://www.communitypartnersincare.org), a clusterrandomized controlled trial, show the benefits of a partnered approach to designing a community-wide depression QI program. CPIC findings suggest that, compared with providing technical assistance to agencies, engaging diverse health care and community-based agencies in planning and implementing a depression QI program in their community 14,15 improved mental health-related quality of life, increased physical activity, reduced homelessness risks factors and behavioral health hospitalizations among depressed individuals, and shifted delivery of mental health services toward community-based agencies. 16,17 Based on CPIC findings, the Los Angeles County (LAC) Board of Supervisors added the Department of Mental Health's (DMH) HNI 18 to the LAC's strategic plan. HNI was designed to increase existing mental health, substance use, health care, and social services for low SEP minorities. DMH leadership invited CPIC partners to support HNI's development to ensure its relevance and cultural appropriateness for communities distrustful of research and publicly funded services. 19,20 In preparation, academic and community members of the CPIC study steering council conducted a community-wide conference 21,22 to share CPIC findings and engage patients, providers, and representatives of community organizations in identifying HNI's main focus. The main conference activity was a Delphi-based consensus-building exercise 23,24 to assess community needs and prioritize social determinants of mental health to be addressed within the HNI. The Delphi method is based on the idea of iterative data collection, which allows participants to learn about and discuss the responses provided by others and then revise their answers in light of the discussion. This method has been used successfully in other studies to assess community needs and priorities. 23,24 The goal of this manuscript, which was written by CPIC academic and community partners who have been working together for more than 7 years on a wide range of communityacademic partnered mental health research projects, is to describe and summarize the Delphi process and its results to 1) illustrate how community-based organizations, patients, families, and community members could be systematically engaged in the process of designing community-wide health policy initiatives, 2) show how community engagement has already affected HNI design and implementation, and 3) explain how community engagement could be used for collaborative policy planning in other communities. Our manuscript illustrates how participatory research partnerships can support policy development and implementation at the local level by informing policymakers about community preferences and needs and working with them on designing large-scale interventions that are likely to be accepted within community. 25 --- METHODS The community conference co-organized by academic and community members of the CPIC steering council took place on September 12, 2014 in South Los Angeles, a predominantly minority, low SEP community. Eighty-six stakeholders from South Los Angeles and Hollywood, including people with depression, mental health professionals, DMH employees, social workers, researchers, case managers, and clergy, all of whom had a significant experience and expertise in either dealing with, or helping those suffering from, depression attended this conference. Most attendees had also participated in previous local, community-based, long-term, communityacademic partnered research initiatives and were knowledgeable about research process and the needs of depressed individuals living in Los Angeles. Conference attendees were not compensated for their time, but were served breakfast and lunch and were eligible to receive CME/CEU credits. Conference attendees participated in a two-round Delphibased exercise, 24 which was co-conducted by an academic (D.K.) and a community (P.W.) partner, who worked together to develop a Delphi protocol, design data collection sheets, and determine the best analytic approach. All data collection activities were reviewed and approved by the RAND's Human Subjects Protection Committee. We chose a Delphi approach, instead of a survey, to allow participants to respond based on their own professional and personal experience first, and then to revise their initial responses based on the new information they received during the conference. 23 In round 1, participants rank-ordered eight needs of depressed individuals with the goal of prioritizing the needs to be addressed first so the HNI could have the greatest likelihood of improving depressed individual's overall well-being. Participants were instructed to consider how much the overall wellness could be improved if not only low mood, but also each of these needs, or social determinants of mental health, could be addressed. The needs, which participants rank-ordered from 1 (highest impact) to 8 (lowest impact), included finding housing, accessing quality health care, improving relationships with others, improving spiritual wellbeing,* finding work, getting benefits (i.e., unemployment, food stamps), improving mental wellness, and combatting racism and racial violence. The first six needs were identified as part of an ongoing qualitative study of people living with depression (see below); Trained community or academic partners facilitated discussion groups using a semistructured protocol and encouraged participants to explain how collaboration among community agencies could help to address these needs. Notes were taken during the discussion by the facilitators to capture participants' reasons for ranking a given need as their top priority. After discussion, participants who did not leave the conference after lunch provided their round 2 rankings of needs. We used two analytic approaches to rank order the needs to ensure robustness of our findings. We first rank-ordered the needs based on the mean ranks and then based on the percentage of participants selecting a particular need as their top priority. We qualitatively summarized participants' discussion comments related to each need to contextualize ranking results. In particular, we were interested in understanding why some participants ranked a given need highly, whereas others did not do so. --- RESULTS Seventy-five percent of participants were female and 43% were African American. Twenty-nine percent represented mental health agencies, 19% were community members (including depressed individuals), 16% represented social services agencies, and the remaining 36% represented religious, primary care, substance abuse, homeless, public health, and academic agencies/institutions. Results are based on the input from 68 participants answering all ranking questions in both rounds (79% of conference attendees). Seventy-four percent of participants changed at least one of their answers between rounds. When ranks were changed, the typical change was plus/minus one ranking place, and it did not affect the top priority. access to health care moved to the bottom. Participants varied in their perspectives on addressing mental wellness: whereas more than one-fifth of participants considered this need to be their top priority in both rounds, one-quarter of round 1 participants and roughly one-third of round 2 participants put it at the bottom of their list. To describe mental wellness, participants used a variety of terms, including joy, mindfulness, and self-esteem. Those who prioritized mental wellness often argued that mental wellness encompasses other needs and is the basis for taking care of all other needs. They stated that being mentally well helps people to make good deci-sions about themselves and people around them, which is a prerequisite for helping others. Those participants, especially clinicians, who put this need at the bottom of their lists often felt that mental wellness was already included as a component of other needs and therefore should not be prioritized on its own. Finally, in ranking access to health care, the majority of participants placed this need consistently in the middle of their lists, with only 6% making it their top priority. Although some participants felt that access to quality health care was very important for addressing mental health needs, others argued that addressing health care needs was not as important as addressing some other needs on the list. --- DISCUSSION Our results illustrate a wide range of opinions about how best to help depressed Angelenos, which may be partially explained by the diversity of conference attendees' backgrounds and complexity of the issue. Conference attendees, however, agreed that community-wide collaborative efforts to address depression among ethnic minority and low SEP populations in LAC may have the highest impact on the overall well-being of depressed individuals if community agencies can help them to find stable and affordable housing. Indeed, housing was ranked number 1 in both rounds and using both analytic approaches. Addressing unemployment, emphasizing mental and spiritual well-being, and facilitating access to quality health care were also deemed important. These findings suggest a strong community preference for a multiprong HNI that addresses not only social (housing and employment), but also Health Home. 27 In particular, CPIC leaders contributed to the discussion of incentives to support collaborations across historically siloed sectors to improve outcomes through evidence-based integration strategies, such as depression collaborative care, while addressing social determinants of health, such as housing and employment. Although sensitive to the analytic approach and limited to the perspective of conference attendees, the vast majority of whom have participated in previous community-wide initiatives, our findings illustrate the importance of addressing housing needs of depressed individuals, while paying attention to their social, spiritual, and health care access needs. Therefore, we recommend that new policies designed to address depression in under-resourced communities account for social, spiritual, economic, and political factors. We also suggest that a successful planning and implementation of a depression health care agenda may require engagement around social determinants of mental health to generate community buy-in. We recommend that community members, academics, and policymakers consider using the Delphi-based method described in this paper to inform the design and implementation of evidence-based policy initiatives. If carefully designed to account for community priorities and implemented in a partnered manner, such initiatives are likely to be more relevant to communities' needs and have a strong potential to positively affect the lives of a large number of individuals.

epressive disorders are the leading cause of adult disability in the United States, 1,2 are associated with reduced quality of life, and are risk factors for physical health problems. 3 Although depression is prevalent in all ethnic groups, compared with Whites, racial/ethnic minorities have less access to evidence-based depression care and worse treatment outcomes. 4 Similarly, individuals with lower SEP (i.e., low educational attainment, low income) tend to have higher rates of depression than more affluent individuals. 5 Depression QI programs based on chronic disease management models have been shown to improve depression outcomes, 6,7 particularly for minority and low SEP populations. Nonetheless, access to such programs is limited in minority, under-resourced communities. 8 Furthermore, improvements

In this issue, the article by Huang et al. (1) joins 3 other American studies (2)(3)(4), 5 studies of European populations (5)(6)(7)(8)(9), and 1 study carried out in Hong Kong, China (10), all in recent years, that have considered how grandparental education is associated with grandchildren's health. Huang et al. examined the relationship between grandmaternal education and grandchild's birth weight in a US study, the National Longitudinal Study of Adolescent to Adult Health (Add Health). Using marginal structural models, they found a positive association between grandmaternal educational attainment and grandchild birth weight that was independent of the maternal characteristics for which they were able to adjust, and they concluded from a quantitative bias analysis that their results were not likely to result from an unmeasured mediator-outcome confounder (1). It is useful to contextualize Huang et al.'s work within the larger body of literature on education and health. Researchers have concluded that the relationship between education and health is probably bidirectional, such that education affects later health outcomes but early-life health can also affect educational trajectories (11,12). However, since Huang et al. focused on how education can affect health, we will focus primarily on this line of research. Additionally, as in the majority of such studies, Huang et al. focused specifically on the role of educational attainment (1), but it is important to note that other dimensions of the educational experience, including quality, also affect health (11). Within a single generation, hundreds of studies have considered the relationship between educational attainment and health (13)(14)(15). Investigators have generally concluded that higher educational attainment is associated with better outcomes across a wide array of health measures. Intergenerational associations between higher parental education and better child health have also been well documented in the lifecourse and social epidemiology literatures. These studies generally use parental education as a measure of childhood socioeconomic status, often in conjunction with other socioeconomic measures such as parental occupation or family income. Higher parental educational levels have been related to better birth outcomes (16,17) (of particular relevance to Huang et al.'s proposed mechanism of maternal uterine environment (1)) but also to a host of other behavioral, clinical, and mortality outcomes throughout the offspring's life course (18)(19)(20)(21)(22)(23)(24)(25)(26). The much smaller body of literature investigating grandparental education, including the study by Huang et al. (1), has examined relationships with grandchild birth weight and adult weight, adult height, health status, and mortality (1-10). These studies have generally associated higher grandparental education with better grandchild health, but some researchers have reported null findings (4). The persistence of associations after accounting for parental characteristics has also varied by study. The question of the extent to which and the manner in which any effects of grandparental education are mediated by parental characteristics remains an open one, and we welcome Huang et al.'s contribution in this respect. There are many mechanisms by which educational attainment may affect health outcomes in a single generation and in subsequent generations. Cohen and Syme (11) outlined several possible mechanisms for how education can affect health over a single life course, and many of these mechanisms also apply to subsequent generations. For example, education can affect adult socioeconomic position (27), which in turn affects the childhood socioeconomic position of the subsequent generation (28), which likely has health effects across the life course (29)(30)(31). In addition, studies of cumulative advantage suggest that childhood socioeconomic position also affects that individual's educational attainment (32), which can then begin the cycle anew to affect a third generation. More aligned with Huang et al.'s focus on the intrauterine environment (1), educational attainment can also affect health behaviors (33), including potentially healthy behaviors related to pregnancy (34,35). These maternal behaviors could in turn affect the educational attainment (36) and health (37) of the subsequent generation. This issue reflects the broader ongoing challenge in studying social exposures such as education in defining what we mean by direct and indirect effects. There are myriad interconnected ways in which a grandmother's education may influence a mother's life experiences that are relevant to pregnancy outcomes, including environmental exposures, residential neighborhood characteristics, family composition, psychosocial pathways, and nutrition, among others. Given these complex causal pathways, it is virtually impossible to account for a limited set of mediators and then define meaningfully the causal mechanisms driving the resulting estimated direct effect. While we agree with Huang et al. that their results are consistent with hypothesized effects of grandmaternal education on birth weight via maternal intrauterine exposures (1) and would welcome future research in this vein, we would suggest caution in attributing the unmediated ("direct") association of a social exposure with a health outcome to a specific causal mechanism. Similarly, while Huang et al.'s finding that a single, binary mediator-outcome confounder would need to influence birth weight strongly or be very unbalanced across exposure levels to account completely for their result (1) is reassuring, it is plausible that a set of confounders, taken together, could fit this description. The multifactorial approach valued by social epidemiology (38) suggests it is unlikely that there is any strong single unmeasured confounder but rather more likely that there is a set of multiple, interrelated unmeasured confounders that could bias the findings. Complicated causal structures between exposures, confounders, and mediatorscommon in social epidemiology-can complicate bias analyses (39). However, this bias analysis is still a useful exercise for assuaging some concerns readers may have, and we encourage social epidemiologists and others to follow Huang et al.'s example in incorporating bias analyses, particularly when results are modest in magnitude and the goal is to draw some causal inference from them (40). In addition to grounding the study of mechanisms within social epidemiology, it is also worth considering the exposures of interest themselves. Huang et al.'s focus on grandmaternal education is reasonable given their interest in the intrauterine environment and previous findings of a stronger influence of maternal education than paternal education on child health (41). However, this is not to say that paternal (and by extension grandpaternal) education does not also play an important role. Indeed, there is some evidence that paternal education is related to birth outcomes independently of maternal education (42)(43)(44). Paternal education may more strongly predict household socioeconomic resources than mother's education or may affect the intrauterine environment by influencing the mother's use of prenatal care, behaviors (such as smoking or alcohol drinking), or experiences of stress (42,45). Besides the theoretical and analytical challenges posed by potentially overlapping but distinct multigenerational effects of education on the maternal and paternal side, there is the practical challenge that sources of multigenerational data containing information about both the paternal and maternal lineage are exceedingly rare. Another challenge is that logistical limitations in amassing multigenerational data will often lead to analytical samples that are highly selected. As we mentioned above, there will often be data on only the paternal or maternal lineage. Depending on the sampling scheme, the age range of 1 or more of the generations is also often limited. In the Add Health data used in Huang et al.'s analysis (1), grandmothers (G0s) might have been of any age but the oldest mothers (G1s) would have been in their early thirties by the end of follow-up; G1s who subsequently had their first births at older ages would not have been included. Persistent social stratification can also pose challenges to multigenerational social epidemiology studies specifically by limiting variability across generations. For example, in Huang et al.'s study, 96% of G1s whose mother (G0) graduated from college also graduated from college (1). Sociologists have extensively documented trends in educational mobility and the lack thereof in the United States (46,47), and this has implications regarding possible practical positivity violations and less precise estimates for all combinations of maternal and grandmaternal educational attainment. We are glad that Huang et al. considered this in their online supplementary material, and we encourage future researchers to do so as well. The study by Huang et al. (1) contributes to a small but growing body of literature examining associations between grandparental education and grandchild health. It also addresses some of the methodological challenges of this research. Despite these challenges, we believe this line of research shows promise in helping us not only to explain current health disparities but also to consider potential future implications of today's educational patterns and practices. Doing this will require careful consideration of the changing social, political, and demographic landscape in which each generation lives (48). For example, in 1975, around the time many of the grandmothers in Huang et al.'s analysis may have been completing high school, 62% of US women aged 25 years or more had a high school diploma (49); by 2014, this percentage had grown to 89%. The last century has also seen major upheavals in educational and social policies (including school desegregation) and occupational and fertility trends. We look forward to the possibility of new insights produced by research on this topic, and we encourage both the collection of multigenerational information in ongoing cohort studies and the development of new methodologies for analyzing these data meaningfully. --- Conflict of interest: none declared.

An emerging area of social epidemiology examines the relationship between grandparental education and grandchild health. In an accompanying article, Huang et al. (Am J Epidemiol. 2015;182(7):568-578) join the small but growing body of research on this topic. It is useful to contextualize Huang et al.'s work within the much larger body of research examining relationships between education and health within a single generation or across 2 generations. These investigators have generally concluded that higher educational attainment is robustly associated with better health. There are many potential mechanisms through which education and other social exposures may affect health outcomes in a single generation or across generations, and estimating direct and indirect effects can be helpful for assessing specific mechanisms. Researchers conducting multigenerational analyses are faced with several challenges, including limited availability of data for some measures (e.g., educational attainment, and sometimes for 1 grandparent only), limited age ranges of participants, disparate social and political contexts in which study participants of different generations have lived, and patterns of social class reproduction. We encourage future researchers to weave together the careful analytical considerations illustrated by Huang et al. with a rich understanding of the social context for each of the generations studied to help overcome these challenges and advance our understanding of multigenerational social determinants of health.

D e-implementing low-value care is a major challenge within healthcare systems around the world. 1 The perpetuated use of healthcare services that provide little or no benefit to patients, or which may cause harm, represents wasteful consumption of healthcare resources. 2 Since the launch of the Choosing Wisely Campaign in 2012, there has been an exponential increase in research identifying hundreds of low-value practices across all areas of healthcare. [3][4][5] Although many low-value practices have been identified as candidates for de-implementation, their use persists because the process of changing engrained clinical behaviour is complex. While we have established theories, models, and frameworks to guide the process of implementing high-value care into practice, less is known about the process of de-implementing low-value care. Studies have begun to further unravel the complex interplay between processes and determinants (ie, barriers and facilitators) of deimplementation and implementation. Nevertheless, despite advancements in our understanding of de-implementation, low-value care remains a major burden within healthcare systems throughout the world. Prior to the coronavirus disease 2019 (COVID-19) pandemic, reducing low-value care was increasingly recognized as a priority for healthcare system improvement. Now, owing to the many negative health system impacts of COVID-19 (eg, delayed diagnoses and treatments), reducing low-value care should be an even greater priority. 6,7 Ensuring that healthcare providers are delivering high-value care will help mitigate the resource and financial constraints that will impact healthcare systems post-pandemic. 8 In Verkerk and colleagues' recent study "Key factors that promote low-value care: views of experts from the United States, Canada, and the Netherlands, " 9 the authors aimed to explore the factors that promote ongoing use of practices identified as low-value. This commentary will review the article by Verkerk et al, highlight key findings, and offer further consideration for how their findings may be interpreted and applied to future initiatives to reduce low-value care. Verkerk et al interviewed 18 experts from Canada, the United States, and Denmark. Pre-existing frameworks describing drivers of poor medical care and determinants of healthcare professional practice were used to guide interviews and elicit factors that promote low-value care. This enabled the authors to fill a gap within the literature and potentially identify social and system-level factors that are often overlooked, yet at a macro-level are potentially very influential. 10 Key factors promoting use of low-value care that emerged from the interviews included social factors (public and medical culture), system factors (payment structure, influence from industry, malpractice litigation), and knowledge factors (evidence, medical education). The identification and description of these factors are a meaningful addition to the body of literature describing determinants of low-value care 11,12 and offer potential strategies to reduce its overuse. Generalizability of many of the key factors promoting lowvalue care likely depends on context. For example, one of the social factors promoting low-value care identified in the study by Verkerk et al was public culture, and the tendency to believe that 'more is more. ' This suggests that patients may value the receipt of tests and treatments because it makes them feel like something is being done to help them, and understanding this, clinicians may decide to provide tests or treatments when the clinical indication may be weak or absent. Patient education materials, such as those from the Choosing Wisely campaign, have been shown to increase patients' awareness of low-value care and encourage them to initiate conversations about the value of their care with their physicians. 13 The importance of patient perceptions likely varies across clinical contexts. Diagnostic imaging for low-risk low back pain is an example of a low-value practice where patients' expectations or preferences have been shown to significantly influence utilization. 14 Healthcare providers have reported that more patient education and additional time to explain their rationale to a patient would help them reduce low-value imaging for low back pain. 15 Targeting patient expectations through implementation of an intervention within the patient-clinician interaction in primary care may provide an opportunity for the patient to express their preferences and engage in a discussion about the merits of imaging. A national intervention in Australia applied this approach to the patientclinician interaction regarding imaging for low-back pain. In their study, patient-specific educational tools and cliniciantargeted decision-support tools were implemented to assist with decision making regarding imaging for low-back pain. 16 They found that this intervention reduced primary care ordering of imaging by nearly 11% over the study period. Similar results have been achieved with interventions targeting the patient-clinician interaction in other primary care contexts, such as with antibiotic prescribing for upper respiratory tract infections and diagnostic imaging for lowrisk head injuries. 17 In contrast to primary care, where decisions regarding use of low-value tests or treatments are commonly made during the patient-clinician interaction, acute care, and in particular the intensive care unit (ICU), is a care environment where some of the decisions regarding care required to save life or limb may be less influenced by public culture. For example, several studies suggest that for most patients admitted to adult ICUs, a hemoglobin target of 7 g/dL is sufficient, and transfusion to higher hemoglobin levels that more closely resemble normal values is associated with worse outcomes. 18 Red blood cell transfusion when the hemoglobin is 7 g/dL or higher is, for most patients, low-value care. Owing to their severe illness, ICU patients are not aware that their hemoglobin level may be lower than normal, whereas the clinicians are, and thus best positioned to make decisions regarding the merits of transfusion. In this case, an intervention that targeted patients or their family members would be less impactful than one focusing more heavily on clinicians, their medical knowledge, and the strong medical culture that more care and normalization of physiology is better. The more care is better culture and the ability of clinicians to adapt established medical practice patterns in response to new evidence are major barriers to reducing use of lowvalue care that likely transcend all areas of medicine. It is hard for clinicians to unlearn patterns of practice that have emerged from years of medical training and experience. [19][20][21] A recent qualitative evidence synthesis indicates that clinician knowledge is a commonly reported determinant of lowvalue care, 12 yet it is less clear how this should be addressed. Clinicians engage with multiple sources of evidence (eg, journal articles, clinical guidelines) within a medical culture with established norms whilst also subject to their own cognitive biases. All of these elements may contribute to how they interact with and apply their medical knowledge surrounding low-value care. 22 Clinicians are also faced with patients whose complexity frequently exceeds that of those examined in clinical trials, and therefore have difficulty applying evidence to the clinical contexts they encounter. Additional work is required to further explore with clinicians their own experiences interacting with new potentially contradictory evidence and the decision to de-implement care that may no longer be considered high value. In addition to social and knowledge factors, the system in which care is delivered has been shown to influence the delivery of low-value care. For example, a study examining vitamin D screening in the United States and Canada found modest reductions in low-value screening following the release of Choosing Wisely recommendations. 23 However, when a new payment policy eliminating reimbursement for the screening was introduced in Ontario, Canada, the rate of screening was reduced by 93%. 23 Here, an intervention addressing system-level factors was needed in addition to the Choosing Wisely Campaign, which targets knowledge and social factors. Differences in the structure of healthcare systems suggests that context specific interventions may need to be considered. A systematic review of interventions to reduce low-value care identified the importance of systemlevel strategies that aimed to reduce demand of low-value care (eg, patient cost-sharing that incentivizes high-value care over low-value care) and supply of low-value care (eg, value-based pay-for-performance). 24 Research suggests that effective interventions that reduce low-value care are more commonly multi-component interventions that address both system-level factors (eg, payment structure, policy changes) and social and knowledge factors. 24 The factors identified by Verkerk et al complement those cited within the current low-value care and deimplementation literature. Two recent evidence syntheses of determinants of low-value care suggest patient and provider characteristics (eg, knowledge, attitude, behaviours) to be the most cited determinants of low-value care. 11,12 Other factors outside the patient-provider dynamic like the system-level factors identified by Verkerk et al appear to be less commonly reported in the literature, but as demonstrated by Verkerk's findings, this does not dismiss their impact on low-value care. Verkerk's study is an important reminder that no single determinant is responsible for the challenges associated with reducing low-value care; social, knowledge, and systemlevel factors are driving low-value care in an interconnected manner. When designing de-implementation interventions, these social, knowledge, and system factors should be evaluated to understand what the predominant driver of use of the specific low-value practice is and what might work best to reduce its use. As highlighted in this commentary, these factors are likely going to look different depending on the target low-value practice, care setting and health system. In conclusion, the study by Verkerk et al highlights key social, knowledge, and system factors that promote lowvalue care and underscores the complexity of the challenge of de-implementation. Understanding how these key factors vary with contextual factors such as the specific low-value practice and clinical setting is an important consideration in the design of de-implementation interventions. It is essential that we engage all relevant stakeholders, including clinicians and patients, as we continue to build the body of evidence describing determinants of low-value care, pursue initiatives to reduce low-value care, and advance the science of deimplementation. --- Ethical issues Not applicable. --- Competing interests Authors declare that they have no competing interests. --- Authors' contributions Conception and design: EES, JPL, HTS, and DJN. Drafting of the manuscript: EES, JPL, HTS, and DJN. Critical revision of the manuscript for important intellectual content: EES, JPL, HTS, and DJN. Supervision: EES, JPL, HTS, and DJN. --- Authors' affiliations 1 Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada. 2 School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada. 3 Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada. 4 Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada. 5 O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.

Low-value care contributes to poor quality of care and wasteful spending in healthcare systems. In Verkerk and colleagues' recent qualitative study, interviews with low-value care experts from Canada, the United States, and the Netherlands identified a broad range of nationally relevant social, system, and knowledge factors that promote ongoing use of low-value care. These factors highlight the complexity of the problem that is persistent use of low-value care and how it is heavily influenced by public and medical culture as well as healthcare system features. This commentary discusses how these findings integrate within current low-value care and de-implementation literature and uses specific low-value care examples to highlight the importance of considering context, culture, and clinical setting when considering how to apply these factors to future de-implementation initiatives.

Significance Social isolation, a quantitative loss in a person's social relationships, is common in older adults, with 27% of adults aged 60 years living alone. 1,2 During the COVID-19 pandemic, social distancing has been an essential public health strategy. 3 Although many older adults entered independent living communities for activities and socialization, they have been advised to remain in their own apartments or rooms. Meals are delivered to doors, activities have stopped, exercise rooms have closed, and visitors are restricted. These necessary stay-athome measures unfortunately increase social isolation. Social isolation has been associated with adverse health outcomes including increased risk of falls, all-cause mortality, hospitalizations, and cognitive decline, as well as unhealthy behaviors like physical inactivity and poor diet. 4,5 Additionally, in the previous SARS pandemic, isolating infection control practices were associated with increased depression and traumatic stress response symptoms. 6 Social isolation has been associated with less infection resistance, more emergency admissions to hospital, and extended length of stay, factors that may lead to worse outcomes during the COVID-19 pandemic. 7e10 Given the effects on the mental and physical health of older people, interventions targeting social isolation are necessary to mitigate risk of increased morbidity and of infection from COVID-19. 11,12 Information and communication technology strategies show promise in reducing social isolation in older people, with literature demonstrating a positive impact of a telephone befriending program on older adults' perceived health and well-being. 13,14 --- Innovation We created a phone call outreach program, Seniors Overcoming Social Isolation (SOS), in which medical and health professions student volunteers (eg, MD, MD/PhD, Neuroscience, Genetic Counseling) called older adults, living in long-term-care facilities (LTCFs) and the community, at risk of social isolation during COVID-19. The SOS program entailed providers identifying at-risk older adults and then referring the contact information to coordinators who would then pass the info to student volunteers. Student volunteers were provided with an introduction script and a series of conversation starters, general social history questions, and well-being questions (eg, resource needs, groceries) to ask the older adult. Students then phoned the older adults when they had free time available. The goals were (1) to provide companionship and resources for unmet needs of older adults while (2) fostering health professional students' skills in communicating and understanding the needs of older adults in their community. We propose that social phone calls to older adults may reduce social isolation while providing meaningful engagement with the community and a learning experience for students. --- Implementation Older adults at risk for increased social isolation during COVID-19 were identified by their primary care provider or community center coordinator and enrolled in the SOS program. The SOS program coordinator (medical student) sent an e-mail invitation to the firstyear medical school list server (approximately 150 students) seeking student volunteers. Volunteers signed up via an online form and then were assigned older adults to contact through their secure university e-mail. Volunteers were provided with educational reading on geriatric-specific issues and asked to follow a sample script that suggested topics of conversation, including well-being, coping, social supports, and daily activities. The Institutional Review Board deemed this research exempt. --- Evaluation Student volunteers completed a postcall online survey describing the content, self-reflection, and perceived impact of the call. Three authors (E.E.O., M.S.R., L.A.L.) analyzed responses using constant comparative techniques. They independently assessed participant responses for focal themes and convened to compare and compile findings and create a preliminary list of categories and major themes. Identified themes were refined, with coders triangulating their perspectives and resolving any identified discrepancies through discussion. In no cases were the coders unable to reach consensus. The coders organized the content into relevant themes. Descriptive statistics were used to analyze participant surveys. --- Results Fourteen volunteers made 25 phone calls, averaging a length of 8.3 min (standard deviation 4.0). Nearly all volunteers (85.7%) were in medical school (MD or MD/PhD program), and most of those students were in their first year of medical school (75%). There were 2 graduate health program students (eg, medical geneticist and neuroscientist programs) who heard about the program through word of mouth. Volunteers were predominantly female (92.9%) and identified as Asian or white (50% and 43%, respectively). Both conversational and COVID-19erelated themes were discussed during calls (Table 1). Topics related to COVID-19 included health, fears, isolation, coping, and sources of support, whereas other prominent topics ranged from family and friends, to hobbies, to the older adult's past. In addition to providing social connection, several students assisted in addressing unmet needs by referring the older adults to sources of support. Most students felt that the calls were well received; recipients expressed appreciation both for the calls or callers and for those who referred them (Table 2). Some students felt that the call was less impactful, and one felt that they had disrupted the older adult by calling. Student volunteers indicated they had plans to contact a little more than a third of older adults (36%) again. We do not have data about follow-up phone calls. After the telephone contact, many students felt positive and empowered; one described feeling inspired by the older adult's story, and several reflected on the senior's appreciation. Other students acknowledged challenges, such as needing patience and talking about different topics than normally discussed with younger adults (Table 3). --- Discussion and Comment During the COVID-19 pandemic, requisite social isolation is a critical problem among older adults living in assisted and independent living communities. There is ample evidence that this is an important problem desperately needing intervention. To reduce social isolation, we present a practical intervention leveraging health profession graduate students contacting older adults and residents of independent and assisted living by phone. Our results show that it is feasible and has bidirectional benefits for both student callers and older adult residents. Students felt empowered and that they were able to make a difference in the lives of socially isolated seniors. Results also showed that they were learning how to be patient and to slow down in conversations with hearing-impaired seniors, specifically learning important tenets of geriatrics in the process. Older adults appreciated and enjoyed receiving calls, as they were likely interrupting their social isolation. Limitations of this study include the small sample size, single location, and referral of older adults by a provider. Although conducted in a single location (Chicago), COVID-19 was widespread and existed in most of the area's long-term-care communities necessitating isolation. Several students struggled to contact their assigned older adults, potentially because of illness or hospitalizations. This intervention depends on student volunteerism; as classes resume, fewer students may have time to participate. Moreover, this requires Patient enjoyment and appreciated -I think the patient was really happy to have someone to talk to for a bit. -I think the patient was happy that someone called. -I think it was nice for the patient. They seemed eager to share their current situation and were overall quite upbeat, though they said they're not really a "phone person." -He seemed appreciative of the call and looking forward to future calls from me. Perceived too short -We actually would have talked for longer, but the patient said her throat was getting tired. Unclear if replaced physician visit -She wasn't sure why we called since she talked to her doctor last week. Provided resources -I passed on information to someone who could maybe help. Unsure or minimal -Minimal, but not zero. I think the patient was still happy to know that her doctor is looking out for her. coordination of providers in identifying appropriate older adults, student volunteering, and a coordinator assigning seniors to call. Although online sign-ups limit some of the workload, a dedicated volunteer student coordinator is necessary. Seniors Overcoming Social Isolation calls are easily generalizable and can be adopted by most medical schools to connect students to socially isolated seniors in multiple settings. For further generalization, student volunteer groups do not need to be in the same area as those being contacted. Medical schools can partner with rural communities or low-income areas who do not have direct academic partnerships to reduce isolation in hard-to-reach areas. During the COVID-19 pandemic, this simple innovation has been shown to be a feasible route for improving the lives of both older adults and students. The pragmatic innovation described in this article may need to be modified for use by others; in addition, strong evidence does not yet exist regarding efficacy or effectiveness. Therefore, successful implementation and outcomes cannot be assured. When necessary, administrative and legal review conducted with due diligence may be appropriate before implementing a pragmatic innovation.

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Introduction Dementia is an umbrella term for neurodegenerative disorders with progressive cognitive impairment that significantly affects daily living activities. Dementia cases across the world are estimated to triple from about 50 million in 2018 to 152 million by 2050 [1]. Caring for people living with dementia can be quite confronting and challenging for informal or family carers who often experience numerous effects such as psychological morbidity, social isolation, physical ill-health, and financial hardship [2]. Therefore, offering adequate support for family carers is vital for improving the quality of care for people with dementia. Multilingual family carers face added challenges as they have few culturally appropriate home and community-based services to access and endure long wait times for support services, which further delay timely care and amplify distress [3]. The DrawCare study [4] explores ways to address this issue, by using animated short films and digital technologies to support Culturally and Linguistically Diverse (CALD) family carers and people living with dementia in Australia. The study is ongoing. In this poster, we summarize our progress and findings from the developed DrawCare website. --- Methods The study protocol is provided [4]. The full project was designed to have three studies. The theoretical lens followed by this project along with key milestones is illustrated in Figure 1 in page 12 of reference [4]. Covered in 2022 was the first of the three studies. The focus of Study 1 was culturally adapting the World Health Organization (WHO) iSupport Lite program [5] by working with CALD family caregivers, clinicians, service providers, and people living with dementia, as well as partners WHO, Dementia Australia, and the Federation of Ethnic Communities Council of Australia. The objective was to co-produce (using codesign methods) the DrawCare Intervention in nine CALD languages plus English. An integral aspect was codesigning, including six two-hour codesign workshops to cover the six practical support messages of the iSupport Lite program. The workshops focused on three key aspects: (1) Planning and culturally adapting the content as animated short films; (2) Extrapolating key quotes and messages as tip sheets, and (3) Planning a structure for a website for the resources to be presented. Following the workshops, the animated films and the tip sheets were translated into all languages. They were then placed on a website to be carried forward for the subsequent phases including a clinical trial [4]. --- Results The main outcome of Study 1 was the co-designed DrawCare intervention, including animations, tip sheets, and a website (https://drawcare.emergetrial.net/) in ten languages that contains the resources. This website was designed based on identifying and distilling the feedback that emerged from the codesign workshops. --- Conclusions The emerged features from the workshops were: Plain language that is appropriately translatable; Less clutter (i.e., static web page design with no moving objects); twocolored design (i.e., white background and a dark color for title bars); contrasting colors for fonts (i.e., black font on white background, and white font on dark backgrounds); a virtual assistant to help find resources; display optimization for different devices; and capability of feedback collection. The website is an attempt to capture the above features. The content is presented in ten languages. Developing such a multilingual website is challenging as the content and message must be both faithfully represented but also culturally responsive to fit with specific cultural nuances. These lessons learned may have relevance and generalizability beyond the subject of focus, dementia. Future work will include assessing the effectiveness of the intervention through a clinical trial.

Addressing the needs of ethnically diverse multilingual people can be challenging in environments that are non-native to them. The consequences of this issue become more significant in healthcare contexts. Insights from the DrawCare study-an Australian study that explores the effectiveness of a web-based intervention for multilingual family carers of people with dementia-are presented illustrating the enabling role of digital health.

A new study by Caspi et al. 3 contributes substantially to the body of evidence supporting targeted early childhood programs by analyzing rich longitudinal data from a large and representative sample of New Zealand children. The authors follow subjects over their lives from birth through age 38 4 and enrich their primary sample with matched individual records from a variety of administrative data sources. They report that 20% of the sample accounts for 60-80% of a variety of adult social ills manifest by sample members. A small set of childhood indicators of disadvantage (low IQ; low self-control; childhood maltreatment; and low family socioeconomic status) are powerful predictors of multiple lifetime problem behaviours related to health, crime, education, earnings, and social engagement. This study advances well beyond the approach typically used in studies of child development. The standard approach predicts one outcome at a time using measures of family disadvantage. Instead, the authors predict constellations, or aggregates, of behaviours, and show that a short list of indicators of disadvantage is powerfully predictive of who exhibits the clusters of adverse outcomes constituting their aggregates. There are many possible measures and clusters of measures of adverse adult outcomes that might be included in their aggregates. However, the authors show that their compelling results do not rely on the choice of any particular measure. There is a "hardcore" group of disadvantaged children who contribute to many social ills when they are adults even when aggregates are formed in different ways. Their analysis identifies a group of individuals for whom interventions might be effective. It suggests a source of major social problems. The emphasis of this paper is, however, on predicting adverse adult outcomes. Evidence that childhood adversity predicts adult adversity is an important building block for shaping an effective policy intervention. But the paper stops short of providing any evidence on which, if any, interventions might be effective in preventing the adverse adult behaviours grouped in their clusters. It does not inform us of whether their empirical relationships are due to genes or environments nor does it conduct any mediation analyses to unpack the channels of environmental influences that produce adult adverse outcomes. Fortunately, there is a companion body of literature consistent with the evidence in this paper that provides guidance on the effectiveness of early childhood interventions and their channels of influence. Several early childhood interventions in the U.S. evaluated by the method of random assignment have followed disadvantaged children up to ages 30-40, the same range of ages reported in this paper. The interventions give enriched early childhood environments to disadvantaged children. Their findings are relevant today because they are based on basic principles of child enrichment widely implemented in a variety of new and ongoing programs. The economists studying these interventions use benefit/cost and rate of return analyses to place diverse outcomes on a common and interpretable footing of a money metric. Doing so produces policy-relevant aggregates. If a social program provides benefits above the market opportunity cost of funds, it is socially efficient to invest in that program. The targeted populations enrolled disadvantaged children very comparable to those in the Dunedin New Zealand sample analyzed by the authors. Multiple adult outcomes are measured that are comparable to the ones used in this paper, including health, healthy behaviors, crime and smoking. For example, the HighScope/Perry Preschool Program targeted disadvantaged 3-4 year-old children 5 . An analysis of this program by Heckman et al. reports an overall benefit/cost ratio of 7 to 1 with a rate of return of 7-10% per annum 6 . (The rate of return is the rate at which a dollar investment increases in value each year after the program is implemented.) These benefits account for the welfare cost of using public revenue to finance their costs counting various forms of tax avoidance. The Carolina Abecedarian Project (ABC) started earlier (age eight weeks) and lasted until age five. Follow-up continued through the mid-30s 7 . A recent study by Garcia et al. reports a benefit/cost ratio of 6 to 1 with a rate of return of 12% a year, again counting any distortions caused by public funding 8 . Figure 1 from Garcia et al. shows the total value of the monetized benefits and their components across major life domains. Recent papers by Conti et al. 9 and Heckman et al. 10 show the causal channels through which these effects are obtained. It would be productive to examine the mediators of the Dunedin study to examine the role of family and social influences. The authors are well positioned to do so. Net Present Value of Main Components of the Life-Cycle Benefit/Cost Analysis, Carolina Abecedarian Project Note: Program costs: the total cost of ABC/CARE, including the welfare cost of taxes to finance it. Total net benefits: for all of the components considered. These include labor income: total individual labor income from ages 20 to the retirement of program participants (assumed to be at age 67). Parental income: total parental labor income of the parents of the participants from when the participants were ages 1.5 to 21. This arises from subsidizing childcare. Crime: the total cost of crime (judicial and victimization costs). Health: gain corresponding to better health conditions until predicted death. Source: Garcia et al. 8 --- The body of evidence in the cited papers, coupled with new evidence in this paper, all point to the multiple benefits to society of detecting and addressing early the conditions of disadvantaged children. Targeting disadvantaged children is effective social policy.

By linking data from a 40-year birth cohort study with multiple administrative databases, Caspi and colleagues show that 20% of the population accounts for 60% -80% of several adult social ills. Outcomes for this group can be accurately predicted from as early as age 3, using a small set of indicators of disadvantage. This finding supports policies that target children from disadvantaged families and complements recent literature on the life-cycle benefits of early childhood programmes. In the past 10 years or so, there has been growing public support for early childhood programs. The most effective programs target children from disadvantaged families 1 . Despite this evidence, many politicians and thought leaders continue to promote universal programs, primarily on political grounds 2 .

caregivers or no local ADNA, and limited local leadership support were other factors noted that could limit expansion. Importantly, Veterans were often overwhelmed by the employer responsibilities they needed to fulfill. Addressing these concerns remains a challenge to VISN 8 and national leadership. --- SESSION 1010 (PAPER) --- ALZHEIMER'S DISEASE AND RELATED DEMENTIAS (SRPP) I Abstract citation ID: igad104.0012 Hospital-to-skilled nursing facility (SNF) transitions are fraught with coordination challenges, motivating selective investments by hospitals to improve transitional care practices with "preferred" (e.g. high-volume) SNF partners. Because these partners have some agency in which patients they admit, it is unclear whether Medicare beneficiaries with social or clinical complexities, such as individuals with Alzheimer's disease and related dementias (ADRD) have equitable access to these preferred SNFs. To answer this question, we use a linear probability choice model to test the differential effect of a SNF's "preferredness" on patient placement for ADRD vs non-ADRD beneficiaries. We use a 1:1 matched sample of ADRD and non-ADRD fee-for-service beneficiaries (N=76,762) to account for other primary factors affecting placement (i.e. discharging hospital, beneficiaries' home address). After controlling for SNF characteristics, the estimated effect of a SNF being "preferred" on likelihood of placement was 12.7% lower for patients with ADRD (0.092 vs 0.103 for non-ADRD; p< 0.001). Simulation results suggest that, as a preferred SNF is assumed to have an increasing percentage of a hospital's discharges, the likelihood of a patient being discharged there grows much faster for non-ADRD patients compared to those with ADRD. Our findings show that ADRD patients may have unequal access to SNFs that are receiving the most investments from hospitals in the form of transitional care improvements. Policymakers should consider systemic investments that benefit all SNF partners, not just the most preferred based on shared discharges, while also weighing the costs of dispersing these investments too broadly. --- ACCESS TO PREFERRED POSTACUTE CARE PATHWAYS FOR PATIENTS WITH ALZHEIMER'S DISEASE AND RELATED DEMENTIAS evidence on the relationship between nativity and cognitive impairment. To our knowledge, our study is the first to analyze how nativity and neighborhood interact to influence dementia risk. Ten years of prospective cohort data (2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018)(2019)(2020) were retrieved from the National Health and Aging Trends Study, a nationally representative sample of 5,362 U.S. older adults aged 65+. Cox regression analyzed time to dementia diagnosis using nativity status (foreign or native-born) and composite scores for neighborhood physical disorder (litter, graffiti, vacancies) and social cohesion (know, help, trust each other), after applying sampling weights and imputing missing data. Average baseline neighborhood physical disorder was significantly higher among foreign-born (0.28) compared to native-born (0.18) older adults [t=-2.4, p=.02]. Average baseline neighborhood social cohesion was significantly lower for foreign-born (3.57) compared to nativeborn (4.33) older adults [t=5.5, p<.001]. After adjusting for sociodemographic, health, and neighborhood variables, foreign-born older adults had a 51% significantly higher dementia risk (aHR=1.51, 95% CI=1.19-1.90, p<.01). There were no statistically significant interactions for nativity with neighborhood physical disorder or social cohesion. Our findings suggest foreign-born older adults have higher neighborhood physical disorder and lower social cohesion compared to native-born older adults. Despite the higher dementia risk we observed for foreign-born older adults, this relationship was not moderated by either neighborhood physical disorder or social cohesion. Further research is needed to understand what factors are contributing to elevated dementia risk among foreign-born older adults. By 2060, the prevalence of Alzheimer's disease and related dementias (ADRD) in the U.S. is predicted to more than double to 14 million. African Americans (A.A.) 65 and older are 2.5 times more likely to develop Alzheimer's than same-aged White Americans. Furthermore, A.A. are twice as likely to be underdiagnosed, leaving the A.A. community underserved with respect to ADRD. To gain insight into the key drivers of this underdiagnosis, we performed a scoping review of research on attitudes and perceptions held within the A.A. community regarding ADRD, which may impact diagnosis and screening. We searched PubMed, CINAHL, Web of Science, and Black Studies Periodicals Database for studies from 2002 to 2022 using keywords: "Dementia" or "Alzheimer's" and "African Americans," "Ethnicity," "Racial Groups," "Blacks," or "Ethnic and Racial Minorities," and "Health Knowledge, Attitudes, Practice," "Health Services Needs and Demand," or "Perception." We identified 318 studies; 49 met inclusion criteria after title and abstract review and were selected for full manuscript review. We discussed all included manuscripts and identified pertinent themes, noting potential method bias. An identified "knowledge gap" among A.A. about dementia, particularly a belief that dementia is part of normal aging or God's will, was prominent. Other themes included mistrust of the medical community, a desire to maintain everyday family life, the need for culturally appropriate resources, and cultural expectations to provide care despite institutional support obstacles (John Henryism/Superwoman schema). Understanding differences in attitudes and beliefs toward dementia among African Americans may support developing effective strategies to address disparities. People with Alzheimer's and related dementias require increasing assistance with basic life activities, yet one in three lives alone (i.e., is aging solo). Drawing on a strengthsbased perspective, this study seeks to identify barriers and facilitators to successful aging among adults who are aging solo with cognitive impairment or early dementia. We conducted semi-structured interviews with 15 adults aging solo with a diagnosis of cognitive impairment or early dementia (age 48-81, mean 69; 80% female; 86% white; 13% black; 7% Hispanic) and used a hybrid inductive/deductive thematic analysis approach to analyze the data. Participants identified self-advocacy, friendship networks, financial resources, and institutions (e.g., assisted living) as potential assets that could address future care needs. Participants described an identity as self-sufficient, fear of being a burden, and worries about exploitation as barriers to help-seeking. Facilitators to care-seeking from friends, neighbors, and others included a belief that helping is rewarding for others, being able to provide reciprocal favors, and framing careseeking as self-advocacy. Conclusion: Adults aging solo with early dementia face a number of challenges but also exhibit numerous strengths and can use a diversity of skills, attitudes, relationships, and tangible resources to address increasing care needs. --- SESSION 1015 (SYMPOSIUM) Abstract citation ID: igad104.0016 --- NEIGHBORHOODS AS A SPACE AND PLACE FOR HEALTHY AGING: NOVEL APPROACHES AND A VIEW OF THE FUTURE Chair: Andrea Rosso Co-Chair: Michelle Carlson Discussant: Yvonne Michael The importance of neighborhood environments for health outcomes has gained increasing recognition in the past two decades. Both space (physical environment) and place (social environment) have implications for health behaviors and risk for acute events and chronic diseases. This symposium brings

ranked perceived agency role was information and assistance (mean=2.41; SD=1.02), followed by direct service provision (mean=2.45; SD=1.52), coordination of aging services (mean=2.63; SD=1.54), education (mean=3.40; SD=1.11), and training (mean=4.10; SD=0.99). The most commonly mentioned areas needed for the region to become agefriendly were supportive community services (66.3%), public transportation (44.9%), safety and security (41.6%), available and affordable housing (40.4%), access to healthcare (38.2%), and housing maintenance/modification (24.7%). The most common themes from open-ended responses included outreach, collaboration, and promoting aging in place. These findings suggest the imperative of providing accessible, high-quality services that promote aging in place in urban areas through community outreach and collaboration activities. Detroit area seniors are a vital community resource, and ongoing stakeholder input is needed as part of collaborative efforts to meet their complex emerging health and social needs.

Introduction The recent explosion in deployment of pervasive systems like sensor and cellular networks, and the emergence of the user-generated information sharing systems like online social networks produce massive amount of data. This data encompasses actions of people, dynamics of cities, and how they evolve over time. It forms digital footprints (Girardin et al. 2008) that allow researchers to better understand human mobility (Gonzalez, Hidalgo, and Barabasi 2008), city dynamics (Reades et al. 2007), and socio-economic (Eagle, Macy, and Claxton 2010), and could ultimately help those who manage and live in urban areas to configure more liveable, sustainable, and efficient cities (Foth 2008). At the same time, these digital footprints create possibility of inferring social dynamics in the urban space, which in turn can provide information about how a city functions and can potentially influence many aspects of urban management by assisting local authorities, service providers, enterprises, and even citizens themselves to make more inform decisions and hence create a more efficient urban environment. Data collected using pervasive systems has been used to sense physical dynamics such as face-to-face social network structure (Eagle, Pentland, and Lazer 2009), activity signature of the physical environment (Calabrese, Reades, and Ratti 2010), and even regional boundaries of a country (Ratti et al. 2010). Copyright c 2011, Association for the Advancement of Artificial Intelligence (www.aaai.org). All rights reserved. While most analyses of online social networking data have implications and applications only within the cyber world (e.g. (Leskovec 2008), (Cha et al. 2010)), here we are realizing the linkage between the cyber and physical worlds and utilizing this connection as the crowdsensing mechanism -particularly for socio-geographical aspect. --- Online Social Networking Data In this work, we use the data collected from a location-based online social network called Foursquare (Foursquare 2011). The 4sq network allows GPS-enabled mobile phone users to interact by communicating their whereabouts to their friend group. The user can check in at a venue, which can be a site of social encounter either located in a building (e.g. restaurant, bar, art gallery) or an open space (e.g. park). Its venue information provides dynamic geo-social aspect that distinguishes it from that of generic online social network e.g. Twitter, Facebook, Linkedin. Checking in at a venue can also earn points and rewards for the user. The typical reasons for checking-in include tracking friends, reporting a new venue, recommending a place, sharing experience, playing game (competing to become the 'major' of a place), and looking for nearby venues. The data acquired from 4sq thus provides us with the social interaction density and its geographical relation to the physical landscape. In this study, we analyze 800,00 data records from the 4sq network consisting of checkins and corresponding venues along with the venue's categories from three different cities: London, Paris, and New York City, over about 16 months (March 2009 to July 2010). The data has been collected by a systematic crawl of the 4sq public search API (Bawa-Cavia 2010).This allows us to capture a snapshot of aggregated geo-social interaction and reveals how social activity is distributed in the urban space. Figure 1 shows the overall geographical density of social activity (checkins), which creates the signature of the three cities. With the venue's category information along with the volume of checkins of each venue, we can capture a richer signature of the city as shown in Fig. 2 where each dot represents a venue, the dot's size corresponds to the amount of checkins, and the color indicates different categories: green, red, blue, magenta, and cyan represent Shop, Arts, Food, Park, and Nightlife, respectively. Therefore the data allows individual as well as cross analysis of the urban space. --- Social Activity Distributions Clearly, one can observe a non-uniform distribution of social activity for each city. This different social activity volume across different areas suggests different social hubs of different activity categories. This motivates us to explore further in terms of how each social activity is distributed (statistically) and how social hubs are distributed geographically. It turns out that social activity is distributed in a nonlinear fashion as shown in Fig. 3. Each social activity appears to follows the Power Law distribution, which means that only a few places attract high social activity while the majority of places show very low social interaction -hence those few places represent the 'social hubs'. Note that plots in Fig. 3 are in log-log scales and each social activity distribution can be described by a power-law decay function y = kx -α where y denotes checkins, k is a constant, and x represents the rank with the decay term α. From Fig. 3, Food and Nightlife appear to form the strongest activity hubsmost clustered. To quantify this non-linear characteristic for further interurban analysis, we estimate the power-law decay term α according to the maximum-likelihood fitting methods with goodness-of-fit tests based on the Kolmogorov-Smirnov statistic and likelihood ratios (Clauset, Shalizi, and Newman 2009). The estimated values of α are plotted in Fig. 4 and it confirms our previous observation of Food and Nightlife be-ing the top clustered social activities. The decay values also reveal a surprisingly low variation among social activities in New York City, which implies that the social interaction of each activity category is distributed in a similar fashion. Paris appears to also have this similar characteristic but with higher decay rates -stronger social hubs. Among the three cities, London seems to be different than others in the way that Food and Nightlife activity form much stronger social hubs than other social activity types -e.g. there are major restaurants and night clubs that seem to attract majority of people. To get a sense of how social centers are distributed geographically, we cluster each social activity category based on the geo-location using the k-means clustering technique. With the number of clusters k = 4 (chosen arbitrarily), Fig. 5, 6, and7 show resulting clusters (with centroids) of each social activity for London, Paris, and New York, respectively. This provides to some extent a geographical distribution of social centers of each social activity category. With our arbitrary choice of number of clusters, London's Park and Shop show a similar cluster distribution while Food and Nightlife are relatively correlated, and Arts is showing a lone different social clustering. For Paris, Arts' and Nightlife's social clusters are geographically distributed similarly while Food, Park, and Shop are sharing a similar pattern. NewYork, on the other hand, is having different so- --- Conclusion Urban spaces are being blanketed by streams of digital data generated by inhabitants. This large pool of bits creates a unique opportunity for harvesting and analyzing behavioral data to better understand about the city and people. we believe that to some extent this study helps us realize the usefulness of online social network data that can be utilized to better understand physical space and sociality. As our future direction, we will continue to investigate on the sole use of this data to understand the city as well as integrating it with data from other sources e.g. transportation, telecommunication to enrich context inference.

Growing pool of public-generated bits like online social networking data provides possibility to sense social dynamics in the urban space. In this position paper, we use a location-based online social networking data to sense geo-social activity and analyze the underlying social activity distribution of three different cities: London, Paris, and New York. We find a non-linear distribution of social activity, which follows the Power Law decay function. We perform inter-urban analysis based on social activity distribution and clustering. We believe that our study sheds new light on context-aware urban computing and social sensing.

INTRODUCTION In the dynamic landscape of the 21st century, consumer culture stands as a major ones [1]. The rise of e-commerce in Indonesia, particularly during the COVID-19 pandemic, has also had a significant impact on consumer behavior. Cultural factors play a significant role in shaping consumer preferences, with segmentation shifting from travel to homebased activities and interests. However, preferences for specific trends and lifestyles, such as products of Korean popular culture and products with halal certification, remain unchanged [2]. Illegal logging practices in Indonesia highlight the tension between economic development and environmental sustainability. Despite laws aimed at preventing and eradicating forest destruction, illegal logging continues to be a significant issue, demonstrating the challenges of enforcing environmental regulations in the face of economic pressures [3]. Culture, brand image, and price also significantly affect consumer buying decisions in Indonesia. In East Java, for example, the strength of Islamic culture and price considerations are primary factors in buying decisions [4]. effectiveness, connectedness to nature, and green value [13]. However, the "throwaway culture," marked by rapid obsolescence and excessive waste, poses significant challenges to sustainability. This culture is particularly prevalent in the foodservice sector, where the COVID-19 pandemic has exacerbated the problem by imposing a throwaway culture for food and personal protective equipment [9]. To address these challenges, consumers need to rethink and devise consumption models that alleviate the effects of the pandemic and increase the availability and consumption of alternative products with social, economic, health, and environmental impacts [14]. Moreover, the transition to a circular economy, which aims to reduce resource use by recycling materials, reusing products, extending their lifespan, and maintaining their economic value, could be an effective strategy to reduce negative environmental impacts [15]. --- Social Justice in Consumer Culture --- RESULTS AND DISCUSSION This section presents the findings derived from the mixed methods research approach used to address the cross-cutting challenges of consumer culture for sustainability and social justice in Indonesia. --- Quantitative Survey Results The --- Case Study Findings Case studies offer a detailed examination of specific consumer practices and business models. --- CONCLUSION To sum up, this study provides a comprehensive analysis of Indonesian Companies are urged to adopt circular economy principles, transparency, and partnerships with regional craftsmen. Strategies for cultural integration embrace ecological practices and work to maintain heritage. This study is a call to action for all parties involved as well as a glimpse of Indonesia's present consumer landscape. Global sustainability initiatives will be impacted by the decisions made today as Indonesia continues on its path of economic development. Indonesia can take the lead in creating a consumer culture that is inclusive, knowledgeable, and culturally relevant in the future. This will ensure that social justice and sustainability coexist peacefully and that ecological resilience and economic prosperity are balanced.

In the context of Indonesia's dynamic socioeconomic landscape, this research focuses on sustainability and social justice while addressing cross-sectoral concerns in consumer culture. Through the use of a mixed-methods approach that incorporates qualitative interviews, quantitative surveys, and in-depth case studies, the study sheds light on the complex interactions between environmental, cultural, and economic elements that influence consumer behavior. Results highlight financial limitations by showing a relationship between sustainable practices and socioeconomic level. Traditional and global cultural influences become important, influencing motivations and creating obstacles. Consumer choices are greatly influenced by business practices, which emphasizes the importance of transparency in promoting positive change. Case studies offer practical examples that highlight both the advantages and disadvantages of consumer behavior. Actionable recommendations for businesses, consumers, and politicians are informed by the combination of quantitative and qualitative findings, paving the way for Indonesia to adopt a more socially equitable and sustainable consumption culture.

THE CHILD SURVIVAL HYPOTHESIS The letter's basic proposition is: ''When children survive in greater numbers, parents decide to have smaller families.'' The inference is that reduced child mortality will somewhat automatically produce a corresponding and largely compensatory reduction in fertility levels, with little appreciable overall impact on population growth. This concept, sometimes termed ''the child survival hypothesis,'' was discussed and researched considerably, particularly during the 1970s. It has some intuitive credence and demographic support, because often historically when death rates began to fall, declines in birth rates followed. 2 However, such an association does not prove causality. Indeed, historically sometimes the 2 rates have declined fairly concurrently, and there are many examples where birth rates began to fall before death rates. 3 Notably, the very intensive province-by-province ''Decline of Fertility in Europe'' analysis found that while there was some weak association between child mortality and fertility decline, fertility decline was also somewhat associated with industrialization, urbanization, literacy, and women's employment. 3 But the study's overriding finding was that fertility declines spread rapidly ''like an epidemic'' through provinces that shared a cultural as well as spatial location, supporting strong ideational and normative explanations-that is, that people recognized that limiting family size was both feasible and acceptable to do. Of course, the situation among modern developing countries varies and is different from that in Europe a century ago. For one thing, child mortality rates have typically declined much more rapidly in developing countries. And modern communications have fueled rising aspirations for many. But notably, substantial mortality declines in a number of countries, especially in Africa, have not yet been followed by appreciable declines in fertility. A prime example is Nigeria (Figure 1). Despite declines in infant mortality over many years, total fertility has persisted at about 6 children per woman. 4 In addition, for the child survival impetus to work, people must also perceive the decline in mortality and act on it. While the literature on that perception is limited, it suggests there is a major time lag before people do perceive such declines. 5 Actually, in all likelihood, the major reason death and birth rates often fall over a similar time frame is due to general modernization changes in society-economic, educational, and social improvements, modern awareness, women's empowerment, rising aspirations, and better access to services that lead to declines in both mortality and fertility levels. But most importantly, for fertility levels to decline, women and couples must have good means to control their fertility, in addition to motivation. So yes, there is indeed something of a virtuous cycle in that lowered child mortality over time very likely does contribute to reduced fertility. But in and of itself, the effect is too little and too late. --- WHAT HAS CAUSED MODERN POPULATION GROWTH? Predominantly declines in mortality. For most of human history, global population growth was extremely slow, because mortality and fertility levels were in fairly close equilibrium. But recent times have taken us rapidly to 7 billion and counting. 4 As demonstrated in the classic work of Thomas McKeown, The Modern Rise of Population, the only plausible explanation is declines in mortality. 6 Consider, there are only 3 possible determinants of population change-fertility, migration, and mortality. Fertility may sometimes have increased marginally but, overall, certainly not appreciably; and migration is net zero for the planet, with mostly some out-migration for most developing countries. That leaves only mortality decrease as the primary explanation for the profound increase in population. Moreover, reduced child mortality plays a huge role. Deaths to children under 5 typically account for at least half of all deaths in pre-transition societies, and child mortality declines have been dramatic. In addition, child survival contributes to population ''momentum'' because most of those surviving children will eventually have children themselves. Thus, not only does reducing mortality contribute to rapid population growth, it is the predominant cause, notwithstanding the partial virtuous cycle that reduced child mortality may partially help over time to reduce fertility levels. --- Does Substantial Population Growth Matter? As Malcom Potts points out in this issue, 7 estimates from the United Nations (UN) for the global population in 2100 range from 6.8 billion to 16.6 billion. Although these are very abstract numbers, the conclusion seems inescapable that the difference in the estimates would have major Women and couples must have good means to control their fertility, in addition to motivation. impact on quality of life for the earth's inhabitants. Indeed, the recent Royal Society report, ''People and the Planet,'' voiced major concern about current shortages of water, food, and fuel as well as environmental degradation, climate change, and urbanization. 8 Population growth appears destined to affect adversely the quality of life of people in the developing world, especially Africa. A key case in point is Nigeria, where, as previously mentioned, fertility levels remain quite high despite major decreases in mortality. The ominous implications are laid out in Figure 2. According to the UN medium projection (which even assumes considerable fertility decrease), Nigeria alone will be approaching a billion people in 2100, only slightly less than the United States and all of Europe combined. 4 Another even more extreme example is the environmentally fragile Sahelian country Niger. Partly because of very intensive health interventions, 9 its infant mortality has declined to about 60/1,000 live births, but total fertility is even higher than in Nigeria, at 7.6 children per woman. 4 Accordingly, its population is projected to increase well over 10-fold, from about 18 million today to over 200 million in 2100. 4 Because of decreasing child mortality and fairly stable fertility levels, in both Nigeria and Niger, their population growth rates have actually been increasing in recent years. While the future is hard to predict, surely it must be clear that such increases in population will likely impair the quality of life severely, particularly for those most in need in these countries. It seems it has become less fashionable to express concern about population growth in recent years, partly because such concern is somehow associated with coercive practices. However, access to family planning is itself becoming better recognized as a human right. 10,11 While we must condemn and steadfastly guard against misguided, and I would say rare, instances of coercion, neither should we ignore the benefits, including human rights benefits, to people and the planet that can come through voluntary family planning, including slower-paced population growth. --- IMPLICATIONS OF THIS INCONVENIENT TRUTH FOR CHILD SURVIVAL AND FAMILY PLANNING PROGRAMMING Like it or not, we face an inconvenient truth. Reducing child mortality does increase population growth, which will likely substantially impair the quality of life for those very people we wish to help. Does that mean we should curtail our child survival efforts? Not at all. We have an ethical imperative to reduce mortality, and it affirms our humanity. But in my view, it also reinforces the imperative to make a full menu of quality voluntary contraceptive services widely available, and as expeditiously as possible. Unmet need for family planning remains high in developing countries. 12 And recent experience in Ethiopia and elsewhere demonstrates that quality family planning programming can be highly successful in advance of major socioeconomic development. 13 As Potts points out and as reinforced in the Gates annual letter, the great appeal of family planning is that it has so many benefits. Those include substantial health benefits for women and children, enhanced women's empowerment, economic benefits for the family, the demographic dividend, reduced pressure on the environment, and the right to determine one's own life destiny. Not just convenient, but a compelling opportunity. -James D Shelton, Editor-in-Chief --- ______________________________________________________________________________________________________________________________________________ Cite this article as: Shelton JD. Taking Exception. Reduced mortality leads to population growth: an inconvenient truth. Glob Health Sci Pract. 2014;2(2):135-138. http://dx.doi.org/10.9745/GHSP-D-14-00062 ß Shelton. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ --- ______________________________________________________________________________________________________________________________________________ We have an ethical imperative to reduce mortality, but we also have an imperative to make quality family planning services widely available. --- Reduced

Taking Exception Reduced mortality leads to population growth: an inconvenient truth Reduced mortality has been the predominant cause of the marked global population growth over the last 3/4 of a century. While improved child survival increases motivation to reduce fertility, it comes too little and too late to forestall substantial population growth. And, beyond motivation, couples need effective means to control their fertility. It is an inconvenient truth that reducing child mortality contributes considerably to the population growth destined to compromise the quality of life of many, particularly in sub-Saharan Africa. Vigorous child survival programming is of course imperative. Wide access to voluntary family planning can help mitigate that growth and provide many other benefits. T he 2014 Gates annual letter, ''3 Myths That Block Progress for the Poor,'' makes many valid points about development, and, commendably, it strongly supports family planning. 1 However, in arguing against what it termed a ''myth''-that saving lives leads to overpopulation-ironically, it succumbs to a common misunderstanding about reduced mortality and population growth.

A 22-year-old man who had bladder exstrophy came to us for definitive management of his condition (figure 1). He was an illiterate, horse cart driver from rural India, and despite his condition he took self-made measures so that he runs a smooth life. He made a self-made urine collection system that included a polythene bag attached to a string and surprisingly the system worked well (figure 2). He had no urine leak outside the system and there was no surrounding skin excoriation. On taking a detailed history, he had no account of whether any antenatal check-up let alone an ultrasound was done while he was in utero. He was normally delivered at home without any medical help. He was from a very poor family, and he recalled that he was taken to a hospital early in childhood for his condition but did not know why any treatment was not done; he could only attribute it to the poor socioeconomic status of his family. He was a well-built man and now had come to seek treatment because his friends advised him. We counselled him about his disease and told him about the difficulties of corrective surgery for exstrophy in adults. We advised him for a cystectomy with continent urinary diversion. He is now awaiting surgery. --- Global healTh problem liST 1. Inequity in healthcare distribution in low-income and middle-income countries. 2. Wealth, gender, caste and religion as a measure of equity in healthcare. --- Global healTh problem analySiS While there have been great advancements in modern healthcare, the bitter truth remains that equitable distribution of healthcare facilities is lacking. India is a great example of this fact, where while in urban cities all the latest healthcare facilities ranging from robotic surgery to the best diagnostic equipment are available, people in certain rural areas do not even have easy access to essential healthcare facilities. Sadly, the people who require essential healthcare the most are the ones deprived of it. The guiding principle for health policies in India has been equitable distribution of healthcare as outlined by Sir Joseph Bhore in 1946. In his landmark report he envisioned universal distribution of health services in India. The three main recommendations of this four-volume long report were integration of preventive and curative medicine, integration of preventive and social medicine in medical education, and setting up of primary Figure 1 Exstrophy in a 22-year-old man. --- Global health healthcare centres (PHCs) in rural areas. 1 But implementation of these has been challenging in India and in other parts of low-income and middle-income countries. To implement equitable healthcare, the Indian government developed a threetier healthcare institution network and various national health programmes. Although these have been successful to an extent, which is evident by the reduced maternal and infant mortality rates, these have failed to provide equitable healthcare access. This is the case throughout India and is not region-specific. The PHCs, which form the lowest tier of the healthcare system in India, are meant to be the first point of contact for the rural population and form the backbone of the healthcare system in India. They provide basic healthcare that includes immunisation and maternal/child care facilities, and are also connected to regional centres for referral services. While setting up these PHCs was an important step, even this has suffered a setback, as they are not functioning as they are expected to. Maybe this is because of a lack of direction and supervision. 2 Let us take our case as an example. In developed countries like Great Britain, there has been significant reduction in the number of cases with exstrophy due to antenatal screening; only two centres in England and Wales are now authorised to treat new cases of exstrophy due to the declining number. 3 In our patient there was no antenatal check-up while he was in utero and he never got to visit any specialist centre for his condition. The two common parameters studied for equity in healthcare distribution are wealth and gender. 4 Our case highlights both of these. Our patient was a poor man from rural India. The majority of expenditure on healthcare by patients in India is out of pocket, and some form of health insurance covers only ~10% of the population. 5 Of the total healthcare expenditure in India, 67% is out of pocket. 6 The poor are less likely to seek medical help than those fortunate enough to have better financial resources because of this. In fact the poor patients have reported financial reasons for not seeking proper medical care. 7 Many times the patients have to sell or mortgage their property to seek medical care; this is a fact that unfortunately we have been witness to in our medical practice many times in the past. Gender inequalities in healthcare access are a major concern for the healthcare system in India and other low-income and middle-income countries. Our patient is an example of a deficient antenatal healthcare access. The importance of gender as a parameter in healthcare equity can be adjudged by the fact that more than half of the studies on equitable distribution of healthcare in India have focused on women. 4 In various studies, it has been shown that caste, education and religion are significant factors in determining inequity in healthcare access in India. People from the so-called lower castes were found to have a lower literacy rate and were less likely to seek medical care as well. 8 9 Our patient was also illiterate and so were his family members, which might have contributed to his delayed access to healthcare. Taking all these factors into account, the government of India has recently in 2018 launched the 'Ayushman Bharat' initiative, which aims at providing universal health coverage. The two major components of this scheme are the creation of health and wellness centres and the National Health Protection Scheme (NHPS). NHPS is an ambitious health insurance scheme that aims to provide rupees 5 lakh (approximately US$6800) health insurance coverage to around 40% of the country's population. The population covered under this scheme includes those who are in most need of healthcare access based on a socioeconomic and caste-based census. 10 Necessity is the mother of invention, and our patient, although could not get access to definitive treatment in his childhood, used a self-devised urine-collecting system to normally lead his life. Although it is challenging to provide universal healthcare access especially in a populous country like India, it is the need of the hour and the present case reiterates this fact. learning points ► While there have been great advancements in healthcare throughout the world, there is still a lack of universal equitable healthcare access. ► Financial status and gender are parameters of utmost importance that determine access to healthcare in the present healthcare system in low-income and middle-income countries. ► It is the need of the hour that, along with advancements in healthcare, better policies for achieving equitable healthcare are implemented in low-income and middle-income countries like India, and while framing these policies parameters such as wealth, gender and education are kept in mind. ► The launch of 'Ayushman Bharat' scheme by the Indian government is a welcome step; however, the results would only be available in the long term. Contributors sp conceived the case report. sp and Ds were major contributors towards writing the manuscript. Bps, aG and sp interpreted the patient data. sp and Ds were involved in the review. all authors read and approved the final manuscript. Funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Competing interests None declared. patient consent obtained. provenance and peer review Not commissioned; externally peer reviewed. --- Global health Copyright 2018 BMJ publishing Group. all rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case report Fellows may re-use this article for personal use and teaching without any further permission. --- Become a Fellow of BMJ Case reports today and you can: ► submit as many cases as you like ► enjoy fast sympathetic peer review and rapid publication of accepted articles ► access all the published articles ► re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact consortiasales@bmjgroup.com Visit casereports.bmj.com for more articles like this and to become a Fellow

We report a case of a 22-year-old man with adult exstrophy. the patient made a self-made urine collection device, which helped him to lead a normal life, carrying out his routine as well as occupational activities smoothly. this patient is a prime example of inequalities in healthcare distribution in low-income and middleincome countries. He was never taken to a proper medical centre to correct his condition nor was his mother ever given proper antenatal healthcare access. His background of being a poor person from rural India highlights the problems of inequalities in healthcare access.

It is humbling as an American to comment on other nations' health policies. Given our nation's policy failures and pathologies, we often instruct by counter-exampleand by illustrating how poor policies can produce poor population health outcomes despite the deployment of great human and material resources. This holds especially true of America's policies towards intoxicating substances. Still, a glance over the fence yields some consolation that other societies face their own challenges and worries. Such was my reaction to Hagit Bonny-Noach's intriguing description of Israeli policies towards backpackers who use drugs [1]. Few Israeli practices are more normative than the backpacking-trip as a rite of passage. Few developments are less surprising than the news that backpacking in far-off locales provides occasion to experiment with the various intoxicating experiences young adult life has to offer. Some such experimentation is expected, and often developmentally appropriate. It also carries real risks. Some of these risks are acute because they involve young men and women using powerful intoxicating substances for the very first time. As elsewhere, the typical Israeli backpacker who uses hallucinogenics or other illicit substances will emerge unscathed. Carrying on with their lives, many might wonder why their parents and public health authorities are so concerned about the joint they might have smoked with friends by the campfire. Yet an important minority will be tangibly harmed. Some of these harms are immediate: Overdose, sexual violence, unintended pregnancy, accidents and injury, toxic reactions to unfamiliar substances. Others, such as addiction disorders, unfold over time, but the harms are equally genuine for the minority of young adults, some with preexisting vulnerabilities, whose experiments with illicit substances go badly. These risks are not unique to Israeli backpackers. Indeed these risks may be more pressing among others, such as young European tourists who frequent Mediterranean destinations with reputations for drinking, drug use, and night partying [2]. Such experimentation may also cast shadows on surrounding lives and communities. Much as Floridians welcome tourist dollars expended by college students over Spring Break, residents are less delighted by alcohol-related injuries and crime [3]. European tourist destinations such as Ibiza face similar community concerns [4]. One can imagine similar reactions among residents of Goa, India, where Israelis are important participants in the local drug scene. Three other themes are noteworthy in this analysis. Harm reduction is both easier and harder when applied to normative behaviors among privileged groups than when it is applied to more-deviant behaviors among marginalized groups Bonny-Noach notes the complex role of social class in defining feasible policy responses. Strictly punitive measures are out of the question when so many drug-using backpackers are members of Israel's social and economic elite. These class dynamics bring more interesting implications, too. Israelis appear relatively comfortable with syringe exchange and related services offered to people who inject drugs (PWID)-a distinctively more marginal group. HIV prevalence in Israel is relatively low. Harm reduction services are available in major cities. On Bonny-Noach's account, this relatively humane response does not reflect particular regard for PWID within Israeli society. It may reflect the opposite. From the perspective of many decision-makers, PWID are already regarded as deviant and addicted. Thus, the population health calculus is straightforward and entirely pragmatic. If harm reduction measures reduce HIV incidence and pass the cost-benefit test, policymakers' very psychological distance from marginalized drug-using communities makes harm reduction the sensible and pragmatic option. Ironically enough, harm reduction can be more culturally fraught when equivocal messages and policies regarding behavioral risks are directed at "normative young adults" engaged in illicit substance use. Here the special circumstances of backpacking facilitates harm reduction interventions that might not be possible under other circumstances. Fortunately, the mere fact that such drug use often occurs offshore-In India, East Asia, or central America-softens the policy dilemma. Israel can offer treatment and prevention services to assist backpackers. Available law enforcement tools for supply-side and demand-side enforcement are correspondingly limited, allowing greater scope for harm reduction interventions such as the "Israeli Warm Home." --- Destination venues may play a critical role in harm reduction Hughes and colleagues plausibly suggest that unfamiliar drug markets, geographies, and climates heighten risks for both backpackers and destination communities. Backpackers arrive at relatively unfamiliar places, where they may not speak local languages, and are almost certain to lack basic information regarding medical services and harm reduction resources. The business models of destination hotels create further risks, as some venues attract tourists through their reputations for uninhibited partying and drug use. Proper regulation by destination authorities--and proper interventions by Israeli public health authorities-might focus on effective partnerships with these venues. Hotels, bars, and other sites can distribute basic information regarding drug-related risks and protective behaviors. They can also post information regarding prevention and treatment opportunities for individuals who need such help. The key is not to impose a zero-tolerance policy, but to ensure basic supports such as cold drinking water are available for those vulnerable to dehydration. The history of harm reduction measures at rave events provides one useful model. --- Certain harms-notably violence-appear notable in their absence Benny-Noach presents 29 headlines from Israeli newspapers (see Table 1). These describe diverse substance-use-related problems associated with backpacking and substance use. Although illegal activity is mentioned in the context of Israeli or Indian police arresting drug dealers, none of these 29 headlines detailed violence perpetrated by or inflicted on Israeli backpackers. Israeli backpackers may, at times, pose a public nuisance within destination communities. They do not, generally, pose a public safety threat or appear to suffer disproportionate levels of predatory crime. This somewhat departs from the European or American experience, where violence is a more prominent drug-related harm. These differences may reflect cross-national differences in alcohol use. Although alcohol disorders are more common among Israelis than stereotypes may suggest, prevalence is still relatively low by cross-national standards. [5] Within the European sample studied by Hughes and colleagues, more than 90% of reported violent incidents occurred when individuals were under the influence of alcohol. More than one-third of the European sample reported being drunk for at least half of their vacation stay. [2] Whatever the explanation, low prevalence of violence and of other non-drug crimes opens further space for less-punitive harm reduction measures. --- Conclusion This is a valuable opportunity. Much can be accomplished when policymakers and the public are unafraid, when they see harm reduction as benefitting their own children and peers. --- Abbreviations IADA: Israel Anti-Drug Authority; SCDAA: Special Committee on Drug and Alcohol Abuse --- Authors' contributions The author read and approved the final manuscript. --- Author information Harold Pollack is the Helen Ross Professor of Social Service Administration at the University of Chicago, and co-director of the University of Chicago Crime Lab, and University of Chicago Health Lab. Ethics approval and consent to participate Not applicable. --- Consent for publication Not applicable. --- Competing interests The author declares that he has no competing interests. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Hagit Bonny-Noach notes the challenging history of illicit substance use among Israeli backpackers. Few Israeli practices are more normative than the backpacking-trip as a rite of passage. Unsurprisingly, backpacking in far-off locales provides occasion to experiment with the various intoxicating experiences young adult life has to offer. Some such experimentation is expected, and often developmentally appropriate. It also carries real risks and causes real harms. Israeli policymakers' efforts to address this issue underscore both the necessity and the difficulty of harm reduction. Bonny-Noach usefully notes the importance of social class as both a facilitator and a barrier to effective public health policies to protect young adults from drug-related harms.

ECONOMICS AND MANAGEMENT OF NATIONAL ECONOMY Issue IV (80), 2020 35 The analysis of foreign experience taking into account social tourism in the formation of social policy, determining the degree of readiness of Ukraine to introduce social tourism is carried out. The relevance of this article is that recreation and leisure are important factors in the lives of most people, but may be inaccessible and limited to certain categories of people. Therefore, in our opinion, the decision on the issue of inaccessibility and organization of recreation should be partially taken over by the state. This is due to one of its most important functions, namely social, where the center of security is the person, his life and health. Since most of the functions of the state can be realized through politics, we believe that social tourism can become one of the effective elements of social policy. For tourism to become social, it must be accessible to society and create the opportunity to restore human resources for different categories of people, especially those with disabilities. The article is to reveal the essence of social tourism, to identify the main social components that can become an element of social policy of the state. The proposed results indicate that social tourism can be included in the list of social services, and foreign experience in the use of holiday checks can be used by private enterprises to restore the workforce and improve the health of the team. Prospects for further research requires issues of financial and economic nature, filling the state budget for the allocation of subsidies for the development of social tourism and creating conditions for its accessibility for the poor. Keywords: tourism, social tourism, state social policy, social functions, social programs, holiday checks. • створення сприятливого середовища для людей з інвалідністю; • забезпечення захисту прав дітей та підтримка сімей з дітьми; • соціальна підтримка сімей, що опинилися у складних життєвих обставинах та інших категорій населення; • створення умов для забезпечення достойної старості громадян похилого віку [4] та інші. На нашу думку, туризм може забезпечити такі цілі шляхом: • формування та розбудови туристичних об'єктів відпочинку для людей з інвалідністю на основі державно-приватного партнерства; • виділення соціальних дотацій на відпочинок та підтримку сімей з дітьми, надання їм психологічної підтримки; • надання путівок сім'ям, що опинилися у складних життєвих обставинах, та іншим категоріям населення ( однак доцільність таких послуг повинна визначатись ступенем складності умов проживання, враховуючи першочергові потреби для нужденних сімей); • створення або адаптація туристичних об'єктів до потреб громадян похилого віку. • контроль цільового призначення відпускних.

investitsii (Accessed 18 March 2021) (in Ukr.). 5. Salzer, M., Ivanyuta, D. Coronavirus and foreign investors: in search of a balance between quarantine restrictions and investment protection. URL: https: //yurgazeta.com/publications/practice/inshe/koronavirus-ta-inozemni-investori-v-poshukah-balansumizh-karantinnimi-obmezhennyami-ta-zahistom-inv.html (Accessed 18 March 2021) (in Ukr.).

medical expenditures. The aggregate CI burden was $627B (95%CI: $511B-$743B): 59% due to ADRD and 41% to MCI. Individuals with MCI without progression to ADRD lost healthy life years valued at $119K (95%CI:$99K-$139K). Those with early CI onset were more likely to be from disadvantaged populations and carried the largest per capita burden [$376K (95% CI: $315K-$436K)] cumulating to 60% on aggregate, nearly half of which experienced during MCI. Individuals with lower education, progression to ADRD, or racial/ethnic minorities also carried disproportionate burden. MCI represents 41% of the overall CI burden and disproportionately affects individuals with early CI onset. Characterizing CI-related health and economic disparities at milder stages and younger ages should be prioritized. Abstract citation ID: igad104.1730 --- THE IMPACT OF A NATIONWIDE PHYSICAL ACTIVITY INTERVENTION FOR DIABETES AND HYPERTENSION PREVENTION Cynthia Chen 1 , Gregory Ang 1 , Chuen Seng Tan 1 , Falk Müller-Riemenschneider 1 , and Yot Teerawattananon 2 , 1. National University of Singapore, Singapore, Singapore,2. Health Intervention and Technology Assessment Program,Muang Nonthaburi,Nonthaburi,Thailand Increasing physical inactivity is a primary risk factor for diabetes and hypertension, contributing to rising healthcare expenditure and productivity losses. We examined the cost-effectiveness of the National Steps Challenge (NSC), an annual nationwide mHealth intervention to increase physical activity in Singapore. We used a Markov model to assess the long-term impact of increased physical activity from NSC on adults. Conducting NSC yearly for 10 years on a mean cohort size of 654,500 participants is projected to prevent 6,120 diabetes cases (95% credible interval: 3,690 to 9,040), 10,300 hypertension cases (6,260 to 14,700) hypertension cases and 4,950 death cases (3,280 to 7,040), leading to 78,800 QALYs (56,500 to 102,000) gained. From the health system perspective, assuming no differentiation of cost among different physical activity levels within each health state, the healthcare cost savings from the averted cases is estimated to be SGD674 million (239 million to 1.48 billion), with SGD364 million (57.8 million to 1.04 billion) for diabetes and SGD311 million (95.0 million to 690 million) for hypertension. Using a willingness to pay threshold of SGD10,000, NSC was cost-saving at -SGD4,510 (-14,000 to 1,430) per QALY gained. We project that increasing physical activity from a yearly nationwide physical activity intervention delays the incidence of diabetes and hypertension. Our results suggest that the intervention is cost-saving and improves the quality of life. The estimated cost savings are more significant when indirect costs are considered, hence providing important information for decision-making in countries when considering similar large-scale physical activity programmes. --- SESSION 4390 (PAPER) --- GENDER, ROLES, AND HEALTH GENDER AND HOUSEWORK IN THE POSTRETIREMENT CONTEXT In Jeong Hwang 1 , Joseph Svec 2 , and Jeong Eun Lee 3 , 1. Harvard University, Boston, Massachusetts, United States, 2. Saint Joseph's University, New York City, New York, United States, 3. Iowa State University, Ames, Iowa, United States In recent years, social scientists have noted an uptick in "unretirement" of older adults as a large number of retirees have reentered the labor force. Not only do older Americans' labor-force reentry have implications for our economy as a whole, this also raises important questions regarding the social and interpersonal relationships within households. Specifically, women, compared to men, might be disproportionately subject to work-family conflicts, due to the gendered expectation that women take primary responsibility for household labor. In this study, we examine 758 American couples aged 65 and above from the 2005-2019 Health and Retirement Study (HRS) core survey and the supplemental Consumption and Activities Mail Survey. We examine whether and to what extent couple's retirement and re-entry into the labor force correspond with changes in the distribution of household labor. Specifically, we expect that while both men and women shift their household labor contributions in accordance to changes in their formal work statuses, changes in men's contributions are attenuated relative to women's. The results show that while both male and female retirees spend more time housework when their spouses work, women tend to perform more housework when they re-enter the labor force whereas men's contributions decline significantly upon their re-entry. These patterns are increasingly evident from the analysis focused on routine tasks, typically done by women. These results highlight how gender ideological scripts can frame relational contributions and expectations as well as their persistence despite shifts in economic contributions to the household. Abstract citation ID: igad104.1732 --- GENDER, SEXUAL ORIENTATION, AND SPOUSAL CAREGIVING FOR THOSE WITH DEMENTIA: A FOCUS ON EMOTION WORK Toni Calasanti, Sadie Giles, and Jing Geng, Virginia Tech, Blacksburg, Virginia, United States This study draws upon and expands three research streams. The first relates to spousal caregiving for those with dementia, and gender differences in stress. Based on gender divisions of labor, men are more likely to take a task-oriented approach to caregiving; women take a more holistic, empathetic approach. The second strand relates to emotion work, wherein caregivers manipulate their own emotions to produce a desired outcome in another (Hochschild, 2003). Research shows that spouses find performing emotion work "draining" (Umberson, et al., 2020), and that women do it more. Finally, we draw upon research that finds that samesex couples are more egalitarian in their division of labor than are straight couples; how this impacts caregiving approaches or emotion work is unclear. Weaving these together, our study explores how inequalities of gender and sexuality intersect in shaping caregiving by older adults who care for their demented spouses. Our analysis of in-depth interviews conducted among 69 straight, gay, and lesbian caregivers finds that, first, heterosexual men rarely engage in emotion work, though they do manage their own feelings. Second, heterosexual wives overwhelmingly manipulate their feelings in attempts to gain compliance from their spouses, calm them, and/or make them happy. Finally, both gay men and lesbians perform emotion work, and they tend to combine the task-oriented and holistic approaches to care. These findings make clear that gender differences found in previous caregiving research are not "natural," and suggest that straight men's lower stress levels may result from their tendency to skip emotion work. Abstract citation ID: igad104.1733 --- STRUCTURAL AND FUNCTIONAL ASPECTS OF SOCIAL NETWORKS AND EMOTIONAL WELL-BEING AMONG LGBT OLDER ADULTS Anyah Prasad 1 , Jeffrey Burr 1 , Edward Miller 1 , and Karen Fredriksen-Goldsen 2 , 1. University of Massachusetts Boston, Boston, Massachusetts, United States, 2. University of Washington, Seattle, Washington, United States Network size and composition are structural aspects and perceived support is a functional aspect of social networks. How these social network characteristics are related to LGBT older adults' emotional wellbeing is not well understood. We investigated these relationships using data from The Caring and Aging with Pride study, a cross-sectional survey of 2,560 LGBT Americans aged 50 years and above, employing a series of mediated and moderated-mediated regression analyses. Results indicated that larger social networks were associated with more perceived support and perceived support partially mediated the association between network size and emotional wellbeing. Results also showed that stress was associated with poor emotional wellbeing via depletion of perceived support but less so when LGBT older adults were embedded in larger networks. These findings are in line with the Convoy Model of Social Relationships and The Stress Process Model; further, the results support Kondrat and colleagues' suggestion that social network size has a moderating role, while social support has a mediating role between stress and health. Also, the Theory of Homophily postulates that shared identity may enhance group cohesion and feeling supported. Accordingly, we observed that perceived support and its mediation role were stronger with LGBT and older network members compared to non-LGBT and younger network members. A larger network of non-LGBT older adults had a more direct beneficial association with LGBT older adults' emotional wellbeing. Our observations have practical implications for programs that aim to support LGBT older adults' emotional wellbeing by strengthening social support through their social networks. Research has demonstrated that relationships are important in the lives of older women. Thirty-one women between the ages of 64-86 participated in interviews about their lives and relationships across the life course. In the interviews, women talked about their family of origin, friendships,

The purpose of this paper is to examine the impact of retirement on actual health outcomes and intentions relating to these outcomes for Japanese men and women. The health outcomes investigated relate to alcohol and tobacco consumption, physical exercise, and psychological distress. This paper uses data from the first 14 waves of the Longitudinal Survey of Middle-aged and Elderly Persons (LSMEP) to estimate regression models explaining these health outcomes. An instrumental variable estimator using instruments constructed from the eligibility ages for various aspects of the Japanese pension is used to account for the endogeneity of retirement and income. Individual heterogeneity is dealt with by using a fixed effects estimator. For both men and women, it is found that there is no significant impact of retirement on the extent to which individuals report that they will take care not to drink too much, nor smoke too much, and to engage in a sufficient amount of exercise. While psychological distress declines for both men and women as they retire, the proportion of men drinking alcohol falls while there is no change for women. For both men and women, the proportion who are smoking falls after retirement. The proportion of males and females engaging in moderate amounts of exercise increases following their retirement. Taken together, the results suggest that reductions in stress following retirement are driving the results. Falls in income associated with retirement explain little of the behaviour observed.

than nonimmigrants (Leduc, 1999;Leduc, Proulx, & Sevigny, 1999), and women are often reported to utilize health services to a greater extent than men (Holland, Bradley, & Khoury, 2005;Mackenzie, Gekoski, & Knox, 2006;Mozes & Shmueli, 1998). The findings of gender differences, however, vary across studies and come primarily from studies that examine psychological services. Some studies have revealed that women are more open to psychological help than men (Fischer & Farina, 1995; see also Garland & Zigler, 1994;Husaini, Moore, & Cain, 1994;Leong & Zachar, 1999;Rickwood & Braithwaite, 1994;Solberg, Ritsma, Davis, Tata, & Jolly, 1994;Tata & Leong, 1994), whereas others have found either no gender differences (Atkinson, Lowe, & Matthews, 1995), or gender differences only in some ethnic groups (Sue & Kirk, 1975). Little has been done in the area of HIV prevention, with the exception of a meta-analysis of enrollment data showing higher enrollment rates in women than men (Durantini & Albarracin, 2009;Noguchi, Albarracín, Durantini, & Glasman, 2007). Despite attention to enrollment rate differences, there is a dearth of research on the motivations that lead men and women to enroll in health interventions, let alone HIV-prevention interventions (see Galdas, Cheater, & Marshall, 2005). Explanations for gender differences in enrollment include that men are more frequently uninsured than women (Bond, Lauby, & Batson, 2005), ethnic-minority men are more discriminated against than their women counterparts (Centers for Disease Control and Prevention, 2003;Human Right Watch, 2010;Skiba, Michael, Nardo, & Peterson, 2000), and traditional masculine behavior devalues help seeking as a sign of weakness (Galdas et al., 2005;Smith, Pope, & Botha, 2005). Prevalent notions contend that men are not permitted to disclose malaises because the construction of traditional masculinity locks them into a socially prescribed role that has no place for vulnerability (Courtenay, 2000;Davies et al., 2000;Forrester, 1986;Helgeson, 1987;Lloyd, Jenkins, & Mann, 1996;Mohler, Käppler, Gonçalves, & Gianella, 2005;Robertson, 2001). This explanation seems viable because neither men nor women who are resistant to seek help trust their health-care providers to believe that their pain and suffering are real (Smith et al., 2005) and both groups expect interactions with health services to be shameful and humiliating (Malterud, 2005;Nadler, 1985;Smith et al., 2005). Even in the absence of mean differences in enrollment across men and women, there may be critical differences in the needs that lead men and women to seek HIV-prevention counseling. Meta-analytic data (Durantini & Albarracin, 2009), for example, have indicated that women enroll and stay in HIV-prevention interventions delivered to groups. In contrast, men enroll and stay in interventions delivered to individuals and offering such incentives as health care or payments. Although these data suggest gender differences in the role of social vs. instrumental needs, the studies synthesized in the meta-analysis provided no measures of the needs of clients. Very few studies provide data on enrollment. In this article, we present a study in which the social, emotional, and health concerns of men and women were measured directly and correlated with enrollment in an upcoming session of HIV-prevention counseling. Understanding service use, and specifically enrollment in HIV-prevention interventions, may benefit from theorizing about socially based gender differences. Social psychological research has found that heterosexual males and females differ with respect to their goals of agency (i.e., focus on the self and autonomy) and communion (i.e., focus on other people and relationships; Bakan, 1966;Helgeson, 1994). Due to a combination of biological and social factors, men are more likely to develop personality traits related to agency, whereas women are more likely to develop personality traits related to communion (Helgeson, 1994). Moreover, women are subjected to specific concerns with respect to relationships, particularly when they suffer emotional and/or physical abuse by their partners (Kernick, Wolf, & Holt, 2000). From this perspective, men may enroll in interventions to improve their general health and strength (see e.g., Duncanson, 2005;Pearson, 2003;Pinkhasov et al., 2010), whereas women may be more attracted to interventions to address emotional needs and relationship problems (for speculation about these issues, see Durantini, Albarracin, Mitchell, Earl, & Gillette, 2006). Of course, men and women are also likely to enroll in HIV-prevention interventions based on deficiencies in their current condom use. HIV-prevention risk is the obvious factor that leads researchers to attempt to enroll clients into risk reduction programs, but it is likely not the only need clients attempt to fulfill when they agree to enroll. --- Method In our study, a sample of 350 sexually active, north Floridian men and women were recruited for a health interview. Halfway through the interview, the interviewer paused the administration and announced a 30-minute break. At this point, an observer/counselor entered the room to perform work unrelated to the interview and unobtrusively observed the participant's enrollment in a brief HIV-risk-reduction counseling session. The enrollment behavior was analyzed as a function of various complaints measured before the counseling offer was made. Specifically, participants reported on various physical complaints, such as whether they regularly experienced heart palpitations, upset stomach, headaches, or muscular pain. They reported if they were overtly abused by their sexual partners, and if they felt nervous, anxious, unsafe, or threatened in the presence of their partners. Past condom use and intentions to use condoms, as well as various demographics, were measured. The analyses compared enrollment across gender groups. --- Results --- Descriptive results and differences across genders A description of the sample appears in Table 1. This sample is characteristic of the impoverished clients of North Central Florida and the Southeast of the US. As described in Table 1, the sample was relatively young, African-American, poor. The participants also had an average of two children. Importantly, the sample was at considerable risk for HIV and sexually transmitted infections (STIs) as indicated by the number of recent STIs. Specifically, participants were asked "in the past year, how many times have you had a sexually transmitted disease such as Syphilis, Gonorrhea, Herpes, or Chlamydia?" in response to which 11% of males and 13% of females reported at least one STI during the past year. Participants were also at risk due to their low level of condom use (21% reported using condoms all the time), and high number of partners (29% of the males and 22% of the females had had more than one partner during the last three months, with between 2 and 10 partners for males, and 2 and 7 partners for females). The sample characteristics in Table 1 were compared across men and women by means of analysis of variance for continuous variables and chi-square tests for categorical variables. Men (vs. women) worked more hours, had a higher average of alcoholic drinks per week, were less likely to have a main partner, and had more physical complaints than women. Women (vs. men) had more emotional complaints than men. No other group difference was significant. Counseling enrollment tended to be higher in women, but this difference was not statistically significant. --- Predictors of counseling enrollment in men and women We predicted that different needs may lead men and women to enroll in counseling, and that these needs could be broader than HIV-risk reduction. To test these possibilities, we conducted a logistic regression in which enrollment in counseling (yes = 1) was predicted from all of the variables in Table 1. In addition, this equation included the variables related to physical, emotional, and partner-violence complaints as well as past sexual behavior and interactions between these measures and gender (dummy coded so that 1 = women, 0 = men). This analysis appears in the first panel of Table 2 and shows significant interactions of gender with physical complaints and partner violence. The decomposition of this interaction was conducted by repeating this logistic regression but separately for women and men and without the indicator variable for gender or interactions involving gender. These regressions appear in the bottom panels of Table 2 and show clear-cut differences in the needs associated to enrollment in each gender group. Physical complaints had a positive association with enrollment in men but not in women, whereas partner violence had a positive association with enrollment in women but not in men. No other interactions reached significance. --- Discussion Over the years, demographic and social factors have shown to contribute to people's decision to participate in health promotion programs (Sohler et al., 2009;Tedstone Doherty & Kartalova-O'Doherty, 2010). Migratory status has also proved to influence the use of health services (Kim et al., 2010;Kim, Jang, Chiriboga, Ma, & Schonfeld, 2010;Leduc, 1999;Leduc et al., 1999;Nandi et al., 2008). Nonetheless, there has been little attention to the individual motivation for enrollment in HIV prevention programs, except for a couple of meta-analyses (Durantini & Albarracin, 2009;Durantini et al., 2006;Noguchi et al., 2007), even when the government has been spending vast resources on that field. Motivations for enrollment in HIV-prevention programs are a scarcely studied topic, even when researchers and practitioners have developed many creative resources for attracting reluctant audiences. Filling this gap, the current research showed that enrollment in HIV-prevention interventions differs between men and women and is facilitated by needs broader than HIVrisk reduction. The present article summarizes results from a study conducted with 350 participants, providing important information about their motivations: women, who worry about their relationship with a violent partner, pay relatively smaller attention to their HIV-risk reduction needs and are more strongly attracted to interventions that provide social support and may allow them to discuss relationship issues (Durantini & Albarracin, 2009). Men, who are usually more reluctant to seek medical care than women (Mackenzie et al., 2006;Sohler et al., 2009), looked more ready to accept an opportunity to talk about health when they had health-related concerns to begin. We can hypothesize health counseling was relatively not threatening to men and thus provided an avenue to addressing their health concerns. Another explanation for our findings related to factors influencing men's acceptance of counseling would be that men's health concerns are likely to be more serious than women's because the mean turn to medical services less frequently than women. Therefore, interventions may need to meet women and men's personal goals and thus package HIV-risk reduction among other goals of concern for the recipients of the intervention. Given that interventions should reach vulnerable audiences and not just willing ones, it is imperative to develop procedures that increase participation by the needed populations (Albarracin, Durantini, & Earl, 2009). Procedures can be designed to change an audience's behavior with respect to the preventive interventions themselves, including enrollment. These procedures, termed meta-interventions, entail a standardized introduction or context change (e.g., delivery setting) intended to increase exposure to a behavioral intervention (Albarracin et al., 2009). In the context of our findings, invitations to HIV-riskreduction counseling should highlight the ability of counselors to provide assistance with family violence, as well as more general health concerns. Such procedures, combined with more comprehensive training for counselors, should ensure the availability of services that match the needs of the clients in addition to public health mandates.

Although reducing HIV risk is a primary motive for the design of HIV prevention interventions, the goals of the clients may be very different. Social theories of gender suggest that women, who often seek to resolve social and relational problems, may see HIV-prevention counseling as a mean of resolving partner violence. In contrast, men, who often worry about their physical strength, may seek to enroll in HIV-prevention programs when they experience physical symptoms unrelated to HIV. An unobtrusive study was conducted to observe enrollment in HIV risk-reduction counseling after measuring partner-violence complaints (e.g., feeling threatened or being hit), emotional complaints (e.g., fatigue or anxiety), and physical complaints (e.g., cardiovascular or digestive symptoms). The sample was a group of 350 participants, 70% clients from a state-health department in North Central Florida and 30% community members. Consistent with predictions, complaints of partner violence had a positive association with enrollment in women but not in men, whereas complaints about physical health had a positive association with enrollment in men, but not in women. Emotional complaints did not predict enrollment in either gender group. This study suggests that broad, gender-specific population needs must be competently addressed within HIV-prevention programs and may be strategically used to increase program enrollment.

Introduction Current treatment strategies have turned HIV infection into a chronic disease and life expectancy for people living with HIV (PLHIV) continues to increase. [1][2][3] Moreover, treatment options are still expanding and new antiretroviral agents are less toxic and more convenient than earlier antiretroviral therapy (ART). As such, the vast majority of PLHIV can currently lead a relatively normal life. Consequently, PLHIV can make a professional career or may return to work after a period of disability. 4 Previous research showed that a majority of PLHIV work. Furthermore, employment seemed to positively influence health-related quality of life. 5 The present study aimed to explore experiences of PLHIV in the workplace concerning disclosure and adherence to ART. --- Materials and Methods In collaboration with Sensoa, the Flemish expertise centre for sexual health, a research project was conceived. Literature research was performed and emerging themes were discussed together with the experts of Sensoa, resulting in a scientific and practice-based approach. --- Participants All PLHIV who were currently working or had been working in the past, were eligible for inclusion. The target audience was reached by flyers distributed in the Flemish AIDS reference centres in Antwerp, Brussels and Ghent and during HIV cafe ´s (informal meetings among peers), by announcements on the website of Sensoa, their daughter website 'www.levenmethiv.be' (5 'living with hiv'), their Facebook account and the community website 'HivMix'. --- Questionnaire Results from the literature research were used to outline the structure of the questionnaire. 4,[6][7][8][9] In consultation with Sensoa, the questions were chosen and formulated, resulting in a tree-structured questionnaire examining two main themes: disclosure and medication-intake in the workplace. In addition, socio-demographic data (gender, age), date of HIV diagnosis and information about the work situation (work schedule, job type, etc.) were also included. It was decided to use an online questionnaire as this is an easy, low-cost and quick method to collect data. --- Statistical analyses All results were exported from the questionnaire software ('Qualtrics') to SPSS.22 (SPSS, Inc., Chicago, IL, USA). Descriptive analyses were performed and are reported via numbers and percentages. Associations were examined via chi-square tests. --- Results Population A total of 67 PLHIV participated in the study, among whom 54 fully completed the questionnaire. There were 50 men and four women, with a median age of 42 years (IQR 33-51 years). Forty-four people were currently working (12 blue-collar workers * , 25 whitecollar workers * , five self-employed and two public servants). Ten people were unemployed and one of them did not return to work after HIV diagnosis, rendering other questions no longer applicable. Almost three quarters of the remaining participants worked full-time (39/53, 73.6%). --- Disclosure Almost half of the respondents did not inform any of the colleagues about his/her seropositive status (23/ 53, 43.4%). People who disclosed, mostly told close colleagues only (22/53, 41.5%), an official trustee (13/ 53, 24.5%) or executives (12/53, 22.6%). When being asked what hindered disclosure, half of the people reported to have fear for professional consequences (such as discharge, loss of clients) (28/53, 52.8%) and to be afraid for social consequences (such as discrimination, nagging) (26/53, 49.1%). Twenty-one participants (42.0%) worried about people telling others and 11 respondents (22.0%) mentioned to have followed someone's advice to not disclose at the workplace. Those who disclosed, mostly did this of their own free will (23/30, 76.7%). Justifying their changing health state (10/30, 33.3%) or the (more frequent) absences (8/30, 26.7%), but also the desire to be honest and not to live with a secret were the most cited reasons to disclose (4/30, 13.3%). In the majority of the cases, no professional changes appeared after disclosure (18/30, 60.0%), or the change was positive (i.e. more understanding from colleagues, 8/30, 26.7%). Nonetheless, three participants (10%) declare that they got fired after they had disclosed. As compared to blue-collar workers, significantly more white-collar workers had disclosed their seropositive status in the workplace (4/12, 33.3% vs 17/ 25, 68.0%, P50.046). Disclosure was not found to be associated with other factors (gender, age, time since diagnosis, disclosure to environment, P.0.05). --- Medication intake Forty-seven participants (88.7%) reported to take ART, among whom 38 (80.9%) once daily. Twentyone participants took their medication in the workplace and none of them reported problems doing so, neither towards colleagues, neither towards infrastructure. Half of the 26 others took the decision not to take medication at work consciously, in consultation with their physician. Variable work time tables were most frequently reported as a hindering factor to adherence (5/21, 23.8%). On the other hand, access to food (8/21, 38.1%), drinks (7/21, 33.3%) and the proficiency to quickly take ART (7/21, 33.3%) were reported to be supporting factors. --- Discussion Our findings confirm the general good health among PLHIV in Belgium. 10 For this study population, being seropositive does not necessarily hinder a professional career, since the vast majority of respondents work full-time. Strikingly, almost half of the participants did not disclose in the workplace, despite the many solidarity campaigns, etc. This number is almost double as compared to French PLHIV (29.9%), 7 but less than British PLHIV (61.5%). 6 The lower disclosure percentage seen in the French study may be partly due to the fact that this study took place in 2002-2003. Ten years ago, openness about HIV may have been less frequent. The higher disclosure percentage in the UK study is probably biased by the study population, almost completely consisting of homosexual, white men. They are more likely to disclose to employers than heterosexual men/women and homosexual men from ethnic minority groups. 11 Fear for discrimination or discharge is high, and seems to be the main reason to not disclose. Previous research among French-speaking Belgian PLHIV showed that 6.5% of the people who disclosed experienced difficulties afterwards (being refused a job, blocked career, etc.) 12 The latter demonstrates that information and solidarity campaigns from organizations as Sensoa are highly needed. Internalized stigma, the fear and shame PLHIV experience from within, remains an increasingly recognized additional barrier. 13 Some PLHIV argue that disclosure will not give any added value, or they consider it a private affair. 6 Hence, it should be acknowledged that the decision to disclose is a personal choice and that achieving 100% disclosure might be an unrealistic goal. Differences in job context may influence the decision to disclose the status. We have found that white-collar workers disclose more frequently than blue-collar workers. However, this issue should be further explored in bigger study samples and confounding factors should be taken into account. Those could be: type of working environment, the reputation of the person, colleagues' knowledge about HIV, anticipated negative consequences and awareness of the sexual orientation of the person living with HIV (mainly applicable for homosexual people). 6,8 Data about medication intake in the workplace, revealed that this is less an issue than expected. Many PLHIV do not take ART at work, since certain regimens need to be taken before sleep or along with the main course, which is mostly in the evening. If they do take ART at work, they do not seem to encounter difficulties. Availability of accommodations, such as flexible work hours or easy access to food and drinks, were reported to be helpful, corresponding with previous research about adherence in the workplace. 9 Some limitations of this study should be acknowledged. Our relatively small sample size does not fully represent the Belgian HIV cohort, since there are more female PLHIV (37 vs 7%) and a lower percentage is on ART (75 vs 87%). 10 Our study methodology is also susceptible for recruitment bias towards people who are currently working. Moreover, our results should be further studied in depth by means of qualitative research (e.g. focus groups). Nevertheless, these first results already show tendencies and can inspire further actions and campaigns. In conclusion, half of the PLHIV did not disclose their seropositive status in the workplace mainly due to fear for discrimination. The potential barriers need to be further explored.

Objectives: As HIV is currently a chronic and manageable disease, an increasing amount of people living with HIV (PLHIV) are (again) active on the labour market. Since research on this topic is scarce, this study aimed to explore experiences of PLHIV in the workplace, especially concerning disclosure and adherence to antiretroviral therapy. Methods: A questionnaire was developed and validated in collaboration with Sensoa (Flemish expertise centre for sexual health) and participants were recruited using flyers and announcements on websites. Results: A total of 54 PLHIV completed the questionnaire, among whom 50 (92.6%) males. Half of the participants did not disclose their HIV status in the workplace, mostly due to being afraid of social or professional consequences. Those who disclosed, reported no changes in the workplace or even reported receiving more empathy. A minority of participants have to take antiretroviral medication at work and they reported no particular problems related to medication intake. Conclusion: Despite improved solidarity and information campaigns, many PLHIV still do not disclose their HIV status in the workplace, most frequently due to fear for discrimination. More actions are warranted, as well as addressing possible self-stigma. Adherence to antiretroviral therapy in the workplace posed little or no problems.

Some have leveraged the idea of intimacy to problematize the individual's position and role at one end of these poles. In this paper, we ask how intimacy is conceived and mobilized as a category of datafication and its products. We take it up as less a demarcation of particular types of data, and more as a socially productive framing: it does work that goes far beyond mere description. We recast intimacy as marshaling the production of individual bodies and their relations to broader structures of power and epistemologies. --- Intimate Data So Far In literature to date, intimacy marks an effort to describe data's objective and affective effects on people. "Intimate data" is hardly a consistent or unified category, but some salient themes do emerge. Often, intimate data is used to mark a particular category of tracked behaviors or activities that are deemed-as a matter of legal or social convention-private or sensitive (Weltevrede and Jansen 2019). Here, the "intimate" in intimate data is cast as a metric: the closer the datafied phenomena is to that individual's fleshy body, the higher its degree of purported intimacy. For example, intimate data are often envisioned to encompass sexual encounters, movement through a city, fertility apps, or fitness activities. These critiques are usually situated within broader consideration for enrollment in economic production, especially circuits of capitalist production (Gidaris 2019;Sadowski 2019). Some key assumptions prop up this approach to the "intimate" in intimate data: it assumes a public/private dichotomy (even when the argument complicates it), it reifies existing categories or kinds of relationships already deemed "intimate" (by the law, by medicine, and so on), and it assumes a legible and identifiable "body" outside of the contingent and ontogenetic forces that bring them into being. Consequently, this approach sometimes evokes the language of individual or group "privacy" a way to mark and resist such data extraction processes. --- Recasting Intimate Data Without denying that these assumptions can be-at times, in some contexts-politically expedient, we want to surface them and inquire into their limits, especially for making sense of data's social-reproductive effects. First, taking the idea of a "body" for granted sidesteps the way bodies themselves become legible through unequal socio-political relationships. Intimate data do not merely index data about or "close to" an individual body, but also reflect and extend orders that unevenly distribute the benefits and burdens of visibility and social participation: orders that are often enabled by the assumed dichotomy between public and private life. Here, we recall Nash's (2019) critique of the (white) feminist anti-violence advocacy that sought to make more permeable the boundary between the private, domestic space of the home and the public, disciplinary forces of the state. Nash reminds us that what counts as a private or intimate space worthy of special consideration is not only gendered, but racialized, and that impacts of intimate violence will always be different for Black women than for white women. Heeding Nash's reminder, we want to emphasize that the act of labeling this or that data "intimate" is never just about marking data as sensitive or close to a body, but instead marshals broader relations of gendered and racialized power. In this way, "intimate data" are always bound up with the production and regulation of gender, race, sexuality, class, citizenship status, and beyond. Second, we submit that the terrain of "intimate data" can serve as less of uncritical recitation of categories and experiences already assumed intimate and more as an analytic for studying the cultural production of intimacy and, perhaps, unmaking intimacy's hegemonic associations. A small but growing number of scholars gesture at this conceptual possibility (e.g., Pienaar et al 2021). For one, Kwon et al (2018, 19) remind us that "intimate data is not intimate per se, nor is intimacy a property of the data, but is an interactional outcome". Aligned with these works, we gesture toward an idea of "intimate data" that is less descriptive and more analytic. As Grayson (1998, 544) argued, new technologies make the once settled and protected rules of intimacy suddenly "visible and available for (re)interpretation and (re)inscription." Following this, we note that popular discussions of data ethics or data justice visibilize the hermetic liberalism of idealized autonomous subjects through their debates over consent and exchange. Instead of reinscribing these ethical relations, we offer a politics of data as eliciting confessions, creating vulnerabilities, and developing new possibilities for governing (inter)personal and other relations. To quote the late Berlant (1998, 286), "rethinking intimacy calls out not only for redescription but for transformative analyses of the…conditions that enable hegemonic fantasies to thrive in the minds and on the bodies of subjects…".

Increasingly pervasive and invasive forms of data collection and extraction characterize contemporary life across the globe. Much research has clarified how such datafication shifts relations between technology and society (Van Dijck 2014), but there are persistent unresolved questions related to the tensions between datafication of social groups and datafication of individuals. While datafication technologies help produce and monitor meaningful or manageable populations, they also operate and have effects at the level of the individual, and such practices have frequently been engaged through the idea of intimacy. Personal habits and browsing histories now produce tremendous value for private companies (Cheney-Lippold 2018), while in the United States physical and other movements are subject to geospatial surveillance through smart phones (Valentino-DeVries 2020). Additionally, sensors directly applied to individual bodies have become more widespread, with high-profile examples like Fitbit, Apple watches, and fitness tracking apps eclipsing more insidious cases like Amazon's Halo watch that always listens to your voice and asks you to take undressed selfies to measure BMI (Hern 2020). These transformations are happening on a global scale, but look different in particular socio-political and legal geographies.

I. INTRODUCTION T ODAY the online social network Twitter has more than 300 million monthly active users [1], with many of them actively following sports events, stars or clubs to exploit the possibilities of obtaining the latest news through instantaneous messaging [2]. Large football clubs and football leagues invest money in establishing official social media channels to engage with their fan basis [3], and seek to purchase players who bring them a massive number of Twitter followers [4]. Social media presence is especially important for clubs that rely more heavily on broadcasting and commercial revenues than on match day revenues, such as the global top 20 clubs from a recent analysis of the Deloitte Football Money League [5]. Because global fans have limited options to be present at matchday events, popularity on Facebook together with Twitter is a good indicator to judge the global follower success of a football club. On the other hand, the geographic and socio-economical environment of a user still plays an important role in determining the probability of engaging with a globalized phenomenon. As such, complex spatial structures and the dynamics of changes in them have for some time been a focus of the scientific community as well as marketing experts. Recently, there has been a growing literature on the concept of urban scaling, which connects measurable outputs of cities to their size [6][7][8][9][10][11][12][13][14]. Urban scaling laws have been detected for various quantities with respect to city size, such as GDP [15], urban economic diversification [16], touristic attractiveness [17], crime concentration [18,19], human interactions [20], election data [21] or even building heights [22]. Some of these measures follow a superlinear relationship with urban size, which means that the quantities are disproportionally overrepresented in larger cities. These measures include GDP, number of patents or certain business types, where larger cities facilitate more E. Bokányi and G. Vattay are at the Department of Physics of Complex Systems, Eötvös Loránd University, Budapest Hungary. A. Sóti is the member in the Doctoral School of Regional Sciences and Business Administration at Széchenyi István University, Györ, Hungary. the accumulation of wealth and resources needed for such phenomena. On the other hand, infrastructural-like quantities have sublinear scaling laws reflecting efficiency due to urban agglomeration effects. In this paper, we investigate urban scaling laws for geolocated Twitter football club followers for three major widely acknowledged clubs: Real Madrid, Manchester United and Bayern Munich. We calculate the scaling exponents for the number of followers of each club in the urban systems of five different countries. While the scaling exponents of clubs differ significantly within countries as well, the variations in the exponents across countries suggest that the more wealthier a country is, the more sublinear its follower scaling exponent, and vice versa. --- II. MATERIALS AND METHODS Twitter freely provides approximately 1% of its data for download through its API. For those users that allow this option on their smartphones, the exact GPS coordinates are attached to their messages, the so-called tweets. By focusing the data collection on these geolocated tweets, we could determine the home location for a selected most active users in the database using the friend-of-friend algorithm clustering on their coordinated messages. This left us with a total of 26.3 million Twitter users that have home coordinates associated to them. We constructed a geographically indexed database of these users, permitting the efficient analysis of regional features [23]. Using the Hierarchical Triangular Mesh scheme for practical geographic indexing, we assigned cities to each user. City locations were obtained from http://geonames.org, city bounding boxes via the Google Places API. We downloaded the Twitter user identifiers of the followers of three selected football clubs: Real Madrid, Manchester United and Bayern Munich. Table 1 shows the number of followers (people who follow at least one of the three teams, later referred as overall follower count) that are also in our geolocated user database, which meant roughly 2-3% of all followers in all three cases. The theory of urban scaling [7] suggests that there is a power-law relationship between a socio-economic indicator arXiv:1812.04453v1 [cs.SI] 11 Dec 2018 measured in a city and its size. We can formulate this powerlaw relationship with the following equation: Y = Y 0 N β ,(1) Where Y denotes the investigated quantity, N is the number of inhabitants in a city, Y 0 is a normalization constant, and β is the so-called exponent that characterizes the behavior of the quantity in connection to changing city size. In the literature, it has been observed, that this β parameter differs only slightly from 1. Most urban socio-economic indicators have superlinear β > 1 exponents, which is caused by larger cities being the centers of wealth, innovation and creative processes. Sublinear scaling β < 1 characterizes material quantities associated with infrastructure, where the agglomeration into cities is more economic, which manifests in fewer overall road length, or overall cable need etc. [6]. If we take the logarithm of both sides, the equation becomes a linear relationship: log Y = log Y 0 + β • log N,(2) It is then enough to fit a line onto the log Ylog N pairs. We used binning of the data, where we took the mean of logN and logY in each bin, and then fitted a line onto them using an OLS fit with weighting the bins by 1/ --- √ N . This error calculation assumes that higher follower numbers carry less error when fitting the scaling curves [24]. --- III. RESULTS AND DISCUSSION The geographical distribution of users that follow at least one of the three clubs can be seen in Figure 1. A major fan base is in Western Europe, North and Latin America as well as in the Pacific Region. Because Spanish and English teams are among the investigated clubs in Spain and in Great Britain the number of followers is high. As analyzed countries, we chose the home countries of two of the teams, Spain and the UK, and we included traditional football supporter countries like Mexico. We chose Indonesia from from the Pacific Region, and Columbia from South America. We also analyze the USA since it is a country with high Twitter penetration. In the top left corner of Figure 2, we can see the urban scaling relationships of Spain for the three clubs (Real Madrid Fig. 2. Number of followers for the three selected clubs (A-C), and combined follower number (D) as a function of city size in Spain. Black diamonds correspond to bin averages, dashed lines represent the OLS fits with exponents β RM = 1.07 ± 0.08, β M U = 0.90 ± 0.12, β BM = 0.65 ± 0.09 and β All = 0.89 ± 0.06, respectively. in the top left, Manchester United in the top right and Bayern Munich in the bottom left corner), and for the number of overall followers (bottom right corner). The exponent of Real Madrid, the "home" team is superlinear (β RM = 1.07 ± 0.08), while the exponent of the other two teams are sublinear with β M U = 0.90 ± 0.12 for the Manchester United, and β BM = 0.65 ± 0.09 for the Bayern Munich, respectively. Is is spectacular how the second biggest city in Spain, Barcelona is a clear outlier in the Real Madrid urban scaling curve, with having much less followers than the size of the city would predict. The overall follower numbers in Spain also have a sublinear scaling. In Figure 3 when we look at scaling curves in the UK, which has the longest football traditions of all of the countries, we again see a similar picture of the exponents, with that of Real Madrid being higher than the other two, though it is only around the linear regime with β RM = 1.00 ± 0.11. However, Manchester United, apart from the outlier points of Manchester and its surroundings has an astoundingly low sublinear exponent beta M U = 0.68 ± 0.08 that suggests a strong relative decline of interest for this team with the city size. The overall follower trend is also strongly sublinear in the UK. The case of the USA in Figure 4 is very similar to that of Spain, where Real Madrid followers scale superlinearly, but the other two clubs have a sublinear relationship with city size. A very different effect takes place in Indonesia according to Figure 5. Here, all four scaling relationships are in the highly superlinear range, which means that club followership is a measure that is driven by urban factors. Though less pronounced because of slightly smaller, but still superlinear exponents, this is also the case for Columbia in Figure 6. The summary Figure 7 shows that Columbia, Indonesia and Mexico, are the countries whose exponents for the overall supporter count are superlinear. This means that in these countries that globalized football tracking is an increasingly urban phenomenon. In countries where football culture is older, and/or general income is higher, sublinear exponents may signal a relative attention shift for football to smaller settlements, and a change in the composition of consumers of football-related content. This may be an important message for marketers trying to increase social media attention and responsiveness, because people from different environments may need quite different targeting messages. The difference between the club exponents in the same country suggests that Real Madrid followers are relatively more abundant in bigger cities, and the other two teams have more or less the same exponents. This suggests that even Black diamonds correspond to bin averages, dashed lines represent the OLS fits with exponents β RM = 1.17 ± 0.08, β M U = 1.07 ± 0.09, β BM = 0.99 ± 0.06 and β All = 1.12 ± 0.05, respectively. within a country, different clubs may have different follower audiences and fans from different cultural backgrounds. --- IV. CONCLUSION In this paper, we analyzed urban scaling in the follower numbers of three football clubs, Real Madrid, Manchester United and Bayern Munich. We determined user geolocation from Twitter messages that had GPS coordinates attached to them, and fitted scaling relationships using population data for cities of six different countries. While for higherincome countries, urban scaling exponents tended to be in the sublinear, linear or in a few cases, a slightly superlinear range, exponents for lower-income countries are almost exclusively superlinear. This suggests that in a globalized football fandom, very different factors drive followership. Exponents also exhibited variations between clubs, which suggests that the followers of different football clubs are embedded into different socio-economical environments that is related to the degree of urbanization as well.

Social sciences have an important challenge today to take advantage of new research opportunities provided by large amounts of data generated by online social networks. Because of its marketing value, sports clubs are also motivated in creating and maintaining a stable audience in social media. In this paper, we analyze followers of prominent footballs clubs on Twitter by obtaining their home locations. We then measure how city size is connected to the number of followers using the theory of urban scaling. The results show that the scaling exponents of club followers depend on the income of a country. These findings could be used to understand the structure and potential growth areas of global football audiences.

Written statement Since 2013, the discourse of the ultra-nationalist party Vox has mobilized a rightwing backlash in Spain against feminist movements and LGBTQ+ inclusive measures that have sought to deconstruct the hegemonic power of the white heterosexual male. The far-right ideology of Vox and their insistence on the heteronormative male/female binary, however, is hardly new. How can we better understand the persistent causes and consequences of presentday homophobia and misogyny in Spain? In this video essay, I trace a longer trajectory of violence as demonstrated in the film Black bread (2010) by Agustí Villaronga. The film is set in a small Catalan village during the Franco regime when political opponents and sexual 'dissidents' were not only imprisoned, tortured, and murdered, but their vulnerability and rage became manipulated by those in power. It is a film that depicts a world of political and sexual repression where children learn that violence is not an anomaly but a tool. In that context, fear and rage bind together and function to govern the lives of the main characters. This video essay explores how the film provokes thought on the complexity of rage, arguing that it can drive political change and transcend heteropatriarchal norms, or reinforce them. In the groundbreaking text 'The uses of rage', Audre Lourde (1981, p. 280) argues that marginalized groups have «a well-stocked arsenal of anger potentially useful against those oppressions, personal and institutional, which brought that anger into being. Focused with precision it can become a powerful source of energy serving progress and change». For Lourde, rage constitutes a refusal of the deadening force of pain. She frames guilt and impotence as useless feelings and obstacles in realizing the creative possibilities of rage. As this video essay holds, the shifty workings of shame and gaslighting must be added to this list of barriers that disallow anger to be used constructively. I explore how the film makes visible the process through which the powerful manipulate the rage of the marginalized by shifting blame for their oppression. When shame and fear fuel rage, it loses its productive potential and becomes destructive. The film's narrative provides the perspective of a Republican family's queer son who is born in poverty as he comes of age during the postwar years. Along with the young protagonist, viewers discover the secrets related to multiple crimes committed in the village, all of which are rooted in political violence, homophobia, and aggressive masculinity. This video essay unravels these stories of betrayal and deciphers the film's primary motifs. The main character's annihilation of his beloved caged birds suggests that rage keeps him captive instead of setting him free. Returning to Lourde's theorization of anger, rage can mean pain but also survival if it is faced with clarity and used for illumination and protection. The child's rage, however, allows him to survive in body alone as he never learns what Lourde calls the tools to face anger constructively. Instead, he denies his roots out of fear and unexplored rage. In that process, he reconstructs himself in the image of those behind his pain. Unlike Lourde's example, the anguish of being excluded and silenced only teaches him to remain unseen. To paraphrase Lourde's metaphor, these are the bricks that go into walls against which the oppressed will bash their consciousness, unless it is recognized that those bricks can be taken apart (279). Through the protagonist's intractable dilemma, Villaronga makes evident the enormous struggle that channeling rage entails. There is no cinematic vision of a productive use of rage. The conclusion suggests that merely representing that destructive process serves its purpose. The inclusion of this video essay in this special issue makes inroads in the study of the uses of rage and its representation. It also offers a pathway to delineate a longer trajectory of inequality, anti-gay hate, and toxic masculinity in present-day Spain. Nearly five decades after the death of Franco, and eight decades after the 1940s context in which Black bread is set, debates around gender and sexuality remain fraught and dangerous. By scrutinizing the breadth and historical depth of the exclusionary projects rooted in patriarchal power and the social invisibility that they produce, we not only gain a deeper understanding of the past but also a sharper insight into the present.

This video essay explores how the film Black bread (2010) by Agustí Villaronga foregrounds repression. It is a film that depicts a world of inequality and homophobia where children learn that violence is not ananomaly but a tool. Through the audiovisual format I argue that the film provokes thought on the complexity of rage and how to either challenge or perpetuate heteropatriarchal norms. The film makes visible the process through which the powerful manipulate the rage of the marginalized by shifting blame for their oppression. When shame and fear fuel rage, it loses its productive potential and becomes destructive. In denying his roots out of fear and rage, the protagonist reconstructs himself in the image of those behind his pain. there is no cinematic vision of a remedy to cruelty, or a productive use of rage. The conclusion suggest that representing that destructuve process in esnogh.

of understanding cultural issues and linking social factors to better understand the barriers and facilitators of obesity risk in immigrants. Recommendations for developing culturally tailored weight-control programs matched to the ethnicity of immigrant populations are provided. The study investigating the role of acculturation, as measured by generational status, on BMI in Canadian youth reported that first-generation immigration was significantly related to higher BMI z-scores in adolescents as compared to second and third generations. Specifically, first-generation immigrants had more weight gain compared to other generation groups in adolescence. These findings expand on a growing literature demonstrating that generational timing of immigration may be a risk factor for obesity, and that maintaining traditional cultural orientation is associated with lower rates of obesity (Renzaho, Swinburn, & Burns, 2008). Although the relationship between first-generation immigration and higher prevalence of overweight has shown mixed results in some previous studies, findings in the article in this issue showed that race and ethnicity were also important factors to consider in understanding these complex relationships. Specifically, analyses stratified by race showed that this relationship tended to be stronger in Black, South Asian, and other first-generation immigrant groups. These findings suggest that first-generation youth may be at greater risk for developing unhealthy lifestyle patterns, such as poor dietary and physical activity habits. However, further research should explore how acculturation and race may be related to barriers for engaging in healthy lifestyle habits. For example, a recent qualitative study by Shelton and colleagues (2011) showed that both African American and Latina women reported having many stressors, including economic hardships, demanding caretaking relationships, inflexible work policies, and mistrust of health care providers. Those who were immigrants also reported that they experienced social isolation and were experiencing high levels of stress in general. Thus, health promotion efforts should take into account the additional stressors experienced by ethnic minority women and their families, and how immigration challenges may further impact these difficulties. The study on acculturation and obesity reported in this issue is also one of the first to examine longitudinal patterns of overweight status across generational status in children and adolescents. Overtime, BMI change for first-generation immigrants was associated with greater weight gain, but no direct measures of acculturation were integrated into the study measures, making it difficult to know exactly what the mechanisms are by which generational status is related to the development of obesity in young immigrants. As noted in a growing body of literature, more qualitative studies that address longitudinal and developmental issues related to engaging in healthy lifestyles are needed in underserved and ethnic minority populations (Wilson, Zarrett, & Kitzman-Ulrich, 2011). In particular, research on intergenerational effects of culture may provide important insights into family and generational issues that are protective or which may increase the risk for developing obesity. For example, in a qualitative study by Renzaho, Green, Mellor, and Swinburn (2011), Somali and Ethiopian migrant families indicated that intergeneration themes related to immigration included challenges with maintaining traditional parenting, family functioning, and family relations. In addition, these families reported that maintaining a healthy lifestyle of physical activity and diet was challenging, and that parents were more restrictive in controlling their youth's behaviors and discouraged autonomy. Thus, future efforts to develop policies and health promotion programs among immigrant populations should integrate a parenting focus to better assist parents with how to communicate with their youth about the importance of engaging in healthy lifestyles, given the transition to a new cultural environment. Recently, investigators have argued for an ecological approach to understanding lifestyle factors that relate to obesity in underserved and ethnic minority populations that incorporates a stronger focus on social factors, including social context (Sallis, Owen, & Fisher, 2008;Wilson, 2009;Wilson, Ellerb, Kugler et al., 2012). Recent studies demonstrate that social factors are important for improving health behaviors in underserved low income, ethnic minority populations (Sallis et al. 2008;Wilson et al, 2012). In particular, research is needed to better understand social interactions and parent-related supports specific to acculturation of young immigrants who may be at increased risk for developing obesity. Understanding the socialization and cultural integration of immigrants may increase our understanding of how to address the barriers and create more positive social environments that encourage increased activity, healthy eating, and supportive climates for engaging in healthy lifestyles. There is an increasing body of literature that indicates that parent support and positive neighborhood conditions are both important for buffering the negative effects of poverty and poor environmental conditions on the development of obesity in youth (Lawman & Wilson, 2012). In a recent study by Sussner, Lindsay, Greaney, and Peterson (2008), immigrant Latina mothers reported that beliefs about feeding practices, lack of physical activity, lack of social support, and increased social isolation all contributed to a lifestyle that was prone to developing obesity. Taken together, these studies reviewed highlight the need for health promotion efforts that address the specific barriers related to parental beliefs and understanding of how to build social relationships that could reinforce health behaviors for engaging in physical activity and healthy eating. Health promotion efforts among immigrants need to address multiple systems within the family's environment, including the neighborhood, schools, and religious and cultural affiliations. Health promotion programs for obesity prevention in culturally diverse populations have focused on incorporating cultural tailoring approaches that address the specific needs of the target population with respect to promoting healthy lifestyles. The most successful health promotion interventions for underserved and ethnic minorities have incorporated culturally targeted and culturally tailored intervention components using multisystemic approaches, and these approaches could be applied to young immigrants (Wilson, 2009). Furthermore, in a recent qualitative study by Lindberg and Stevens (2011), Mexican-American women indicated that they wanted more opportunities to engage in behavioral interventions that provided culturally centered behavioral strategies for improving nutrition and food choices within the family context. Kreuter and colleagues (2003) have provided an overview of cultural tailoring for improving health behaviors. They propose that interventions can incorporate peripheral strategies that give program materials the appearance of cultural appropriateness by using certain images and pictures of group members. In addition, linguistic strategies have also been used to develop program materials that are dominant to the native culture of the ethnic minorities. Interventions that have ''socio-cultural'' or ''deep structures,'' typically integrate cultural values and norms into the intervention programming and have been demonstrated to be effective tailoring approaches for health behavior change (Resnicow, Davis, Zhang, et al. 2008;Resnicow, Davis, Zhang, et al. 2009). Deep structures or socio-cultural strategies have also been shown to be successful, when integrated within the health-related context of interventions that target culturally diverse ethnic populations (Resnicow, Braithwaite, Ahluwalia, & Dilorio, 2001). All of these tailoring strategies could be implemented within immigrant families for promoting healthy lifestyles and obesity prevention. In summary, the article on acculturation and risk of obesity in this issue raises important questions about why and how immigration may lead to greater prevalence of risk for developing obesity in youth. Obtaining contextual information (i.e., via qualitative studies) for understanding the social and environmental processes will continue to inform future research for developing effective culturally tailored health promotion approaches in these high-risk populations of immigrants. In addition, developing culturally tailored approaches for improving parent support and social integration, as well as broader environmental supports for healthy lifestyles will be critical to reversing and preventing these trends in childhood obesity among immigrants. Future research should replicate these findings presented in this issue and explore the mechanisms across different ethnic and cultural groups to better understand how to best tailor obesity prevention efforts for immigrant youth. --- Conflicts of interest: None declared.

Understanding risk factors related to acculturation and the risk of developing obesity is important, given the increasing number of immigrants in the United States. A summary of key findings from the ''Generation of Immigration and Body Mass Index (BMI) in Canadian Youth'' article in this issue are presented, and the implications for future research and health promotion efforts are discussed in this commentary. An emphasis is placed on the importance

Introduction The topic of reproductive health is crucial in the Toba Batak Ethnicity, especially in the context of Batakness, due to several factors. Firstly, there is a scarcity of previous research on this topic in the Toba Batak community, which has led to a lack of understanding of the specific reproductive health needs and challenges faced by this group. The research on the reproductive health of the Toba Batak community is still limited, and more studies are needed to explore the unique challenges and needs of this population. Therefore, it is crucial to conduct more research to gain a better understanding of the reproductive health issues in the Toba Batak community. As stated by Mafina et al., (2009), reproductive health is also defined as a set of methods, techniques, and services that promote reproductive health and well-being by preventing and resolving reproductive health issues such as sexual health, life status, and personal relationships, as opposed to just providing consultation and treatment related to reproduction and diseases transmitted through sex. Secondly, there is a need to understand the local understanding and cultural beliefs surrounding reproductive health in the Toba Batak community. This is important to ensure that reproductive health programs and services are culturally appropriate and acceptable to the community. Cultural beliefs and practices of the Toba Batak community may affect reproductive health-seeking behaviour, and it is necessary to understand these factors to develop effective interventions. Understanding cultural practices and beliefs is critical in designing reproductive health interventions that are culturally sensitive and acceptable. Moreover, reproductive health issues are prevalent in the Toba Batak community, which further emphasizes the importance of this topic. Reproductive health problems such as maternal mortality, unintended pregnancies, and unsafe abortions are still prevalent in the Toba Batak community. Addressing these reproductive health issues is essential to improve the overall health outcomes of the Toba Batak population. In conclusion, the topic of reproductive health is vital in the Toba Batak ethnicity, particularly in Batakness, due to the scarcity of previous research, the impact of cultural beliefs and practices, and the prevalence of reproductive health problems. It is crucial to conduct more research and develop culturally sensitive interventions to address these issues effectively. Adolescence is the period between childhood and adulthood. This term refers to the period of time between the onset of puberty and the attainment of maturity, which generally begins at 14 years of age in boys and 12 years of age in girls. At the ages of 11-16 years for men and 10-15 years for women, adolescent growth and development is very rapid (Samadi, 2004). Adolescent women in puberty face a number of challenges, including the development of female behavior, physical changes, menstrual cycle conditions, acne, obesity, and disease (Samadi, 2004). During puberty, an individual experiences physical, psychological, and social changes as they transition from childhood to adulthood. Puberty is a holistic transition between childhood and sexual maturity. Menstruation, which typically occurs in young girls between the ages of 9 and 16, is a sign of puberty. The first appearance of menstruation in females and wet dreams in males differs for each individual. Nutritional status is one of the many causes of this disparity. Usually, a girl gets her first period between the ages of 12 and 13, but in this case, it happens between the ages of 8 and 9, which is called "early menstruation."Menstruation is an important part of a woman's life cycle. It shows that a young woman has grown up, especially in her reproductive organs. This time period also shows the different ways a child's life changes over time. Change is not only limited to the physical, but also includes social, psychological, economic, and spiritual changes. Reproductive health is an important aspect of health that receives little attention. Because people believe that these cases are taboo to discuss and because of family socio-cultural constraints regarding gender aspects that can affect the way of thinking and behavior of women and men, adolescent reproductive issues are thought to be very sensitive and should be brought to the forefront. --- Research Method A descriptive research method is used for material on reproductive health in the view of the Toba Batak ethnicity, where the descriptive research method itself is a research method that shows the characteristics of the population or phenomenon being studied. As a result, this research method focuses primarily on explaining the research object and answering the question of reproductive health from the perspective of the Toba Batak ethnicity. --- Result and Discussion Article 71 of Health Law Number 36 of 2009 says that reproductive health is a state of complete physical, mental, and social health, not just the absence of disease or disability related to the reproductive system, functions, and processes in men and girls. The Government Regulation of the Republic of Indonesia Number 61 of 2014 on Reproductive Health has rules about reproductive health. According to the World Health Organization (WHO), health is a condition that includes physical, mental, and social health and does not simply mean the absence of disease and disability. Meanwhile, according to Health Law Number 36 of 2009, health is a physically, mentally, spiritually, and socially healthy state that allows everyone to live productively socially and economically. Batak culture is a way of life that has been developed by the Batak people in their society. Patterns and types of relationships between Batak people are also governed by this culture.The Batak people's kinship system is patrilineal, meaning it is based on the father's lineage. This patrilineal kinship system is the backbone of Batak society, which is made up of descendants, clans, and ethnic groups all linked by line. Traditions of the Toba Batak tribe are carried out through ceremonies that start with conception, birth, weaning, illness, disaster, and end with death. A special traditional ceremony marks the transition between each level of life. Traditional ceremonies are performed to avoid harm that will befall blessings, health, and safety. This is one of the guiding principles behind the execution of every traditional Toba Batak ceremony. In everyday life, the Toba Batak tribe has its own culture. The culture that has been passed down from generation to generation determines all behaviors. In dealing with health issues, the Batak Toba tribe employs a variety of cultural practices, including newborn care (Swasono, 1998). The Toba Batak tribe's culture has unique traditions that have been passed down from generation to generation. --- Menstruation During puberty, teenagers will go through a variety of experiences. Several physical and psychosexual changes will occur during this period, including feelings of attraction to the opposite sex and changes in appearance. The child's first menstruation usually comes with its own set of benefits and memories. Depending on their knowledge, each child will have different feelings. Menstruation occurs once a month. Menstruation is inextricably linked to its associated symptoms, one of which is dysmenorrhea, or abdominal pain during menstruation. Menstruation is not a new phenomenon in human life, but not everyone is comfortable discussing it. This assumption can be seen in the participants' expressions and the findings of the observations, which show that menarche is a taboo subject in Batak society (Simanjuntak et al., 2013). This is evident from the following participant behaviors and expressions: Two of the six participants stated unequivocally that menarche is a taboo subject that should not be discussed. Menstruation is a very personal matter that should not be discussed in the Batak Toba community (Simanjuntak, 2008).This statement was reinforced by the teenagers' parents, who stated that menstruation did not need to be discussed and that it was preferable for teenagers to experience it naturally. Parents also believe that teenagers will figure it out on their own (Surmiasih & Priyati, 2018). --- Birth In Toba Batak culture, caring for newborns begins with a baby-welcoming ceremony called manomunomu (picking up people with a ceremony, hailing them), followed by fixing the baby's navel cord with sharp bamboo scales on a bed of yam seeds the size of three fingers, depending on the baby (Pandingan, 2011) . Then, for the afterbirth, planting will be carried out, which is generally planted on muddy soil (rice fields). The shaman then breaks and chews the hazelnut before giving it to the baby in order to clean the dirt that the baby carries from the womb as well as the first food digestion, which is known as tilan (first feces). --- Postnatal Care The patterned cultural value system incorporates all aspects of people's values. Community life is a pattern of group life in various forms. According to (Roma, 2010;Sitorus, 2011), regarding saline treatment for the Toba Batak ethnicity, specifically: 1. Performing daily housework such as cooking, laundry, and cleaning. --- 2. Putting charcoal under or beside the mother to keep her and her baby warm 3. The husband gave the mother water and black beer with the expectation that she would recover quickly and be strong enough to return to work in the fields once she was fully recovered because farming is their primary source of income. --- 4. Give the mother food, especially wake-awake and napinadar chickens, so that the remaining blood in her uterus drains quickly, she gets better quickly, and breastfeeding is easier. 5. Assist the mother in urinating, bathing, and changing clothes if she so desires. --- Menopause Knowledge about menopause is essential for women going through menopause to understand what menopause is like, what symptoms and signs of menopause are, and how to manage complaints that occur during menopause. With this information, women who are getting close to menopause will be better prepared mentally to go through menopause and deal with any problems that may come up. --- Conclusion In everyday life, the Toba Batak tribe has its own culture. The culture that has been passed down from generation to generation determines all behaviors. In dealing with health issues, the Batak Toba tribe employs a variety of cultural practices, including newborn care. The Toba Batak tribe's culture has unique traditions that have been passed down from generation to generation. Teenagers aren't ready for menstruation because they don't know enough about it, their parents don't help them, and their friends don't help them.Menarche is shocking, worrying, and frightening because of this lack of preparation. If adolescents have previously received information from their parents and social environment, this will not occur. According to how people in the Toba Batak culture see things, postpartum care has its own ways of making sure the body stays healthy, getting rid of dirty blood, and expressing breast milk.(ASI). Menopause is a vulnerable stage in elderly women, so be prepared by learning about early menopause. Women who have not gone through menopause will be more physically and psychologically prepared and independent before entering the premenopausal phase with all of the changes that occur. Efforts are made by following a healthy diet, exercising regularly, and consuming traditional herbs.

Reproductive health is a complete physical, mental and social well-being in all matters including the reproductive system and function, and the reproductive process and is not just a condition that is free from disease and disability. Everyone must be able to have a satisfying and safe sexual life for himself, also be able to reduce and fulfill his desires without any obstacles, when, and how often to have children. Inland communities who are still lacking in understanding reproductive health knowledge and lack of adequate facilities for health checks, enhance adolescents' understanding of the process of change that occurs in themselves, especially young women facing menarche, need to provide health information and also understanding from their closest people, family and friends. the social environment becomes a support system. The importance of receiving news about early menopause and how to deal with early menopause so that there is no excessive anxiety.

HOUSING AND HOME MODIFICATION FOR AGING IN PLACE: PERSPECTIVES, PROGRESS, AND FUTURE DIRECTIONS Jon Pynoos, University of Southern California, Los Angeles, California, United States Aging in place remains a high priority of older adults. However, the home environments in which they reside often have hazards and lack supportive features, putting them at risk of falls and making it difficult to carry out daily activities. People who need home modifications the most (i.e., vulnerable populations) are the least likely to have them. In response to the needs of the growing population of older adults, there has been notable progress in the field. Now, with an increasing recognition of the impact of housing on health, there are new opportunities to move the field forward. Highlighting Powell Lawton's contributions as a foundation, this lecture will: 1) review major developments in research, service delivery, policy, and consumer education, and 2) discuss recommendations for action that practitioners, researchers, policymakers, and advocates could undertake to realize Lawton's vision of home environments that support aging for all. --- SESSION 4275 (PAPER) --- MEANINGFUL MODERATORS AND PATHWAYS Abstract citation ID: igad104.1622 --- DETERMINANTS OF INFORMAL CARE TRAJECTORIES IN ENGLAND Giorgio Di Gessa 1 , and Christian Deindl 2 , 1. University College London,London,England,United Kingdom,2. TU Dortmund University,Dortmund,Germany In the context of an ageing population, combined with long-standing challenges in the delivery of formal social care for older people, unpaid caregivers play a key role in promoting the quality of life of older people and their extended families and ensuring that needs for care and support are met. Although many studies have provided snapshots of informal care provision, few so far have examined longitudinal patterns of informal care provision among older people. This paper aims to describe caregiving trajectories in later life and to examine how socioeconomic, demographic, and health characteristics of older adults relate to these patterns (including needs and enabling factors). Using six waves of the English Longitudinal Study of Ageing, we conduct latent trajectory analysis to cluster people's diverse trajectories into a finite number of groups. The intensity of informal care provision is also considered when identifying longitudinal trajectories. Preliminary results show five distinct trajectories of informal care provision (including those who never provide informal care, those who provide sporadic informal care, those with increasing and decreasing commitment to care provision, and those who care throughout). Gender, age, health, income, living arrangements, and family compositions all relate to long-term trajectories of informal care, with younger married women in good health more likely to provide informal care throughout. Support should be provided to this group of caregivers, given that engagement in long-term caregiving might be detrimental to mental health. Abstract citation ID: igad104.1623 --- DIFFERENCE IN TIME SPENT CAREGIVING BETWEEN CAREGIVERS OF IMMIGRANT AND NONIMMIGRANT OLDER ADULTS Zainab Suntai 1 , and Joana Okine 2 , 1. Baylor University, Waco, Texas, United States, 2. University of Alabama, Tuscaloosa, Alabama, United States Each year, the number of informal caregivers in the United States continues to rise, in conjunction with the increasing aging population. Concurrently, the number of immigrants in the United States had progressively increased over the past few decades, leading to an intersection of three pivotal issues: caregiving, aging, and immigration. While there are several studies targeting caregiving in the United States, fewer studies have aimed to understand the experiences of caregivers of older immigrants. This study examined differences in time spent caregiving between caregivers of older immigrants compared to caregivers of older non-immigrants. Data were taken from Round 11 (2022) of the National Study of Caregiving, a nationally representative study of informal caregivers caring for an older adult with functional limitations. Chi-square tests were used to test bivariate associations, and a multivariate logistic regression model was run to determine the relationship between and older adult's immigration status and time spent caregiving by their caregiver. Results showed that caregivers of older immigrants were significantly more likely to report that they provided care every day, compared to caregivers of non-immigrants. These results point to potential cultural implications for immigrant families, who are generally less likely to use formal caregiving avenues such as nursing homes, and less likely to use additional services such as home health aides. Implications for researchers, policymakers, and practitioners are discussed. Abstract citation ID: igad104.1624 --- DIFFERENTIAL EFFECTS OF ADULT CHILDREN'S HEALTH PROBLEMS ON PRIMARY AND SECONDARY CAREGIVING FOR PARENTS Catherine Stepniak 1 , J Jill Suitor 1 , and Megan Gilligan 2 , 1. Purdue University, West Lafayette, Indiana, United States, 2. University of Missouri, Columbia, Missouri, United States Adult children often serve as primary and secondary caregivers to their aging parents as they face greater needs for assistance. However, it could be expected that the flow of caregiving support from adult children to parents might be disrupted if adult children are facing their own serious health challenges. Surprisingly, the literature provides no clear picture of the way in which children's health moderates their provision of care to older parents. In the present study, we shed new light on this question using quantitative and qualitative data collected from 156 mothers ages 75-85 regarding assistance provided by their 586 adult children as part of the Within-Family Differences Study. Additionally, we will explore if there are differences based on timing of the children's health problems, the types of health problems (physical health vs. psychological health), and gender of the adult children. Quantitative analyses showed that adult children with serious health problems were just as likely as their healthy siblings to be a primary or secondary caregiver to their mothers. Qualitative data revealed the complex emotional and practical cost-benefit analyses mothers and their adult children with health problems engaged in to maintain reciprocal support exchanges. Our findings underscore the importance of using mixed-method approaches to understand the ways in which the provision of care to parents is shaped by adult children's own health status. Abstract citation ID: igad104.1625 Understanding factors that increase susceptibility to scams in old age is of critical importance. Cognitive functioning has been demonstrated to be an important factor in predicting financial exploitation and scam risk. There is also evidence that subjective age, or one's perceived age relative to chronological age, may be associated with financial exploitation risk. This study examined the interactive effect of subjective age on the relationship between global cognition and susceptibility to scams. Sixty-five participants underwent an assessment of global cognition (Mini-Mental State Examination; MMSE), reported their subjective age, and responded to a self-report questionnaire on scam susceptibility. A main effect of global cognition on scam susceptibility was found (b = -0.029, ß = -0.280, p = 0.028); there was no main effect of subjective age on scam susceptibility (p = 0.819). An interaction between cognition and subjective age was found, such that the negative association between cognition and scam susceptibility increased as subjective age increased (b = -0.185, ß = -0.311, p = 0.016). Examination of conditional effects demonstrated that the relationship between cognition and scam susceptibility was not significant amongst those with subjective ages below one standard deviation (SD) of the mean, but was significant for those whose subjective ages fell around or above the mean (within 1SD, b = -0.03, SE = 0.01, p = 0.03; +1SD, b = -0.06, SE = 0.02, p = 0.001). Findings suggest that individuals with older subjective ages may be particularly vulnerable to the negative effects of lower cognition on scam susceptibility. --- SUBJECTIVE AGE MODERATES THE RELATIONSHIP BETWEEN GLOBAL COGNITION AND SUSCEPTIBILITY TO SCAMS

during the first 4 years. Afterwards, the low OSA risk group continued to have significant increase in odds of functional hearing loss but not the elevated OSA risk group. OSA might be a novel risk factor for hearing loss. Screening and treating OSA might be important for hearing loss prevention.

Background: Literature focusing on migration and maternal health inequalities is inconclusive. This is potentially explained by heterogeneous definitions and settings. Our objective was to assess migrants' risk of severe maternal outcomes compared to native women in high income countries overall, according to host country, and by the migrant's region of birth. Methods: Systematic literature review and meta-analysis using MEDLINE/Pubmed and EMBASE databases between 1990 and 25 March, 2022. Observational studies comparing the risk of maternal mortality or all-cause or cause-specific severe maternal morbidity in high income countries between migrant, defined by birth outside the host country, and native women, were included. Case-control and case studies were excluded. We performed random-effects meta-analyses when possible. Subgroup analyses were planned by host country and migrant's region of birth. --- Results: From 2010 unique references, 36 studies reporting data from 32 databases were included. In Europe, migrants had a higher risk of maternal mortality than native women (RR 1.4;95%CI 1.1-1.6), but not in USA and Australia. Migrants born in sub-Saharan Africa (RR 3.3;, Latin America and the Caribbean (RR 2.8;95%CI 1.2-6.9), and Asia (RR 1.8;95%CI 1.3-2.4) were at higher risk of maternal mortality than natives, but not those born in Europe or the Middle East and North Africa. Patterns were similar for all-cause severe maternal morbidity. --- Conclusions: The differential risk of severe maternal outcomes in migrant versus native women in high income countries varies by host country and by women's region of origin. Our findings provide insight into the mechanisms of these inequalities. --- Key messages: In high income countries, the differential risk of severe maternal outcomes in migrants (born outside the host country) compared to natives, varies by the host country and the region of birth. Our findings strengthens the evidence supporting the need to fight migrant's health inequalities and to customise related health policies in each context.

was assessed according to the modified Adequacy of Prenatal Care Utilization Index through multivariable logistic regression models. Results: Among the 4803 migrant women included, 16.3% had a partial and 3.8% a total language barrier. Migrants with language barrier had resided less time in France, experienced social deprivation and undocumented status more frequently than those with no language barrier. Compared to migrants with no language barrier, those with partial (RR 1.23, 95%CI 1.13-1.33) and total (RR 1.28, 95%CI 1.10-1.50) language barrier were at higher risk of inadequate PCU. Adjustment for maternal age, parity, and region of birth did not modify these association, which were noted particularly among socially deprived women.Migrant women with language barrier have a higher risk of inadequate prenatal care utilization than those without. These findings underscore the importance of targeted efforts to bring women with language barrier to prenatal care.Compared with migrant women with no language barrier, those with such barrier, either total or partial, have a higher risk of inadequate prenatal care utilization. These findings underscore the importance of targeted efforts to bring women with language barrier to prenatal care.

of the Network, challenges remain in responding to the growth of inequality and the impact of economic austerity on aging policies. Against the background of these limitations, this paper sets out a 'Manifesto for the age-friendly movement' aimed at raising the aspirations of what is now a world-wide movement. The areas covered in the Manifesto are: challenging social inequality; widening participation; co-producing and co-designing age-friendly communities; encouraging multi-sectorial and multi-disciplinary collaboration; and integrating research with policy. The paper concludes with a discussion on developing age-friendly work as a contribution to a new agenda for urban aging. --- TOWARDS AN ACTIVE CARING COMMUNITY IN BRUSSELS A. Smetcoren 1 , L. De Donder, PhD 2 , D. Duppen, Ms 3 , N. De Witte, PhD 4 , O. Van Mechelen, Ms 5 , D. Verté, PhD 6 , 1. Vrije Universiteit Brussel,Brussels,Brussels Hoofdstedelijk Gewest,Belgium,2. Vrije Universiteit Brussel,Brussels,Belgium,3. Vrije Universiteit Brussel,Brussels,Belgium,4. University College Gent,Gent,Belgium;Vrije Universiteit Brussel,Brussels,Belgium,5. Kenniscentrum Wonen,Welzijn en Zorg,Brussels,Belgium,6. Vrije Universiteit Brussel,Brussels,Belgium This study addresses how age-friendly social environments can support frail older people to 'age actively in place'. A qualitative study was performed involving 11 focusgroups (e.g. older residents, volunteers, professionals) in two disadvantaged neighborhoods in Brussels. Findings indicate five key issues crucial to consider when creating supportive agefriendly social environments: 1) the decreasing availability of kinship support networks; 2) the significance of neighbors in the support networks; 3) the idea of making existing connections and networks 'visible'; 4) the multi-dimensional relational aspects of support; and 5) the need to move beyond care and support. The discussion highlights that although age-friendliness could have a significant impact on all age groups living within a given neighbourhood, it could be particularly beneficial to those who lack the means to improve their situation and to those more reliant on their immediate locality for support, providing new support prospects for 'ageing well in place'. --- DEVELOPING AGE-FRIENDLY CITIES: LEARNING FROM THE EXPERIENCE OF BRUSSELS, MANCHESTER, AND MONTREAL S. Remillard-Boilard, The University of Manchester, Manchester, England, United Kingdom This paper presents the findings of a cross-national study comparing age-friendly developments in three large urban centres: Brussels (Belgium), Manchester (UK) and Montreal (Canada). Drawing on a series of in-depth interviews conducted with 45 local key stakeholders, this paper aims to present different approaches to creating age-friendly cities. This theme is developed by, first, examining different strategies cities have used to develop their age-friendly work; and second, by presenting a number of success factors and challenges influencing the development, implementation and evolution of age-friendly policies. Given the wide variety of contexts in which age-friendly policies are developed, this paper argues that understanding how cities operationalise

than those in the MHAS. Cognitively impaired individuals in the MHAS were more likely to be living with a spouse only. In both nations approximately one-fifth of the cognitively impaired live alone. Conclusion: Cognitive impairment is associated with differential living arrangements in Mexico and the U.S. We discuss the policy implications of this growing burden for both nations.

respect early in the partnership provided a foundation for community engagement and played an intricate part in effectively mobilizing the unit. Providing services via the mobile unit served as an effective way to address issues related to access to care and availability of healthcare providers. It also presented an opportunity for the detection and prevention of mental and medical illness that can be easily assessed by screening measures. Furthermore, when the medical issues were linked to health outcomes, such as metabolic syndrome (MSX) and cognitive impairment, the mobile unit helped promote both physical and mental well-being among rural mid-life and older adults. Descriptive analyses and analysis of variances (ANOVA) were performed to assess the effect of gender, race, and community on the number of MSX risk factors. Results of a three-way ANOVA revealed a significant interaction between gender, age and community on the number of risk factors; post hoc analyses indicated rural communities with lower social economic status (SES) and predominantly African American residents were at greater risk for developing MSX compared to communities with higher SES. The mobile unit provided a great way to engage mid-life and older adults while offering preventive health screenings in rural communities. Survey research designs that integrate contextual data have become more prevalent in recent decades, presumably to enable a more refined focus on the person as the unit of analysis and a greater emphasis on inter-individual differences due to social forces and contextual conditions. This article reviews varied approaches to contextualizing survey data and demonstrates the value of two integrative approaches for the study of human development and aging-the use of interviewer ratings and neighborhood information (measured via census tracts). The utility of an integrative approach is illustrated with data from the Health and Retirement Study, revealing what is gained by using a contextualized approach and how substantive conclusions may be misdirected when contextual factors are neglected. Neighborhood disorder, measured by respondent and interviewer ratings, as well as geocoded neighborhood socioeconomic data were used to predict disability and depressive symptoms among older adults. Results indicate that racial and ethnic differences in functional limitations and depressive symptoms may be overestimated when failing to include contextual neighborhood characteristics. To enhance the predictive validity of survey data, investigators should consider meaningful contextual data for specific research questions. Panel surveys for older adults would ideally contain data up to the end of participants' lives. This allows analysis of key changes, including increasing health and social care use, that more commonly occur in the final years of life. However, all panel surveys suffer from attrition across waves, including non-response. Missing data analysis tends to categorise participants as either participating, missing or dead. Using linked mortality data within the English Longitudinal Study of Ageing (ELSA) a person's death is recorded even if they have missed several waves of data collection. This enables us to determine not just if data is missing but how much data is missing before end-of-life. Three research questions are addressed: 1) For those who have died between waves 1 and 5 of ELSA, how many waves were missing prior to death? 2) What is the average amount of missing data at end-oflife? 3) Is the amount of missing data randomly distributed? Specifically does cause of death relate to how much data is missing? Analysis indicates that almost 30% of those who have died have 1, 2 or 3 waves missing prior to death and the amount of missing data is not random. Using multistate life tables, it is demonstrated that cause of death relates to the chances of having more waves missing. In conclusion, those with declining function over a long period of time are more likely to have more waves missing. These patterns of missingness should be considered when analysing data from older populations. --- CONTEXTUALIZATION OF SURVEY --- PATTERNS OF MISSING DATA AT THE END-OF-LIFE --- RETENTION OF PARTICIPANTS IN LONGITUDINAL ALZHEIMER'S DISEASE STUDIES: WHO STAYS? Y. Hu, H. Iqbal, L.M. DeLaney, P. Hidalgo, S.L. Stark, Washington University in St. Louis, St. Louis, Missouri A high attrition rate is a major barrier in conducting longitudinal studies. The aim of this retrospective cohort study is to explore the traits of participants in longitudinal Alzheimer Disease (AD) studies in order to investigate retention barriers and facilitators. To determine the relationships of baseline demographics, cognitive status (The mini-mental state examination), AD biomarkers (elevated cerebral amyloid-beta (Aβ) burden measured by positron emission tomography), and the retention rate in an AD research, Pearson correlation, Welch's t test and chi-square were conducted. A retention score was calculated by dividing the number of missed appointments by the number of scheduled appointments. There were 660 participants (age mean = 74.9 ± 9.2; 60.2% female; 85% Caucasian) who have records of clinical assessments in our study; 71 participants (89.24%) who have a retention score lower than 70% were selected in low retention group for comparison. The results showed that older age (r=.599, p<.01), being male (c 2 = 4.53, p= 0.03), lower cognitive status (t= 6.60, p=0.01), and higher Aβ burden are significantly related to higher retention rate. The result of this study provided an initial exploration of

Alabama collaborated to increase healthcare access among rural mid-life and older adults. This interdisciplinary healthcare team utilized a mobile unit to provide health screenings and behavioral assessments. The establishment of trust and

setting, 2) built environment, 3) sense of place, 4) symbolic landscape and 5) everyday activities and outer/society components of 1) beliefs and philosophies, 2) social relations/inequality and 3) territoriality. The purpose of this study was to explore how environments that older adults are engaged in (e.g., Irish Men's Sheds) exemplify characteristics found in Gesler's therapeutic landscape model. Interviews with Men's Sheds participants aged 65+ (N = 37) were conducted in County Limerick, Ireland. After transcription, Braun and Clarke's (2020) intuitive 6-step process for thematic analysis was used to interpret the data. Interviewee transcripts revealed that the social relations/inequality component of the therapeutic landscape model was most evident in the narratives. The men explained that it was important to create an inclusive space for all men to feel welcome and valued. For example, a participant said, "Some [members] are living on their own, maybe they're lonely and they feel kind of unwanted… so, the shed has made a difference to them. Limited research has explored the association between neighborhood environments and cognitive functioning using longitudinal reports of neighborhood quality. The current study examined the longitudinal association between perceived neighborhood characteristics and computerized cognitive performance among Black adults. This study included 584 community-dwelling socioeconomically diverse Black adults (Mage = 56.27, SDage = 8.94; 58% female) from waves 3 & 4 of the Healthy Aging in Neighborhood of Diversity across the Life Span (HANDLS) study. Neighborhood quality was assessed using three scales about built environment disorder (e.g., litter), social cohesion (e.g., close-knit neighborhood), and social control (e.g., neighbors act if fight in front of house). Cognitive functioning was assessed using the computerized Joggle battery. Multivariable linear regression analyses were conducted with each cognitive measure as the outcome measure. Models were adjusted for age, sex, education, reading literacy, poverty status, and depressive symptoms. In the adjusted models, living in a neighborhood with increasing built environment disorder was associated with slower performance (p <.05) on an attention measure. Increasing social cohesion was associated with faster performance (p <.05) on memory, attention, and visual orientation measures. Similarly, increasing social control was associated with faster performance (p <.05) on attention, executive function/reasoning, visual orientation, and speed measures. Additionally, increasing social control was associated with greater number of correct responses (p <.05) on an attention and executive function/reasoning measure. Significant interactions were observed between changes in neighborhood quality and covariates. These findings amplify the importance of understanding how changes in neighborhood quality impact cognitive performance among Black adults. Abstract citation ID: igad104.2679 --- LONG-TERM EXPOSURE TO FINE PARTICULATE MATTER AND DEPRESSIVE SYMPTOMS AMONG CHINESE OLDER ADULTS Jiaan Zhang, Fudan University, Shanghai, Shanghai, China (People's Republic) There is a growing body of evidence suggesting that air pollution, especially PM2.5 (particulate matter with a diameter of 2.5 micrometers or less), has been associated with adverse mental health outcomes, but the long-term association with depressive symptoms remains unclear. The purpose of this study is to examine the long-term effect of cumulative exposure to PM2.5 on depressive symptoms among Chinese older adults. Using a nationally representative sample of older adults in China (N=16,064), we tracked their depressive symptoms over a 16-year period (2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018). Air pollution data were linked to respondents using provincial identifiers. Three-level random intercept linear regression models that account for the nesting of repeated observations (level-1) within individuals (level-2) and individuals within provinces (level-3) were used to examine the long-term cumulative effects of PM2.5 exposure on depressive symptoms. We found that every 10-μg/m3 increase in cumulative exposure to PM2.5 increased the levels of depressive symptoms by 0.28 points (β = .28, p < .01), controlling for individuallevel sociodemographic characteristics and social support, health-related behaviors, and health status. Furthermore, the association between cumulative PM2.5 exposure and more depressive symptoms is more pronounced for urban residents than for rural residents. Our analysis shows that air pollution is a risk factor for depression in older Chinese adults. Findings suggest that stronger PM2.5 regulations, especially in urban areas, may enhance mental health. Abstract citation ID: igad104.2680 --- THE ASSOCIATIONS OF ENERGY CONSUMPTION AND EXPENDITURE WITH SELF-PERCEIVED WELL-BEING AMONG CHINESE ADULTS Qiyini Ma 1 , Fei Sun 2 , and Hong Mi 1 , 1. Zhejiang University, Hangzhou, Zhejiang, China (People's Republic) --- , 2. Michigan State University, East Lansing, Michigan, United States Background and Objectives: Households in China have gradually moved to use of cleaner fuels, but the proportion using solid fuels in daily life remains as high as 30%, resulting in approximately 420,000 premature deaths annually. Energy use and its impact on health may differ by age, as less active lifestyle in later life may lead to increased household energy consumption aggravating poor health consequences. The twofold aims of this study are: 1) to examine energy consumption patterns and expenditure between young Chinese (aged 18-59) and older Chinese (aged 60 or above), and 2) to identify how energy consumption patterns and expenditure are associated with self-perceived wellbeing in the two respective age groups. Methods: A total of 2,303 valid samples (M age = 51, SD = 16.2) were obtained from Chinese General Social Survey (CGSS) in 2015. Hierarchical linear modelling analyses were employed using HLMs 6.08 for each age group to examine the influence of individuallevel factors and cluster-level covariates (i.e., environmental pollution, health care resources, and economic development at provincial level). Results: Among the young adults, those using oils, gas, and electricity reported better self-perceived wellbeing than those using solid fuels. Among the older adults, reliance on fuel gas and energy expenditure were associated with better self-perceived wellbeing. Conclusions: The harnessing of cleaner energy has the potential to increase subjective wellbeing across age groups. For older adults, the higher energy expenditure might indicate a dormant or isolated lifestyle, which calls for practice interventions to improve social engagement and promote wellbeing. --- SESSION 7570 (POSTER) --- GENDER AND AGING Abstract citation ID: igad104.2681 --- BACKWARD WALKING SPEED: A NOVEL MOBILITY MEASURE FOR YOUNGER AND OLDER ADULTS Braden Popelsky, Kelly Ylitalo, and Samuel Hockett, Baylor University, Waco, Texas, United States Mobility is fundamental to healthy aging. Forward walking speed (FWS) is a well-established measure of mobility, physical functioning, and fall risk but fewer studies have assessed backward walking speed (BWS). This study explored the relationship between FWS, BWS, and fall-related factors. Independently ambulatory, community-dwelling young adults (n=20; age: 22.9 years ±1.6) and older adults (n=19; age: 70.2 years ±6.2) completed forward and backward walking assessments on a 3.9 meter long instrumented pressure mat. Paper surveys assessed sociodemographic characteristics, fall history, and fear of falling using the Falls Efficacy Scale -International (FES). FWS, BWS, and directional difference percent change ((FWS-BWS/FWS)*100) were compared using independent sample t-tests, and simple linear regression was used to model the relationship between mobility measures and fear of falling. In the total sample (n=39), 23% of adults reported a fall in the previous 12 months. Compared to older adults, young adults exhibited significantly faster FWS (138.3 cm/sec ± 16.5 vs. 119.3 cm/ sec ±23.4; p=0.006) and BWS (82.6 cm/sec ±18.2 vs. 63.8 cm/ sec ±20.7; p=0.005). Males displayed a significantly lower mean directional difference percent change (39.4 ±11.4 vs. 47.4 ±11.1; p=0.034), than females. Among older adults, BWS was strongly and negatively correlated with FES scores (r=-0.58; p=0.009). BWS explained a greater proportion of variance in fear of falling compared to FWS (33.93% vs. 24.84%). BWS and directional difference in walking speed may be novel measures of physical functioning. Prospective

to medical appointments had not changed. The use of virtual visits allowed residents to remain connected with their loved ones while minimizing the risk of exposure to the virus. The findings of this study can help policymakers and transportation providers understand the impact of the pandemic on the mobility of individuals in community-based care settings. The results can also inform the development of strategies to improve transportation services and ensure the mobility of residents after the pandemic. Ultimately, the study can contribute to enhancing the overall quality of life for individuals in community-based care settings in Oregon.